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Canada Health Act Annual Report 2019-2020

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(10.6 MB, 388 pages)

Organization: Health Canada

Date published: 2021

Cat.: H1-4E / H1-4E-PDF

ISBN: 0842-3202 / 1497-9144 (PDF)

Pub.: 200432

Table of Contents

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:

We also greatly appreciate the extensive work effort that was put into this report by our production team, including desktop publishers, translators, editors and concordance experts, printers and staff of Health Canada.

Minister's Message

I am honoured to present to Parliament and to Canadians the Canada Health Act Annual Report 2019-2020. 

This past year can only be described as challenging on many fronts. The COVID-19 pandemic continues to have a substantial impact on our lives here in Canada and around the globe.  Although the timeframe for this report includes just the early days of the pandemic, those first few months saw Canadians having to make fundamental changes in our daily routines as we worked together to flatten the curve. As we all know, throughout the pandemic, many Canadians have experienced tragic consequences, including the loss of family members, dealing with financial uncertainty, and we have all been adjusting to reduced social interactions and periods of isolation. Yet despite the harsh realities of this past year, I continued to be inspired by the many ways in which Canadians have come together to support one another, and, importantly, to be kind to one another.

I feel strongly that one of the factors that positioned us well to respond to the pandemic is our universal health care system. In fact, a policy brief issued by the United Nations Secretary General, in October 2020, highlights the necessity of universal health coverage to both effectively address the COVID-19 pandemic, and to prepare for future crises. One of the strengths of our health care system is that all eligible residents are insured through their provincial or territorial health care plans. In a time when Canadians are worrying about many things, paying for needed medical care is not one of them. In the midst of this pandemic, it is clear how vitally important universal health care is, and why we must vigorously defend it.  

Upholding the Canada Health Act remains a central component of my mandate. The Act ensures all Canadians have equitable access to health care services based on their need, not on their ability, or willingness, to pay. When patients seek required care, they should not face the barrier of patient charges. It is for this reason that I authorized a deduction from New Brunswick's federal health transfer payments in March 2020. Legislation in the province prevents the coverage of abortion services received outside hospitals and this lack of coverage has directly resulted in patient charges. Additionally, Newfoundland and Labrador and British Columbia were also subject to deductions resulting from patient charges. While it is never my preference to take deductions from provinces or territories, when patients are charged for insured health services, I will take every measure available to me to see such charges come to an end. 

Under the Canada Health Act Reimbursement Policy, when provinces and territories have been subject to a deduction from federal health transfers due to patient charges, they are eligible to receive a reimbursement if they choose to work with Health Canada and take the necessary steps to put a stop to the charges. I am pleased that Newfoundland and Labrador and British Columbia both took action to eliminate the barriers to care that patient charges pose, and as such, qualified for reimbursements under this policy during the reporting period.

In British Columbia, patient charges have been the subject of a lengthy court challenge, Cambie Surgeries Corporation v. British Columbia (Attorney General), which culminated in a landmark judicial decision in September 2020 ruling in favour of the publicly funded health care system. The Court, in its 880 page ruling, affirmed the central principle of Canada's health care system – that care should be based on need, not the ability to pay. The Government of Canada will continue to support British Columbia in its defense of our universally accessible health care system as this case makes its way through the appeals process.

The values which underpin the Canada Health Act, those of equity, fairness, and solidarity, are the very values I think will help us come out of this pandemic collectively stronger as a nation. This past year, Canadians have demonstrated that we will be there for one another, we will protect our most vulnerable, and that we will stand together even when we have to stand apart.

Chapter 1 - Canada Health Act Overview

This section describes the evolution of Medicare in Canada; the Canada Health Act, its key definitions, requirements, regulations, and penalty provisions; and excluded persons and services. It also outlines interpretation letters from former federal Ministers of Health sent to their provincial and territorial counterparts, following months of consultation:

Additionally, in 2002 The Honourable A. Anne McLellan wrote to her provincial and territorial counterparts to outline the Canada Health Act Dispute Avoidance and Resolution process.

The Evolution of Medicare in Canada

Canada’s single-payor public health care insurance system, “Medicare”, is financed through a progressive tax system, which allows risks to be pooled and costs to be shared by all Canadians. Our health care insurance system evolved into its present form over more than six decades. Saskatchewan was the first province to establish universal, public hospital insurance in 1947 and, 10 years later, the Government of Canada passed the Hospital Insurance and Diagnostic Services Act (HIDSA), to encourage provinces and territories to provide universal coverage for these services by sharing in their costs. The unanimous adoption of HIDSA by the federal Parliament launched the largest single program ever undertaken in peace-time Canada, and by 1961, all the provinces and territories had public insurance plans that provided universal access to hospital services. Saskatchewan again pioneered by providing insurance for physician services, beginning in 1962. The Government of Canada enacted the Medical Care Act in 1966, to encourage provinces and territories to provide universal coverage for physician services by sharing in their costs. By 1972, all provincial and territorial plans had been extended to include physician services.

In 1979, at the request of the federal government, Justice Emmett Hall undertook a review of the state of health services in Canada. In his report, he affirmed that health care services in Canada ranked among the best in the world, but warned that extra-billing by doctors and user charges levied by hospitals were creating a two-tiered system that threatened the universal accessibility of care. This report, and the national debate it generated, led to the enactment of the Canada Health Act.

We, as a society, are aware that the pain of illness, the trauma of surgery, the slow decline to death, are burdens enough for the human being to bear without the added burden of medical or hospital bills penalizing the patient at the moment of vulnerability. The Canadian people determined that they should band together to pay medical bills when they were well and income earning. Health services were no longer to be bought off the shelf and paid for at the checkout stand. Nor was their price to be bargained for at the time they were sought. They were a fundamental need, like education, which Canadians could meet collectively and pay for through taxes.

Justice Emmett Hall, Royal Commission on Health Services, 1961

Adopted unanimously by Parliament in 1984, the Canada Health Act, Canada's federal health care insurance legislation, codified the national principles which underpin federal funding for hospital and physician services and added prohibitions on patient charges which threatened to undermine universal access to care.

In Canada, the roles and responsibilities for the health care system are shared between the federal, provincial and territorial governments. The provincial and territorial governments have primary jurisdiction in health care administration and delivery. This includes setting their own priorities, administering their health care budgets and managing their own resources. The federal government, under the Canada Health Act, defines the national principles that are to be reflected in provincial and territorial health care insurance plans.

What is the Canada Health Act?

The Canada Health Act sets out the primary objective of Canadian health care policy, which is “… to protect, promote and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to health services without financial or other barriers.”

The Act establishes criteria and conditions related to insured health services and extended health care services that the provinces and territories must fulfill to receive the full federal cash contribution under the Canada Health Transfer (CHT).  In fiscal year 2019-2020, the CHT was $40,373,000,000. Additional information on federal, provincial and territorial funding arrangements is available by visiting the Department of Finance’s website.

The aim of the Act is to ensure that all eligible residents of Canadian provinces and territories have reasonable access to medically necessary hospital, physician, and surgical-dental services that require a hospital setting on a prepaid basis, without charges related to the provision of insured health care services. A copy of the Act is provided in Annex A.

Key Definitions under the Canada Health Act

Insured health services are medically necessary hospital, physician, and surgical-dental services (performed by a dentist in a hospital, where a hospital is required for the proper performance of the procedures) provided to insured persons.

Extended health care services are certain aspects of long-term residential care (nursing home intermediate care and adult residential care services), and the health aspects of home care and ambulatory care services.

Insured persons are eligible residents of a province or territory. A resident of a province is defined in the Act as “… a person lawfully entitled to be or to remain in Canada who makes his home and is ordinarily present in the province, but does not include a tourist, a transient or a visitor to the province.”

Insured hospital services include medically necessary in- and out-patient services such as accommodation and meals at the standard or public ward level and preferred accommodation if medically required; nursing service; laboratory, radiological and other diagnostic procedures, together with the necessary interpretations; drugs, biologicals and related preparations when administered in the hospital; use of operating room, case room and anaesthetic facilities, including necessary equipment and supplies; medical and surgical equipment and supplies; use of radiotherapy facilities; use of physiotherapy facilities; and services provided by persons who receive remuneration therefore from the hospital.

Insured physician services are medically required services rendered by medical practitioners. Medically required physician services are generally determined by the provincial or territorial health care insurance plan, in consultation with the medical profession.

Insured surgical-dental services are services provided by a dentist in a hospital, where a hospital setting is required for the proper performance of the procedure.

“Thanks to medicare, no one need worry about any financial burden resulting from an unforeseen illness. Since health insurance is a collective program, all Canadians share the cost of medical care for which they could not pay individually. Their taxes provide anticipated payments towards the cost of the insured health services they will eventually need. This program is not only for the young, the wealthy and the healthy. It is designed also to help the poor, the old and the chronically ill. The latter group is the one most affected by the charging of direct fees.”

April 11, 1984 debate on the enactment of the Canada Health Act, statement by Senator Jacques Hébert

The Canada Health Act

Figure

Text description

If the provinces and territories fulfill the Canada Health Act's criteria and conditions:

Five Criteria:

  • Public Administration
  • Comprehensiveness
  • Universality
  • Portability
  • Accessibility

Two Conditions:

  • Information
  • Recognition

And ensure there is no extra-billing and user chargers for insured health services

They are entitled to their full Canada Health Transfer

Requirements of the Canada Health Act

The Canada Health Act contains nine requirements that the provinces and territories must fulfill in order to qualify for the full amount of their cash entitlement under the CHT.

They are:

The Criteria

1.0 Public Administration (section 8)

The public administration criterion of the Canada Health Act requires provincial and territorial health care insurance plans to be administered and operated on a non-profit basis by a public authority, which is accountable to the provincial or territorial government for decision-making on benefit levels and services, and whose records and accounts are publicly audited. However, the criterion does not prevent the public authority from contracting out the services necessary for the administration of the provincial and territorial health care insurance plans, such as the processing of payments to physicians for insured health care services.

The public administration criterion pertains only to the administration of provincial and territorial health care insurance plans and does not preclude private facilities or providers from supplying insured health care services as long as no insured person is charged in relation to these insured health services.

2.0 Comprehensiveness (section 9)

The comprehensiveness criterion requires that the health care insurance plan of a province or territory must cover all insured health care services provided by hospitals, physicians or dentists (i.e., surgical-dental services that require a hospital setting).

3.0 Universality (section 10)

Under the universality criterion, all insured residents of a province or territory must be entitled to the insured health care services provided by the provincial or territorial health care insurance plan on uniform terms and con­ditions. Provinces and territories generally require that residents register with the plan to establish entitlement.

4.0 Portability (section 11)

Residents moving from one province or territory to an­other must continue to be covered for health care services insured by the home jurisdiction during any waiting period imposed by the new province or territory of residence (up to three months), before coverage is established in the new jurisdiction. It is the responsibility of residents to inform their province or territory’s health care insurance plan that they are leaving and to register with the health care insurance plan of their new province or territory, in order to avoid any gaps in coverage.

Residents who are temporarily absent from their home province or territory, or from Canada, must continue to be covered for insured health care services by their home province or territory. If insured persons are temporarily absent in another prov­ince or territory, the portability criterion requires that insured services be paid at the host province’s rate. If insured persons are temporarily out of the country, insured services are to be paid at the home province’s rate.

The portability criterion does not entitle a person to seek services in another province, territory, or country, but is intended to permit a person to receive medically necessary services in relation to an urgent or emergent need when absent on a temporary basis, such as on business or vacation.

Prior approval by the health care insurance plan in a person’s home province or territory may be required before coverage is extended for elective (non-emergency) services to a resident while temporarily absent from their province or territory.

5.0 Accessibility (section 12)

The intent of the accessibility criterion is to ensure that insured persons in a province or territory have reasonable access to insured hospital, medical, and surgical-dental services that require a hospital setting, on uniform terms and conditions, unprecluded or unimpeded, either directly or indirectly, by charges (extra-billing or user charges) or other means (e.g., dis­crimination on the basis of age, health status, or financial circumstances).

Reasonable access in terms of physical availability of medically necessary services has been interpreted under the Canada Health Act using the “where and as available” principle. Thus, residents of a province or territory are entitled to have access on uniform terms and condi­tions to insured health care services at the setting “where” the services are provided and “as” the services are available in that setting. For example, if a hospital in one region of a province was providing highly specialised services, that would not mean that all hospitals in the province would be required to provide the same service. Rather, it means that all residents of the province should have access to the service wherever it is being offered, on the same basis.

In addition, the health care insurance plan of the province or territory must provide:

The Conditions

1.0 Information (section 13[a])

The provincial and territorial governments are required to provide information to the federal Minister of Health as prescribed by regulations under the Act.

2.0 Recognition (section 13[b])

The provincial and territorial governments are required to recognize the federal financial contributions toward both insured and extended health care services.

The Provisions - Extra-Billing  and User Charges

The provisions of the Canada Health Act pertaining to extra-billing and user charges for insured health care services in a province or territory are outlined in sections 18 to 21. If it can be confirmed that either extra-billing or user charges exist in a province or territory, a mandatory dollar‑for‑dollar deduction from the CHT payments to that province or territory is required under the Act.

Extra-Billing (Section 18)

Under the Act, extra-billing is defined as a charge by an enrolled physician or dentist (i.e., a dentist providing insured surgical-dental services in a hospital setting) to an insured person for an insured service in addition to the amount paid by the provincial or territorial health care insurance plan. For example, if an enrolled physician was to charge a patient any amount for an office visit that is insured by the provincial or territorial health care insurance plan, the amount charged would constitute extra-billing. Extra-billing is seen as a barrier or impediment for people seeking medical care, and is therefore also contrary to the accessibility criterion.

User Charges (Section 19)

A user charge is defined as any charge for an insured health care service, other than extra-billing. This includes any charge levied for insured hospital services, or any non-physician related services provided in conjunction with an insured physician service at a non-hospital facility (e.g., private clinic or private practice).  In other words, if patients were charged a fee as a condition of receiving insured health care services, that fee would be considered a user charge. User charges are not permit­ted under the Act because, as is the case with extra-billing, they constitute a barrier or impediment to access.

What is a patient charge?

Figure

Text description
  • If an enrolled physician or dentist…
  • Charges an insured resident…
  • For an insured service…
  • An amount in addition to the amount paid by the provincial or territorial health insurance plan that…
  • is extra-billing.
  • Other charges (e.g., for supplies) related to the provision of insured health services…
  • Are user charges.

Other Elements of the Act

Regulations (Section 22)

Section 22 of the Canada Health Act enables the federal government to make regulations for administering the Act in the following areas:

To date, the only regulations in force under the Act are the Extra-billing and User Charges Information Regulations. These Regulations require the provinces and territories to report annually to Health Canada on the amounts of extra-billing and user charges levied. A copy of these Regulations is provided in Annex A.

Penalty Provisions of the Canada Health Act

Mandatory Penalty Provisions

Under the Act, provinces and territories that allow extra-billing and user charges are subject to mandatory dollar-for-dollar deductions from the federal transfer payments under the CHT. For example, if it is determined that any amount of extra-billing by physicians has occurred in a province or territory, the federal cash contribution to that province or territory will be reduced by that same amount. Although deductions are usually based on informa­tion provided by the province or territory in accordance with the Extra-billing and User Charges Information Regulations, where information is not provided, or is incomplete, Health Canada will make an estimate of the amount of extra-billing and user charges. This process requires consultation with the province or territory concerned. Deductions based on estimates have been made on numerous occasions.

Provincial and territorial financial statements of extra-billing and user charges received during the reporting period are provided in Annex D.

Discretionary Penalty Provisions

Non-compliance with one of the five criteria or two conditions of the Act is subject to a discretionary penalty. The amount of any deduction from CHT payments is based on the magnitude of the non-compliance, and is approved by Cabinet.

The Canada Health Act sets out a consultation process that must be undertaken with the province or territory before discretionary penalties can be levied. To date, the discretion­ary penalty provisions of the Act have not been used.

Excluded Services and Persons

Although the Canada Health Act requires that insured health care services be provided to insured persons in a manner that is consistent with the criteria and conditions set out in the Act, not all health care services or Canadian residents fall under the scope of the Act.

Excluded Services

A number of services provided by hospitals and physi­cians are not considered medically necessary, and thus are not insured under provincial and territorial health care insurance legislation. Uninsured hospital services for which patients may be charged include preferred hos­pital accommodation (unless prescribed by a physician or when standard ward level accommodation is unavailable), private duty nursing services, and the provision of tele­phones and televisions. Uninsured physician services for which patients may be charged include telephone advice (unless it is insured by the provincial or territorial health insurance plan); the provision of medical certificates required for work, school, insurance purposes and most other purposes; the transfer of medical records; testimony in court; and cosmetic services. Amounts for these services are governed by provincial and territorial Colleges of Physicians, which generally require that charges be reasonable and reflect the cost of services provided.

The definition of insured health services exclude services to persons provided under any other Act of Parliament (e.g., certain services provided to veterans) or under the workers’ compensation legislation of a province or territory.

In addition to the medically necessary hospital and physician services covered by the Canada Health Act, provinces and territories also provide a wide range of other programs and services, such as prescription drug coverage, non-surgical dental care, ambulance services and optometric services, at their discretion and on their own terms and conditions. These services are often targeted to specific population groups (e.g., seniors, children, and those receiving social assistance), with levels of funding and scope of coverage varying from one province or territory to another.

Excluded Persons

The Canada Health Act definition of “insured person” excludes members of the Canadian Forces and persons serving a term of imprisonment within a federal penitentiary. The Government of Canada provides coverage to these groups through separate federal programs.

The exclusion of these persons from insured health care service coverage predates the adoption of the Act and is not intended to constitute differences in access to publicly insured health care.

Policy Interpretation Letters

There are three key policy statements that clarify the federal position on the Canada Health Act. These state­ments were made in the form of ministerial letters from former federal Ministers of Health to their provincial and territorial counterparts, following months of consultation. Copies of the letters are provided in Annex B of this report.

Epp Letter

In June 1985, approximately one year following the passage of the Canada Health Act in Parliament, federal Minister of Health and Welfare Jake Epp wrote to his provincial and territorial counterparts to set out and confirm the federal position on the interpretation and implementation of the Act. The letter sets forth statements of federal policy intent that clarify the Act’s criteria, conditions and regulatory provi­sions. The letter highlighted the fundamental change signified by the Canada Health Act, which was the prohibition of all patient charges for insured services provided to insured residents.  The Epp letter remains an important reference for assessing and interpreting compliance with the Act.

Marleau Letter - Federal Policy on Private Clinics

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

At the September 1994 federal, provincial and territorial meeting of Health Ministers in Halifax, all Ministers of Health present, with the exception of Alberta’s Health Minister, agreed to “…take whatever steps are required to regulate the development of private clinics in Canada”.

Diane Marleau, the federal Minister of Health at the time, wrote to all provincial and territorial Ministers of Health on January 6, 1995, to announce the new Federal Policy on Private Clinics. The Minister’s letter provided the federal interpretation of the Canada Health Act as it relates to the issue of facility fees charged directly to patients receiving medically necessary services at private clinics. The letter stated that the definition of hospital contained in the Act includes any public facility that pro­vides acute, rehabilitative, or chronic care. Thus, when a provincial or territorial health care insurance plan pays the physician fee for a medically necessary service delivered at a private clinic, it must also pay the facility fee or face a deduction from federal transfer payments.

Petitpas Taylor Letter

On August 8, 2018, the former federal Health Minister Ginette Petitpas Taylor wrote to her provincial and territorial counterparts formalizing three new Canada Health Act initiatives – the Diagnostic Services Policy, the Reimbursement Policy, and strengthened Canada Health Act reporting. These initiatives were the subject of discussion at the federal, provincial and territorial officials’ level and adjustments were made to the requirements of these initiatives based on feedback received from the provinces and territories.

Diagnostic Services Policy

The Diagnostic Services Policy came into effect on April 1, 2020. This policy is a formalization of the application of the Canada Health Act to diagnostic services. It confirms the longstanding federal position that medically necessary diagnostic services are insured services, regardless of the venue where the services are delivered. Under this policy, provinces and territories will be expected to report on patient charges for medically necessary diagnostic services in December 2022 (for any patient charges which occurred during 2020-2021).

DID YOU KNOW? As of April 1, 2020 any patient charges for medically necessary diagnostic imaging services, such as MRI or CT scans, regardless of where these services are provided, are contrary to the Canada Health Act.  If you believe you have been charged inappropriately, you may report these charges to your provincial or territorial health ministry, using the phone numbers provided inside the back cover of this report.  You may also contact the Canada Health Act Division of Health Canada at the following coordinates:

Canada Health Act Division
A.L. 0908C Brooke Claxton Building
Ottawa, Ontario K1A 0K9

medicare_hc@hc-sc.gc.ca
Reimbursement Policy

Should a province or territory be subject to a mandatory deduction, the federal Minister of Health has the discretion to provide a reimbursement if the province or territory eliminates the patient charges that led to the deductions within a specified timeframe. The first deductions eligible for reimbursement under the policy were those taken in March 2018.

Strengthened Canada Health Act Reporting

The aim of strengthened Canada Health Act reporting is to ensure Health Canada has the information required to accurately assess compliance with the Act, as well as to increase transparency for Parliament and Canadians on the administration of the Act, and the state of the publicly funded health care insurance system.

Dispute Avoidance and Resolution Process

In April 2002, former federal Minister of Health A. Anne McLellan outlined in a letter to her provincial and territorial counterparts a Canada Health Act Dispute Avoidance and Resolution process, which was agreed to by provinces and territories, except Quebec. The process meets federal, provincial and territorial interests of avoiding disputes related to the interpretation of the criteria of the Act and, when this is not possible, resolving disputes in a fair, transparent, and timely manner.

The process includes the dispute avoidance activities of government-to-government information exchange; dis­cussions and clarification of issues as they arise; active participation of governments in ad hoc federal, provincial and territorial committees on Act-related issues; and Canada Health Act advance assessments of proposed provincial and territorial policies, regulations and legislation, upon request.

Where dispute avoidance activities prove unsuccessful, dis­pute resolution activities may be initiated, beginning with government-to-government fact-finding and negotiations. If these are unsuccessful, either Minister of Health involved may refer the issues to a third-party panel to undertake fact-finding and provide advice and recommendations.

The federal Minister of Health has the final authority to interpret and enforce the Canada Health Act. In de­ciding whether to invoke the non-compliance provisions of the Act, the Minister will take the panel's report into consideration.

A copy of Minister McLellan's letter is provided in Annex C of this report.

Chapter 2 - Administration and Compliance

Administration

In administering the Canada Health Act, the federal Minister of Health (the Minister) is assisted by Health Canada staff and by the Department of Justice.

The Canada Health Act Division

The Canada Health Act Division of Health Canada is responsible for supporting the Minister in the administration of the Canada Health Act. Members of the Division fulfill the following ongoing functions:

Canada Health Act Compliance

The Canada Health Act Division monitors the operations of provincial and territorial health care insurance plans in order to provide advice to the Minister on possible non-compliance with the Canada Health Act. Sources for this information include: provincial and territorial government officials and publications; non‑governmental organizations; media reports; and correspondence received from the public.

Staff in the Canada Health Act Division assess issues of concern and complaints on a case-by-case basis. The assessment process involves compiling all facts and information related to the issue and taking appropriate action. Verifying the facts with provincial and territorial health officials sometimes reveals issues that are not directly related to the Act, while others may pertain to the Act but are a result of misunderstanding or miscommunication, such as eligibility for health care insurance coverage and portability of health services within and outside Canada. In these instances, matters are generally resolved quickly with provincial or territorial assistance.

In instances where a Canada Health Act issue has been identified and remains after initial enquiries, Division officials ask the jurisdiction in question to investigate the matter and report back. Division staff discuss the issue and its possible resolution with provincial or territorial officials. Only if the issue is not resolved to the satisfaction of the Division after following the aforementioned steps, is it brought to the attention of the federal Minister of Health.

Deductions and Reimbursements under the Act

For the most part, provincial and territorial health care insurance plans meet the criteria and conditions of the Canada Health Act. However, some issues and concerns remain. The most prominent of these relate to accessibility issues, and specifically patient charges for medically necessary health services at private clinics. There are also concerns under the portability criterion.

Newfoundland and Labrador

On the basis of its health ministry's initial report to Health Canada, a deduction in the amount of $70,819 was taken from the March 2020 Canada Health Transfer (CHT) payments to Newfoundland and Labrador in respect of user charges for insured health services provided by an enrolled physician at a private ophthalmological clinic in fiscal year 2017-2018. Because the province had already worked collaboratively with Health Canada to create a mutually agreed-upon Reimbursement Action Plan (RAP) to eliminate these patient charges, and had carried out the plan by eliminating those charges, it received a reimbursement of both its March 2019 and March 2020 deductions. A copy of Newfoundland and Labrador's RAP as well the January 2020 status update on its implementation are presented in Annex E of this report.

New Brunswick

In New Brunswick, surgical abortion services are insured under the provincial health insurance plan but are only covered if performed in hospital; procedures provided in the now-closed private clinic in Fredericton were not covered. Health Canada has raised this issue with New Brunswick at the officials' level and Ministerial levels. The Minister wrote to her New Brunswick counterpart to communicate her concerns about the lack of coverage for abortion services outside hospital, in February 2020.

Although the province's financial statement of extra-billing and user charges for 2018-2019 indicated a nil amount, Health Canada had received evidence of these charges from the Fredericton clinic. On that basis, Health Canada estimated patient charges for fiscal year 2018-2019 in the amount of $140,216, and a deduction in the same amount was taken from New Brunswick's March 2020 CHT payments.

British Columbia

British Columbia submitted a financial statement of extra-billing and user charges during fiscal year 2017-2018, in the amount of $16,753,833. The amount was based on patient complaints, an audit of select clinics (undertaken in 2017 and 2018) and publicly available evidence of $4.7 million of patient charges to insured residents by enrolled physicians at the Cambie Surgical Centre.  A deduction in the same amount was taken from British Columbia's March 2020 CHT payments. British Columbia had already begun to implement elements of its RAP, which it drafted in collaboration with Health Canada after its March 2018 CHT deduction. The elimination of patient charges was hindered by an injunction related to the Charter challenge, known as Cambie Surgeries Corporation v. British Columbia (Attorney General), in the British Columbia Supreme Court. In recognition of the elements of the plan which were successfully implemented during the reporting period, Health Canada authorized a reimbursement of $16,019,539 in March 2020. This represents a partial reimbursement of BC's March 2018 and March 2019 deductions. A copy of the RAP and subsequent status updates are presented in Annex E of this report.

Additional Compliance Issues

Health Canada continues to monitor provincial and territorial compliance with the Act. The following key developments occurred since the 2018-2019 Canada Health Act Annual Report was tabled in Parliament.

Abortion Services

Abortion services are insured in all provinces and territories; however, access to abortion services varies within and between jurisdictions across the country. In addition to the coverage issues in New Brunswick, described earlier in this section, media stories in Ontario have highlighted fees some individuals have been charged to access surgical abortion services in private clinics. Health Canada has learned that while the Ontario Health Insurance Plan provides coverage for physicians' fees related to abortion services in all private clinics, it only covers facility fees in the four private abortion clinics authorized under the province's Independent Health Facilities Act. Health Canada continues to consult with the Ontario health ministry to determine the extent of these patient charges.

Out-of-Country Portability

In April 2019, Ontario announced that it would end its program covering emergency hospital and physician services received by Ontario residents while outside Canada. The province officially eliminated this coverage on January 1, 2020. This was a direct contravention of the Canada Health Act's requirement that provincial and territorial health care insurance plans provide coverage to residents while outside the country. While Health Canada had long been concerned by the coverage levels in some provinces – only Prince Edward Island and the territories appear to be meeting this requirement – Ontario was the first province to eliminate coverage altogether. Its decision to terminate this coverage was overturned in September 2020, as a result of a legal challenge by the Canadian Snowbirds Association. In November 2020, the federal Minister of Health wrote to Ontario, which had initially indicated it planned to appeal this decision, to reiterate that the CHA requires provincial and territorial health insurance plans to provide coverage for Canadians when they are outside Canada.  On November 13, 2020, Ontario abandoned its appeal.

Patient Charges for Medically Necessary Diagnostic Services

As mentioned earlier in this report, in August 2018, the federal Minister of Health wrote to her provincial and territorial counterparts to announce the Diagnostic Services Policy, which formalized the longstanding federal position that medically necessary diagnostic services received in private clinics are considered insured health services. While Saskatchewan is the only province that expressly encourages this practice through legislation, there is evidence of residents paying out-of-pocket to secure faster access to diagnostic services in other provinces, including British Columbia, Alberta, Manitoba, Quebec, New Brunswick, and Nova Scotia. To give jurisdictions time to align their health care systems with the requirements of this policy, the effective date was set for April 1, 2020. Now that the policy is in effect, provinces and territories that permit patients to be charged for these services will be subject to deductions from federal transfers under the Canada Health Act. Provinces and territories will first report on these charges in December 2022. During the reporting period, Health Canada consulted with provinces and territories to offer assistance in preparation for the policy's implementation.

Patient Charges in Primary Health Care Co-Ops

In May 2019, a village in Nova Scotia announced its intent to open a health care co-operative, where patients would be required to purchase a membership and pay monthly dues to receive insured health services. Patient charges, as a condition of receiving insured health services, pose extra-billing and user charges concerns under the Canada Health Act. Health Canada communicated these concerns to the Nova Scotia health ministry, which then conducted an investigation. In follow-up, Nova Scotia reported to Health Canada that the village did not pursue its plans for this co-op. Health Canada considers this issue to be resolved.

During 2019-2020, Health Canada continued to monitor the following ongoing compliance and interpretation issue:

In-Country Portability

Physician services received by Quebec residents when out-of-province are not reimbursed at host province rates, which is a requirement of the portability criterion of the Act. Canadians from provinces and territories other than Quebec also report difficulties having their provincial or territorial health care insurance cards honoured while out-of-province, particularly by walk-in clinics, which runs counter to the spirit of the Act.

History of Deductions, Refunds and Reimbursements under the Canada Health Act

The Canada Health Act, which came into force April 17, 1984, reaffirmed the national commitment to the original principles of the Canadian health care system, as embodied in the previous legislation, the Medical Care Act and the Hospital Insurance and Diagnostic Services Act. By putting into place mandatory dollar-for-dollar penalties for extra-billing and user charges, the federal government took steps to eliminate the proliferation of direct charges for hospital and physician services, judged to be restricting the access of many Canadians to health care services due to financial considerations.

Canada Health Act Compliance from 1984-1987

During the period 1984 to 1987, subsection 20(5) of the Act provided for deductions in respect of these charges to be refunded to the province if the charges were eliminated before April 1, 1987. By March 31, 1987, it was determined that all provinces in which patients had been subject to extra-billing and user charges had taken appropriate steps to eliminate them. Accordingly, by June 1987, a total of $244,732,000 in deductions was refunded to New Brunswick, Quebec, Ontario, Manitoba, Saskatchewan, Alberta, and British Columbia.

Deductions and Subsequent Refunds for Extra-Billing and User Charges from 1984-1987
  1984-1985 1985-1986 1986-1987 Total
NB 3,078,000 3,306,000 502,000 6,886,000
QC 7,893,000 6,139,000 - 14,032,000
ON 39,996,000 53,328,000 13,332,000 106,656,000
MB 810,000 460,000 - 1,270,000
SK 1,451,000 656,000 - 2,107,000
AB 9,936,000 11,856,000 7,240,000 29,032,000
BC 22,797,000 30,620,000 31,332,000 84,749,000
TOTAL 85,961,000 106,365,000 52,406,000 244,732,000

In the first three years after the enactment of the Canada Health Act, almost $245 million in deductions were taken against federal health transfers to provinces, these deductions were refunded when the provinces effectively eliminated the patient charges that led to them.

Canada Health Act Compliance from 1987-2017

Following the Act's initial three-year transition period, during which refunds to provinces and territories for deductions were possible, penalties under the Act did not reoccur until fiscal year 1994-1995. See the chart later in this chapter for penalties occurring from fiscal year 1994-1995 to 2017.

In January 1995, federal Minister of Health, Diane Marleau, expressed concerns to her provincial and territorial colleagues about the development of two-tiered health care and the emergence of private clinics charging facility fees for medically necessary surgical services. As part of her communication with the provinces and territories, Minister Marleau announced that the provinces and territories would be given more than nine months to eliminate these user charges, but that any province that did not, would face financial penalties under the Act. Accordingly, beginning in November 1995, deductions were applied to the cash contributions to Alberta, Manitoba, Nova Scotia, and Newfoundland and Labrador for non-compliance with the Federal Policy on Private Clinics.

British Columbia

In the early 1990s, as a result of a dispute between the British Columbia Medical Association and the British Columbia government over compensation, several doctors opted out of the provincial health care insurance plan and began billing their patients directly. Some of these doctors billed their patients at a rate greater than the amount the patients could recover from the provincial health care insurance plan. This higher amount constituted extra-billing under the Act. Deductions began in May 1994, relating to fiscal year 1992-1993, and continued until extra-billing by physicians was banned when changes to British Columbia's Medicare Protection Act came into effect in September 1995. In total, $2,025,000 was deducted from British Columbia's cash contribution for extra-billing that occurred in the province between 1992-1993 and 1995-1996.

In January 2003, British Columbia provided a financial statement in accordance with the Canada Health Act Extra-billing and User Charges Information Regulations, indicating aggregate amounts actually charged with respect to extra-billing and user charges in private surgical clinics during fiscal year 2000 -2001, totaling $4,610. Accordingly, a deduction of $4,610 was made to the March 2003 Canada Health and Social Transfer (CHST) cash contribution.

In 2004, British Columbia did not report to Health Canada the amounts of extra-billing and user charges actually charged during fiscal year 2001-2002. As a result of reports that British Columbia was investigating 55 cases of user charges, a $126,775 deduction was taken from British Columbia's March 2004 CHST payment, based on the amount the federal Minister estimated to have been charged during fiscal year 2001-2002.

Between 2002-2003 and 2016-2017, deductions totaling $1,773,183 were taken from British Columbia's Canada Health Transfer payments in light of patient charges reported by the province to Health Canada.  The deduction taken to British Columbia's federal health transfers in 2012-2013, in respect of fiscal year 2010-2011, was estimated by the federal Minister of Health and represents the aggregate of the amounts reported to Health Canada by British Columbia and those reported publicly as the result of an audit performed by the Medical Services Commission of British Columbia. This methodology was used until fiscal year 2016-2017.

Alberta

Under the Federal Policy on Private Clinics, total deductions of $3,585,000 were made, from November 1995 until June 1996, to Alberta's cash contribution in respect of facility fees charged at clinics providing surgical, ophthalmological and abortion services. On October 1, 1996, Alberta prohibited private surgical clinics from charging patients a facility fee for medically necessary services for which the physician fee was billed to the provincial health care insurance plan.

Manitoba

From November 1995 to December 1998, deductions totaling $2,055,000 were taken from Manitoba's federal health transfer, under the Federal Policy on Private Clinics. These deductions ended with the confirmed elimination of user charges at surgical and ophthalmology clinics, effective January 1, 1999. However, during fiscal year 2001-2002, a monthly deduction (from October 2001 to March 2002 inclusive) in the amount of $50,034 was levied against Manitoba's CHST cash contribution on the basis of a financial statement provided by the province showing that actual amounts charged with respect to user charges for insured health services in fiscal years 1997-1998 and 1998-1999 were greater than the deductions levied on the basis of estimates. This brought total deductions levied against Manitoba to $2,355,201.

Quebec

In March 2017, on the basis of amounts of extra-billing and user charges reported by the Quebec Auditor General with respect to accessory fees charged in 2014-2015, the federal Minister estimated a deduction amount of $9,907,229. In light of corrective action the provincial government had already taken to eliminate accessory fees in January 2017, that amount was subsequently returned to Quebec by the Government of Canada.

Nova Scotia

With the closure of a private clinic in Halifax effective November 27, 2003, penalties to Nova Scotia for non-compliance with the Federal Policy on Private Clinics ceased. Before it closed, total deductions of $372,135 were made to Nova Scotia's CHST cash contribution for its failure to cover facility charges to patients, while paying the physician fee. A final deduction of $5,463 was taken from the March 2005 CHT payment to Nova Scotia as a reconciliation of deductions that had already been taken for 2002‑2003. A one-time positive adjustment in the amount of $8,121 was made to Nova Scotia's March 2006 CHT payment to reconcile amounts actually charged in respect of extra-billing and user charges with the penalties that had already been levied based on provincial estimates reported for fiscal 2003‑2004.

The March 2007 CHT payment to Nova Scotia was reduced by $9,460 in respect of extra-billing during fiscal year 2004‑2005. This amount was reported to Health Canada by the province based on the findings of an audit, concluded in 2006, of the billing practices of a Nova Scotia physician.

Newfoundland and Labrador

Pursuant to the Federal Policy on Private Clinics, a total of $280,430 was deducted from Newfoundland and Labrador's cash contribution due to facility fees in a private abortion clinic, before these fees were eliminated, effective January 1, 1998.

A deduction of $1,100 was taken from the March 2005 CHT payment to Newfoundland and Labrador as a result of patient charges for an MRI scan in a hospital which occurred during 2002-2003.

From March 2011 to March 2013, deductions totaling $102,249 were taken from CHT payments to Newfoundland and Labrador for extra-billing and user charges, based on charges reported by the province to Health Canada. These charges resulted from services provided by an opted-out dental surgeon who has since left the province and Health Canada considers this matter resolved.

Since the passage of the Act, from April 1984 to March 2020, deductions totaling $87,576,876 have been taken from transfer payments in respect of the extra-billing and user charges provisions of the Act. This amount excludes deductions totaling $244,732,000 that were made between 1984 and 1987, and subsequently refunded to the provinces when extra-billing and user charges were eliminated.

Deductions and Reconciliations to CHST/CHT Cash Contributions in Accordance with the Canada Health Act (in dollars) – 1994-1995 to 2016-2017
  NL PE NS NB QC ON MB SK AB BC YT NT NU Total
1994/95 - - - - - - - - - 1,982,000 - - - 1,982,000
1995/96 46,000 - 32,000 - - - 269,000 - 2,319,000 43,000 - - - 2,709,000
1996/97 96,000 - 72,000 - - - 588,000 - 1,266,000 - - - - 2,022,000
1997/98 128,000 - 57,000 - - - 586,000 - - - - - - 771,000
1998/99 53,000 - 38,950 - - - 612,000 - - - - - - 703,950
1999/00 (42,570) - 61,110 - - - - - - - - - - 18,540
2000/01 - - 57,804 - - - - - - - - - - 57,804
2001/02 - - 35,100 - - - 300,201 - - - - - - 335,301
2002/03 - - 11,052 - - - - - - 4,610 - - - 15,662
2003/04 - - 7,119 - - - - - - 126,775 - - - 133,894
2004/05 1,100 - 5,463 - - - - - - 72,464 - - - 79,027
2005/06 - - (8,121) - - - - - - 29,019 - - - 20,898
2006/07 - - 9,460 - - - - - - 114,850 - - - 124,310
2007/08 - - - - - - - - - 42,113 - - - 42,113
2008/09 - - - - - - - - - 66,195 - - - 66,195
2009/10 - - - - - - - - - 73,925 - - - 73,925
2010/11 3,577 - - - - - - - - 75,136 - - - 78,713
2011/12 58,679 - - - - - - - - 33,219 - - - 91,898
2012/13 50,758 - - - - - - - - 280,019 - - - 330,777
2013/14 (10,765) - - - - - - - - 224,568 - - - 213,803
2014/15 - - - - - - - - - 241,637 - - - 241,637
2015/16 - - - - - - - - - 204,145 - - - 204,145
2016/17 - - - - 9,907,229Table 2 Footnote a - - - - 184,508 - - - 10,091,737
Table 2 Footnote a

This amount was subsequently refunded to the province in light of corrective actions the provincial government had already taken to address the issue of accessory fees at the time of the deduction.

Table 2 Return to footnote a referrer

Understanding This Chart

Canada Health Act Compliance from 2018-Present

As described earlier, the Canada Health Act Reimbursement Policy came into effect in 2018, to provide a positive incentive for provinces and territories to come into compliance, should they be subject to mandatory penalties as a result of patient charges for insured health services. The federal Minister of Health now has the discretion to provide a reimbursement if the province or territory eliminates those charges within a specified timeframe. The first deductions eligible for reimbursement under the policy were those taken in March 2018.

British Columbia

Following collaborative work with Health Canada on an audit project to determine the extent and scope of patient charges in the province, a deduction of $15,861,818 was taken in March 2018 in respect of patient charges during fiscal year 2015-2016. This deduction reflected audit results, patient complaints, and publicly available evidence of $4.7 million of patient charges to insured residents by enrolled physicians at the Cambie Surgery Centre. A similar methodology was used to calculate the province's Canada Health Transfer deductions in March 2019 ($16,177,259) and March 2020 ($16,753,833). 

Following the implementation of the Canada Health Act Reimbursement Policy in 2018, British Columbia consulted with Health Canada on a Reimbursement Action Plan to eliminate patient charges. Because the province successfully carried out some elements of that plan, the province received a partial reimbursement of its March 2018 and March 2019 deductions, in the amount of $16,019,539, in March 2020.

Quebec

In March 2018, using the amount of extra-billing and user charges reported by the Quebec Auditor General with respect to accessory fees charged in 2014-2015 as a proxy, the federal Minister estimated a deduction amount of $9,907,229. In light of corrective action the provincial government had already taken to eliminate accessory fees in January 2017, this amount was subsequently returned to Quebec by the Government of Canada. This reimbursement pre-dated the Reimbursement Policy. Quebec's March 2017 and March 2018 deductions, which, due to Canada Health Act reporting timelines, were taken after patient charges had already been eliminated by the provincial government, served as the inspiration for the Reimbursement Policy.

A further deduction of $8,256,024 was taken to Quebec's March 2019 federal health transfer, reflecting patient charges which had occurred prior to the corrective action taken by Quebec and was immediately reimbursed. This reimbursement was the first made under the Reimbursement Policy.

New Brunswick

In March 2020, on the basis of evidence of patient charges during 2017-2018, a deduction of $140,216 was taken to New Brunswick's Canada Health Transfer payments.

Newfoundland and Labrador

In March 2019, a deduction of $1,349 was taken from CHT payments to Newfoundland and Labrador for extra‑billing and user charges, based on patient charges for insured health services at a private ophthalmological clinic that occurred in 2016-2017, reported by the province to Health Canada.  Similarly, a deduction of $70,819 was taken in March 2020 in respect of charges in this clinic during 2017-2018. 

After its March 2019 deduction, Newfoundland and Labrador consulted with Health Canada on a Reimbursement Action Plan to eliminate patient charges. Because the province successfully carried out that plan, and eliminated these patient charges, the province received a reimbursement of its March 2019 deduction, as well as an immediate reimbursement of its March 2020 deduction.

  2017-2018 2018-2019 2019-2020
Deduction Deduction Reimbursement Deduction Reimbursement
NL - 1,349 - 70,819 72,168
NB - - - 140,216 -
QC 9,907,229Table 3 Footnote a 8,256,024 8,256,024 - -
BC 15,861,818 16,177,259 - 16,753,833 16,019,539Table 3 Footnote b
Table 3 Footnote a

This amount was subsequently refunded to the province in light of corrective actions the provincial government had already taken to address the issue of accessory fees at the time of the deduction.

Table 3 Return to footnote a referrer

Table 3 Footnote b

This amount represents a partial reimbursement of British Columbia's March 2018 (50%) and March 2019 (50%) deductions and was issued based on the elements of the province's Reimbursement Action Plan that were successfully carried out.

Table 3 Return to footnote b referrer

Since the Canada Health Act Reimbursement Policy came into effect, $24,347,731 has been reimbursed to provinces, in recognition of their efforts to eliminate patient charges for insured health services.

Interprovincial Health Insurance Agreements Coordinating Committee

The Interprovincial Health Insurance Agreements Coordinating Committee (IHIACC) was formed in 1991 to address issues affecting the interprovincial billing of insured hospital and physician services. The Committee includes members from each province and territory and a non-voting chair from the Canada Health Act Division. The Canada Health Act Division also provides secretariat functions for IHIACC.

All provinces and territories participate in hospital reciprocal billing agreements, and all, with the exception of Quebec, participate in physician reciprocal billing agreements. These agreements generally ensure that a patient's health care insurance card will be accepted, in lieu of payment, when the patient receives insured hospital or physician services in another province or territory. The province or territory providing the service will then directly bill the patient's home province at agreed-upon rates. The intent of these agreements is to ensure that Canadian residents do not have to pay directly for medically necessary hospital and physician services when they travel within Canada. Of note, these agreements are interprovincial, not federal, and while they facilitate the portability criterion, they are not a requirement of the Act.

On April 1, 2019, IHIACC implemented a new Reciprocal Billing model that allows provinces and territories to more accurately recover the costs of high-cost organ transplant services provided to out-of-province/territory residents. During the early stages of the COVID-19 pandemic response, IHIACC suspended its normal work to serve as an information coordinating body for interprovincial and out-of-Canada health care coverage.  

The Interprovincial Health Insurance Agreements Coordinating Committee's Rate Review Working Group is responsible for determining reciprocal billing rates to ensure that the host province or territory providing the health service is compensated by the home province at a reasonable rate.

Issues related to registration and eligibility requirements are addressed through IHIACC's Eligibility and Portability Agreement Working Group, which is responsible for reviewing eligibility issues and identifying potential inter-jurisdictional gaps in health care coverage.

The Policy Research Working Group examines policy-related issues that impede coverage of insured health services with the aim of increasing the consistency and coordination of interprovincial health care coverage and billing practices.

Chapter 3 - Provincial and Territorial Health Care Insurance Plans In 2019–2020

The following chapter presents the 13 provincial and territorial health care insurance plans that make up the Canadian publicly funded health insurance system. The purpose of this chapter is to demonstrate clearly and consistently the extent to which provincial and territorial plans fulfilled the requirements of the Canada Health Act program criteria and conditions in 2019–2020.

Officials in the provincial, territorial and federal governments have collaborated to produce the detailed plan overviews contained in Chapter 3. The information that Health Canada requested from the provincial and territorial departments of health for the report consists of two components:

The narrative component is used to help with the monitoring and compliance of provincial and territorial health care insurance plans with respect to the requirements of the Act, while statistics help to identify current and future trends in the Canadian health care system. While all provinces and territories have submitted detailed descriptive information on their health care insurance plans, Quebec chose not to submit supplemental statistical information which is contained in the tables in this year's report.

To help provinces and territories prepare their submissions to the annual report, Health Canada provided them with the document; Canada Health Act Annual Report 2019–2020: A Guide for Updating Submissions (User's Guide). The User's Guide is designed to help provinces and territories meet Health Canada's reporting requirements. Annual revisions to the guide are based on Health Canada's analysis of health care insurance plan descriptions from previous annual reports and its assessment of emerging issues relating to insured health services.

The process for the Canada Health Act Annual Report 2019–2020 was launched summer 2020 with bilateral teleconferences. An updated User's Guide was also sent to the provinces and territories at that time.

Insurance Plan Descriptions

For the following chapter, provincial and territorial officials were asked to provide a narrative description of their health care insurance plan. The descriptions follow the program criteria areas of the Canada Health Act in order to illustrate how the plans satisfy these criteria. This narrative format also allows each jurisdiction to indicate how it met the Canada Health Act requirement for the recognition of federal contributions that support insured and extended health care services. This year, provinces and territories were invited to describe the efforts they undertook during the reporting period with respect to coverage and care during the COVID-19 pandemic, which routinely exceeded the requirements of the Canada Health Act.

Key Definitions Provided to Provinces and Territories to Guide their Submissions to this Report

Participating Physician or Dentist is a licensed physician or dentist who is enrolled in a provincial or territorial health care insurance plan.

Non-Participating Physician or Dentist practises completely outside a provincial or territorial health care insurance plan. Neither the physician or dentist nor the patient is eligible for any cost coverage for services rendered or received from the provincial or territorial health care insurance plans. A non-participating physician or dentist may therefore establish their own fees, which are paid directly by the patient.

Opted-out Physician or Dentist is a physician or dentist who is enrolled in the provincial or territorial health insurance plan but has voluntarily opted out of the plan and will therefore bill their patients directly. These charges can be up to, but not more than, the provincial or territorial amount allowed under the fee schedule agreement. The provincial or territorial plans reimburse patients of opted-out physicians or dentists for these charges.

Provincial and Territorial Health Care Insurance Plan Statistics

Over time, the section of the annual report containing the statistical information submitted from the provinces and territories has been simplified and streamlined based on feedback received from provincial and territorial officials, and based on reviews of data quality and availability. The supplemental statistical information tables can be found at the end of each provincial or territorial narrative, except for Quebec.

The purpose of the statistical tables is to place the administration and operation of the Canada Health Act in context and to provide a national perspective on trends in the delivery and funding of insured health services in Canada that are within the scope of the Act.

The statistical tables contain resource and cost data for insured hospital, physician and surgical-dental services by province and territory for five consecutive years ending on March 31, 2020. All information was provided by provincial and territorial officials.

Although efforts are made to capture data on a consistent basis, differences exist in the reporting on health care programs and services between provincial and territorial governments. Therefore, comparisons between jurisdictions are not made. Provincial and territorial governments are responsible for the quality and completeness of the data they provide.

Organization of the Information

Information in the statistical tables is grouped according to the nine subcategories described below.

Registered Persons: Registered persons are the number of residents registered with the health care insurance plans of each province or territory.

Insured Hospital Services within Own Province or Territory: Statistics in this sub-section relate to the provision of insured hospital services to residents in each province or territory, as well as to visitors from other regions of Canada.

Insured Hospital Services Provided to Residents in Another Province or Territory: This sub-section presents out-of-province or out-of-territory insured hospital services that are paid for by a person's home jurisdiction when they travel to other parts of Canada.

Insured Hospital Services Provided Outside Canada: This represents residents' hospital costs incurred while travelling outside of Canada that are paid for by their home province or territory.

Insured Physician Services within Own Province or Territory: Statistics in this sub-section relate to the provision of insured physician services to residents in each province or territory, as well as to visitors from other regions of Canada.

Insured Physician Services Provided to Residents in Another Province or Territory: This sub-section reports on physician services that are paid by a jurisdiction to other provinces or territories for their visiting residents.

Insured Physician Services Provided Outside Canada: This represents residents' medical costs incurred while travelling outside of Canada that are paid by their home province or territory.

Insured Surgical-Dental Services within Own Province or Territory: The information in this subsection describes insured surgical-dental services provided in each province or territory.

Newfoundland and Labrador

The Department of Health and Community Services (the department) is responsible for setting the overall strategic directions and priorities for the health and community services system throughout Newfoundland and Labrador.

The department works with stakeholders to develop and enhance policies, legislation, provincial standards and strategies to support individuals, families and communities to achieve optimal health and well-being. The department provides a lead role in policy, planning, program development, and support to the four Regional Health Authorities (RHAs). The department also works with stakeholders to ensure that high quality, cost effective and timely health services are available for all Newfoundlanders and Labradorians.

The department provides leadership, coordination, monitoring and support to the RHAs, which deliver the majority of publicly funded health services in the province, as well as to other entities that deliver programs and services. This ensures quality, efficiency, and effectiveness in areas such as the administration of health care facilities; access and clinical efficiency; programs for seniors, persons with disabilities and persons with mental health and addictions issues as well as long-term care and community support services; health professional education and training programs; the control, possession, handling, keeping and sale of food and drugs; the preservation and promotion of health; the prevention and control of disease; and public health and the enforcement of public health standards.

With an annual budget of approximately $3 billion, the department accounts for approximately 39 per cent of Newfoundland and Labrador’s total budget. In Budget 2019-2020, funding was provided for various programs and initiatives to make significant improvements to mental health and addictions, home and community care, and primary health care. Included in this was $8.9 million to start construction in spring 2019 on a new adult mental health and addictions facility and expand community-based supports province-wide. An overview of initiatives from the 2019-2020 Budget is available.

In Newfoundland and Labrador, health services are provided to more than 520,000 residents by approximately 32,400 people in the health and community services sector. Of this total, approximately 19,000 people are employed by the four RHAs and approximately 210 people are employed by the Department of Health and Community Services.

The purpose of this report is to clearly describe how Newfoundland and Labrador fulfilled the requirements of the Canada Health Act program criteria, conditions and provisions in 2019-2020.

COVID-19 Measures

Changes to the Medical Care Plan

In response to the COVID-19 pandemic, in March 2020, the department announced that the cost of screening and treatment of any COVID-19 related symptoms or conditions, including hospitalization, would be provided to individuals residing in the province who did not otherwise meet the criteria for Medical Care Plan (MCP) registration. Due to the possibility of delays in receiving documentation resulting from the pandemic, the department also extended MCP coverage for individuals whose cards would expire in the short term. An initial extension was made to June 30, 2020 for all beneficiaries whose cards expired as of March 1, 2020 and a further extension was made to September 30, 2020 for international students and workers who met established criteria.

Virtual Care

A Pandemic Virtual Care fee code for Fee for Service (FFS) physicians was introduced on March 25, 2020 to allow for appointments via virtual care methods (telephone or video conference). This expansion of virtual care services enabled greater access for patients while abiding by the social distancing advisory and provided for a safer workplace for staff and physicians in health care clinics. This service remains in effect. To account for loss of income due to restrictions on visits to medical offices, a Work Disruption policy was introduced for FFS physicians which guaranteed 80 per cent payment for physicians for a 111-day period from March 18 to July 6, 2020, based on their previous claims in the preceding 26-week period. Physicians who provided “additional services”, as defined in the policy, qualified for a 100 per cent top-up, for the duration of their “additional services”. As of June 11, 2020, the capability for virtual appointments with nurse practitioners for urgent, non-emergency health issues via telephone, text or video was implemented. A Virtual Care fee code was introduced for medical consultants as well, covering the period from July 7 to October 1, 2020, but it has since been extended and remains indefinite for the time being.

1.0 Public Administration

1.1 Health Care Insurance Plan and Public Authority

Health care insurance plans managed by the department include the Medical Care Plan (MCP) and the Hospital Insurance Plan (HIP). Both plans are non-profit and publicly administered.

The Medical Care and Hospital Insurance Act came into force on October 1, 2016, replacing both the Medical Care Insurance Act, 1999, and the Hospital Insurance Agreement Act. The Medical Care and Hospital Insurance Act (the Act) can be viewed on the Newfoundland and Labrador House of Assembly website.

As per section 5 of the Act, the Minister of Health and Community Services is required to administer a plan of medical care and hospital insurance for residents of the province. The Act provides authority to make regulations defining who is a resident, prescribing which services are insured services and under what circumstances insured services shall be paid by the minister.

The MCP facilitates the delivery of comprehensive medical care to all residents of the province by implementing policies, procedures and systems that permit appropriate compensation to providers for rendering insured professional services.

The HIP covers insured hospital services received within the province when recommended by a medical practitioner. Eligibility for coverage under the plan is linked with eligibility for the MCP. All beneficiaries of the MCP are automatically entitled to coverage under the HIP.

Both the HIP and the MCP operate in accordance with the provisions of the Medical Care and Hospital Insurance Act and related regulations, and in compliance with the Canada Health Act.

On November 4, 2019, an amendment was made to Section 4 of the Medical Care Insurance Insured Services Regulations which removed paragraph 4.(i)(v) “sex reassignment surgery, when not recommended by the Clarke Institute of Psychiatry” from the list of uninsured services. The effect of the amendment is to remove the requirement for an out-of-province assessment by the Clarke Institute of Psychiatry before proceeding with transition-related surgeries. As a result, assessments can now take place within the province.

1.2 Reporting Relationship

The department is mandated with administering the HIP and the MCP under section 5 of the Medical Care and Hospital Insurance Act. The department reports on these plans through the regular legislative processes, as well as through other public reporting mechanisms (e.g., Public Accounts and the Social Services Committee of the House of Assembly).

The Government of Newfoundland and Labrador has a provincial planning and reporting requirement for all government departments, including the Department of Health and Community Services. Under the Transparency and Accountability Act, the Department of Health and Community Services and the 10 other entities that report to the minister, including the RHAs, produce a strategic plan once every three years and report annually on their performance. Plans and reports are tabled in the House of Assembly and posted on the department’s website.

The 2019-2020 Department of Health and Community Services annual report has not yet been tabled in the House of Assembly.

1.3 Audit of Accounts

Each year, the province’s Auditor General independently examines provincial Public Accounts. MCP expenditures are considered a part of the Public Accounts. While respecting privacy and personal information, the Auditor General has full and unrestricted access to code-based records of the MCP. There were no Auditor General reviews of the department’s programs, services, or MCP expenditures in 2019–2020. The most recent comprehensive audit was a review of the Newfoundland and Labrador Prescription Drug Program (NLPDP) in June 2015.

Specific program reviews are executed in accordance with the Office of the Auditor General plan, which is largely driven by risk. In the planning stages of an audit, the department would be notified by receipt of an engagement letter from the Office of the Auditor General, advising that an audit is being planned and requesting any necessary arrangements to execute it. Therefore, it is not known whether an audit will occur in 2020-21.

The four RHAs are subject to financial statement audits, reviews and compliance audits. Financial statement audits are performed by independent auditing firms that are selected by each RHA. Review engagements are conducted using the Generally Accepted Auditing Standards of the Canadian Institute of Chartered Accountants. Various compliance and physician audits are carried out by personnel from the department under the authority of the Medical Care and Hospital Insurance Act.

Physician records and professional medical corporation records are reviewed to ensure that the records support the services billed and that the services are insured under the MCP. Beneficiary audits are performed by personnel from the department under the Medical Care and Hospital Insurance Act.

The Auditor General’s Report is submitted annually on or before January 31 and is found online.

2.0 Comprehensiveness

2.1 Insured Hospital Services

As of March 31, 2020, the Medical Care and Hospital Insurance Act and the Hospital Insurance Regulations provided for insured hospital services in Newfoundland and Labrador. No amendments were made to the Act during this current reporting period. All the hospital services as defined under the Canada Health Act are insured services in Newfoundland and Labrador.

Insured hospital services are provided for in-patients and out-patients in 15 hospitals, 23 community health centres and 65 community clinics throughout the province. This number remained constant in 2019-2020. As indicated in the statistics table, the change in the number of clinics in 2016-2017 reflects a change in how the department classifies public health facilities. Hospital insured services include:

There were no new services added to the schedule of insured hospital services during 2019-2020.

The coverage policy for insured hospital services is linked to the coverage policy for insured medical services. The department manages the process of adding or de-listing a hospital service from the list of insured services based on direction from the Lieutenant-Governor in Council. Public consultation is not a requirement for de-listing a service.

Currently, Newfoundland and Labrador does not have any private diagnostic clinics that charge patients for services that would be considered insured if provided in a hospital.

2.2 Insured Physician Services

As of March 31, 2020, the enabling legislation for insured physician services was the Medical Care and Hospital Insurance Act and the relevant regulations continued thereunder, which included the:

On November 4, 2019, an amendment was made to section 4 of the Medical Care Insurance Insured Services Regulations which removed paragraph 4.(i)(v) “sex reassignment surgery, when not recommended by the Clarke Institute of Psychiatry” from the list of uninsured services. Health care professionals in Newfoundland and Labrador meeting minimum credentials as established by the World Professional Association for Transgender Health (WPATH) Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People Version 7 (2012) can now perform surgical readiness assessments for transgender patients requiring transition-related surgery.

In 2019-2020 (as of March 31, 2020) there were 1,307 physicians (salaried and FFS) active in practice in the province.

For purposes of the Act, the following services are covered:

In 2019-2020, surgical readiness assessments performed by Newfoundland and Labrador physicians were added to the list of insured physician services. No further services were added.

The Medical Care Insurance Insured Services Regulations also lists specific services which are not insured under the MCP; these include:Footnote 1

Physicians can choose not to participate in the health care insurance plan as outlined in section 8 of the Medical Care and Hospital Insurance Act, namely:

As of March 31, 2020, no physicians had opted-out of the MCP.

Lieutenant-Governor in Council approval is required to add to or to de-insure a physician service from the list of insured services. This process is managed by the department in consultation with various stakeholders. Public consultation is not a specific requirement.

2.3 Insured Surgical-Dental Services

The provincial Surgical-Dental Program is a component of the MCP. Surgical-dental treatments provided to a beneficiary and carried out in a hospital by a licensed oral surgeon or dentist are covered by the MCP if the treatment is specified in the Surgical-Dental Services Schedule.

The Surgical Dental Program provides insured services under the Medical Care and Hospital Insurance Act. An insured service is defined as one that is:

  1. Listed in paragraph 3(1)(b)Footnote 2 of the Medical Care Insured Services Regulations
  2. Medically necessary. The clinical need of the provision and claim of an insured service may be evaluated by the Dental Monitoring Committee of MCP.

Policies on pre-existing conditions necessary to define 'medical necessity' must exist for the specific services to qualify as MCP insured services.Footnote 3

There were 17 dentists/oral surgeons providing insured services under the Surgical-Dental Program as of March 31, 2020.

Dentists/oral surgeons may opt out of the MCP as per section 8 of the Medical Care and Hospital Insurance Act referenced above. These dentists/oral surgeons must advise the patient of their opted-out status, state the fees expected and provide the patient with a written record of services and fees charged. As of March 31, 2020, there were no opted-out dentists. There was no extra-billing in 2019-2020.

Because the Surgical-Dental Program is a component of the MCP, management of the program is linked to the MCP process regarding changes to the list of insured services.

Any addition of a surgical-dental service to the list of insured services must be approved by the Minister of Health and Community Services. There were no new services added to the list/schedule of insured surgical-dental services in 2019-20.

2.4 Uninsured Hospital, Physician and Surgical-Dental Services

Hospital services not covered by the MCP include:

The use of the hospital setting for any services deemed uninsured by the MCP are also uninsured under the Hospital Insurance Plan.

For purposes of the Medical Care and Hospital Insurance Act, the following is a list of uninsured physician services:

The majority of diadependentgnostic services (e.g., laboratory services and x-ray) are performed within public facilities in the province. Hospital policy concerning access ensures that third parties are not given priority access.

Medical goods and services that are implanted and associated with an insured service are provided free of charge to the patient and are consistent with national standards of practice. Patients retain the right to financially upgrade standard medical goods or services. Standards for medical goods are developed by the hospitals providing those services in consultation with service providers.

The Act provides the Lieutenant-Governor in Council the authority to make regulations prescribing which services are or are not insured services for the purpose of the Act. This would involve consultation with the Newfoundland and Labrador Medical Association. There is no specified requirement for public consultation when delisting a service. No services were de-listed from the MCP during 2019–2020.

3.0 Universality

3.1 Eligibility

Residents of Newfoundland and Labrador are eligible for coverage under the Medical Care and Hospital Insurance Act. This Act defines a “resident” as a person who is lawfully entitled to be or to remain in Canada, makes his or her home in the province, and is ordinarily present in the province, but does not include a tourist, transient or visitor to the province.

The Medical Care Insurance Beneficiaries and Inquiries Regulations identify those residents eligible to receive coverage under the plans. There were no amendments to these Regulations during the reporting period. The MCP has established rules to ensure that the Regulations are applied consistently and fairly in processing applications for coverage. The MCP applies the standard that persons moving to Newfoundland and Labrador from another province become eligible on the first day of the third month following the month of their arrival. Under section 6 of the Act, every resident of the province is required to register for the MCP in accordance with the regulations. While there is no specified opt-out provision, a person may, in effect, do so by choosing not to register.

Persons not eligible for coverage under the MCP and HIP include:

If the status of these individuals change, they must meet the criteria as noted above in order to become eligible. Applicants wishing to appeal an eligibility issue may request a formal file review from the Minister of Health and Community Services.

There were approximately 526,151 people registered as active beneficiaries of the MCP as of March 31, 2020.

3.2 Other Categories of Individuals

Foreign workers, international students, foreign clergy and dependants of North Atlantic Treaty Organization (NATO) personnel and applicants for permanent residency are eligible for benefits. Returning Canadian citizens and their dependants born out-of-country, returning permanent residents who hold valid documentation, holders of minister’s permits, convention refugees, resettled refugees or “persons in need of protection” with valid immigration documents are also eligible, subject to MCP approval. Dependants of MCP beneficiaries may also be eligible for coverage.

4.0 Portability

4.1 Minimum Waiting Period

Persons who meet the eligibility criteria who are moving to Newfoundland and Labrador from other provinces or territories are entitled to coverage on the first day of the third month following the month of arrival.

Persons arriving from outside Canada to establish residence are entitled to coverage on the day of arrival. The same applies to discharged members of the Canadian Armed Forces, and individuals released from federal penitentiaries. For coverage to be effective, registration is required under the MCP. Immediate coverage is provided to persons from outside Canada authorized to work in the province for one year or more and their eligible dependants, and to international post-secondary students attending a recognized Newfoundland and Labrador educational institution who have a valid study permit entitling them to stay in Canada for more than 365 days and their eligible dependants. This requirement has been reduced to a six-month work permit for individuals entering the province under the Newfoundland and Labrador Provincial Nominee Program (NLPNP) and the Atlantic Immigration Pilot Program (AIPP). For international health care workers with employment authorizations, the period of employment may be for less than 365 days.

4.2 Coverage during Temporary Absences in Canada

Newfoundland and Labrador is a party to the Interprovincial Agreement on Eligibility and Portability regarding matters pertaining to portability of insured services in Canada.

Sections 12 and 13 of the Hospital Insurance Regulations denote portability of hospital coverage during absences both within and outside Canada. The eligibility policy for insured hospital services is linked to the eligibility policy for insured physician services. No amendments to the Regulations were made in 2019-2020.

Coverage is provided to residents during temporary absences within Canada. The Government of Newfoundland and Labrador has entered into formal agreements (e.g., the Hospital Reciprocal Billing Agreement) with other provinces and territories for the reciprocal billing of insured hospital services. In-patient costs are paid at standard rates approved by the host province or territory. In-patient, high-cost procedures and out-patient services are payable based on national rates agreed to by provincial and territorial health plans through the Interprovincial Health Insurance Agreements Coordinating Committee.

Medical services incurred in all provinces (except Quebec) or territories are paid through the Medical Reciprocal Billing Agreement at host province or territory rates. Claims for medical services received in Quebec are submitted by the patient to the MCP for payment at host province rates.

In order to qualify for out-of-province coverage, a beneficiary must comply with the legislation and the MCP rules regarding residency in Newfoundland and Labrador. Generally, a resident must reside in the province for at least four months in each 12-month period to qualify as a beneficiary. International workers and students may qualify for out-of-province coverage of up to 182 days in a 365 day period. The rules regarding medical and hospital care coverage during absences include the following:

Failure to request out-of-province coverage or failure to abide by the residency rules may result in the resident having to pay for medical or hospital costs incurred outside the province.

Insured residents moving permanently to other parts of Canada are covered up to, and including, the last day of the second month following the month of departure.

No changes to coverage during temporary absences in Canada were made in 2019-2020.

4.3 Coverage during Temporary Absences Outside Canada

Sections 12 and 13 of the Hospital Insurance Regulations denote portability of hospital coverage during absences both within and outside Canada. No amendments were made to the Regulations during the reporting period.

The province provides coverage to residents during temporary absences outside Canada. Out-of-country insured hospital in-patient and out-patient services are covered for emergencies, sudden illness and elective procedures at established rates listed below. Hospital services are considered under the plan when the insured services are provided by a recognized facility (licensed or approved by the appropriate authority within the state or country in which the facility is located) outside Canada. The maximum amount payable by the MCP for out-of-country in-patient hospital care is $350 per day, if the insured services are provided by a community or regional hospital. Where insured services are provided by a tertiary care hospital (a highly specialized facility), the approved rate is $465 per day. The approved rate for out-patient services is $62 per visit and haemodialysis is $220 per treatment. The approved rates are paid in Canadian funds.

Physician services are covered for emergencies or sudden illness, and are also insured for elective services not available in the province or within Canada. Emergency physician services are paid at the same rate as would be paid in Newfoundland and Labrador for the same service. If the elective services are not available in Newfoundland and Labrador, they are usually paid at Ontario rates, or at rates that apply in the province where they are available.

Coverage is immediately discontinued when residents move permanently to other countries.

In 2019-2020, the only change to coverage during temporary absences outside Canada related to workers employed with College of the North Atlantic’s campus in Qatar. For these beneficiaries, out-of-province coverage was extended from three to five years.

4.4 Prior Approval Requirement

Prior approval is not required for medically necessary insured services provided by accredited hospitals or licensed physicians in the other provinces and territories. However, physicians may seek advice on coverage from the MCP so that patients may be made aware of any financial implications.

Prior approval is mandatory in order to receive funding at host country rates if a resident of the province has to seek specialized hospital care outside the country because the insured service is not available in Canada. The referring physicians must contact the department for prior approval. If prior approval is granted, the provincial health care insurance plan will pay the costs of insured services necessary for the patient’s care. Prior approval is not granted for out-of-country treatment or elective services if the service is available in the province or elsewhere within Canada. If an individual opts to receive the service outside Canada it will be covered at the provincial rate if available in Newfoundland and Labrador. If the service is not available in Newfoundland and Labrador, it is usually paid at Ontario rates, or at rates that apply in the province where they are available. Applicants wishing to appeal out-of-province coverage may request a formal file review by the minister.

5.0 Accessibility

5.1 Access to Insured Health Services

Access to insured health services in Newfoundland and Labrador is provided on uniform terms and conditions. Co-insurance charges for insured hospital services and extra-billing by physicians is prohibited in the province.

Section 7 of the Medical Care and Hospital Insurance Act outlines that a practitioner who provides insured services, whether or not he or she has made an election to opt out of participation in the MCP, shall not charge or collect from a beneficiary a fee for those insured services in excess of the amount payable under the Act and regulations. A practitioner or other person who contravenes this is guilty of an offence and liable on summary conviction to a fine of up to but not more than $20,000 for each contravention. Cases of extra-billing and user charges may be identified through the audit process described under section 21 of the Act or may be reported from residents. These instances may be discovered when residents submit claims to the department for reimbursement.

Complaints from residents regarding charges for insured health services are managed by the department. Depending on the circumstance, the department may investigate or refer the matter to the College of Physicians and Surgeons of Newfoundland and Labrador, the regulatory body for physicians in the province, for potential disciplinary action. Residents may also contact the College directly if they feel that they have been subject to improper billing by their physician.

Regarding repayment, section 25 of the Act provides the minister with powers to recover overpayments and interest that were discovered via audit. The Minister of Health and Community Services may do this by entering into an agreement with the practitioner or their professional corporation or the minister may order the practitioner to pay to the minister the overpaid amount plus interest.

Residents wishing to file a complaint regarding medical care that they have received are encouraged to call or email the Complaints Coordinator at the College (1-709-726-8546 or complaints@cpsnl.ca) or call the MCP general inquiries line (Avalon area: 1-866-449-4459; all other regions:1-800-563-1557).

The department works closely with post-secondary educational institutions within the province to maintain an appropriate supply of health professionals. The province also works with external organizations for health professionals not trained in this province. Targeted recruitment incentives are in place to attract health professionals. Several programs have been established to provide targeted sign-on bonuses, bursaries, opportunities for upgrading, and other incentives for a wide variety of health occupations.

With respect to wait times to access insured health services, the department led a number of initiatives, including the Strategy to Reduce Hip and Knee Joint Replacement Surgery Wait Times, the Provincial Emergency Department Wait Time Strategy and the Provincial Endoscopy Wait Time Strategy. These strategies ended in 2017–2018. In 2019-2020, the department lead a provincial initiative to develop and implement a standardized provincial methodology for collecting surgical cancelations. This initiative aims to avoid increases in wait times associated with avoidable cancellations of elective surgeries. Prior to this undertaking, research determined that a national methodology for elective surgical cancellations does not exist, making NL one of a few provinces to put this data collection in place.

A Provincial Pain Advisory Committee (PPAC) has been established with the goals of developing and provincial model of care to standardize pain services in Newfoundland and Labrador and improve access to services for individuals with chronic pain.

5.2 Physician Compensation

Physicians in the province are paid via fee-for-service, salary, or alternate payment plan. As of March 31, 2020 the legislation governing payments to physicians and dentists for insured services continues to be the Medical Care and Hospital Insurance Act. There is no legislation that speaks to the ability of physicians or dentists to levy block fees. The Newfoundland and Labrador Medical Association (NLMA) has published the Physicians’ Guide to Non-Insured ServicesFootnote 4, which provides guidance on third party requested services, other non-insured services, suggested fees and relevant policies.

Compensation agreements are negotiated between the government and the NLMA, on behalf of physicians, and the Newfoundland and Labrador Dental Association (NLDA) on behalf of dentists. A Memorandum of Agreement was reached with the NLMA in December 2017, which increased overall physician compensation by approximately five per cent. The agreement expired on September 30, 2017, but remains in effect until such time as a new agreement is negotiated. The current agreement with the NLDA expires on March 31, 2022. The agreement was signed effective April 1, 2018, with no fee increases.

The Act authorizes the minister to appoint auditors to audit the accounts and claims for payment submitted by physicians and dentists. The Act prescribes the power and duties of auditors, sets out the remedies available and details the processes to be followed. The Act also details the review and appeal processes available to practitioners. Individual providers are randomly selected on a bi-weekly basis for audit.

5.3 Payments to Hospitals

The department is responsible for funding RHAs space for ongoing hospital operations and capital acquisitions. Payments are made in accordance with the Medical Care and Hospital Insurance Act, the Regional Health Authorities Act and the Financial Administration Act. As part of their accountability to the department, the RHAs are required to meet the department’s annual reporting requirements, which include submitting an annual budget, pursuant to section 21 of the Regional Health Authority Act, as well as audited financial statements and other financial and statistical information throughout the year as required.

6.0 Recognition Given to Federal Transfers

Funding provided by the federal government through the Canada Health Transfer and the Canada Social Transfer has been recognized and reported by the Government of Newfoundland and Labrador in the annual provincial budget, through press releases, government websites and various other documents. For fiscal year 2019–2020, these documents include the Public Accounts and Estimates 2019–2020. The Public Accounts and Estimates, tabled by the Government in the House of Assembly, are publicly available and are shared with Health Canada for information purposes.

Registered Persons
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
1. Number as of March 31st 532,415 530,144 526,692 526,278 526,151
Insured Hospital Services Within Own Province or Territory
Public Facilities 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
2. Number 51 103Newfoundland and Labrador table 2 Footnote 1 104 103 103
3. Payments for insured health services ($)           1,164,174,814 1,187,786,538 1,199,247,288 1,260,708,567 1,217,480,996
Private For-Profit Facilities 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
4. Number of private for-profit facilities providing insured health services 1 1 1 1 1
5. Payments to private for-profit facilities for insured health services ($) 899,538 899,418 939,422 1,023,737 954,483
Newfoundland and Labrador table 2 Footnote 1

Classification of public facilities changed in 2016–2017.

Newfoundland and Labrador table 2 Return to footnote 1 referrer
Insured Hospital Services Provided to Residents in Another Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
6. Total number of claims, in-patient 1,607 1,549 1,515 1,648 1,685
7. Total payments, in-patient ($) 21,928,705 25,223,361 22,013,818 26,701,044 24,194,946
8. Total number of claims,
out-patient		 23,105 21,915 24,093 22,701 25,216
9. Total payments, out-patient ($) 8,428,054 8,279,887 9,102,027 9,161,383 10,558,507
Insured Hospital Services Provided Outside CanadaNewfoundland and Labrador table 4 Footnote 1
Pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
10. Total number of claims, in-patient Not applicable Not applicable Not applicable 4 9
11. Total payments, in-patient ($) Not applicable Not applicable Not applicable 261,277 313,310
12. Total number of claims, out-patient Not applicable Not applicable Not applicable 17 65
13. Total payments, out-patient ($) Not applicable Not applicable Not applicable 69,682 455,264
Non pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
14. Total number of claims, non pre-approved in-patient Not applicable Not applicable Not applicable 85 126
15. Total payments, non pre-approved  in-patient ($) Not applicable Not applicable Not applicable 85,231 138,708
16. Total number of claims, non pre-approved out-patient Not applicable Not applicable Not applicable 309 335
17. Total payments, non pre-approved out-patient ($) Not applicable Not applicable Not applicable 31,343 20,837
Newfoundland and Labrador Table 4 Footnote 1

Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report, but did not require provinces or territories to report on previous years.

Newfoundland and Labrador Table 4 Return to footnote 1 referrer
Insured Physician Services Within Own Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
18. Number of participating physiciansNewfoundland and Labrador Table 5 Footnote 1 1,212 1,214 1,231 1,262 1,307
19. Number of opted-out physicians 0 0 0 0 0
20. Number of non-participating physicians 0 0 0 0 0
21. Total payments for services provided by physicians paid through all payment methods ($) Not available Not available Not available Not available Not available
22. Total payments for services provided by physicians paid through fee-for-service ($) 299,597,724 309,039,732 361,707,782 317,338,718 320,407,337
Newfoundland and Labrador Table 5 Footnote 1

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

Newfoundland and Labrador Table 5 Return to footnote 1 referrer
Insured Physician Services Provided to Residents in Another Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
23. Number of services 114,000 123,000 128,000 119,100 127,900
24. Total payments ($) 6,910,000Newfoundland and Labrador Table 6 Footnote 1 9,124,000Newfoundland and Labrador Table 6 Footnote 1 8,511,000Newfoundland and Labrador Table 6 Footnote 1 7,885,750 8,714,768
Newfoundland and Labrador Table 6 Footnote 1

Numbers are rounded to the nearest thousand.

Newfoundland and Labrador Table 6 Return to footnote 1 referrer
Insured Physician Services Provided Outside CanadaNewfoundland and Labrador Table 7 Footnote 1Newfoundland and Labrador Table 7 Footnote 2
Pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
25. Number of services (#) Not applicable Not applicable Not applicable 2,700 2,509
26. Total d payments ($) Not applicable Not applicable Not applicable 262,200 434,941
Non pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
27. Number of services (#) Not applicable Not applicable Not applicable Not available Not available
28. Total payments ($) Not applicable Not applicable Not applicable Not available Not available
Newfoundland and Labrador Table 7 Footnote 1

The claims in NL's data system cannot be separated into pre-approved or non pre-approved, therefore, the numbers reflect the total claims and payments as reported for previous years.

Newfoundland and Labrador Table 7 Return to footnote 1 referrer

Newfoundland and Labrador Table 7 Footnote 2

Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report,but did not require provinces or territories to report on previous years.

Newfoundland and Labrador Table 7 Return to footnote 2 referrer
Insured Surgical-Dental Services Within Own Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
29. Number of participating dentists 19 22 18 22 17
30. Number of opted-out dentistsNewfoundland and Labrador Table 8 Footnote 1 Not available Not available 0 0 0
31. Number of non-participating dentistsNewfoundland and Labrador Table 8 Footnote 1 Not available Not available 0 0 0
32. Number of services provided 3,397 4,843 4,924 5,638 4,097
33. Total payments ($) 592,660 885,610 927,020 1,231,180 713,570
Newfoundland and Labrador Table 8 Footnote 1

Health Canada requested this data as of the 2016-2017 report, but did not require provinces or territories to report data for 2015-2016.

Newfoundland and Labrador Table 8 Return to footnote 1 referrer

Prince Edward Island

In Prince Edward Island (PEI) the Department of Health and Wellness is responsible for providing policy, strategic, and fiscal leadership for the health care system.

The Health Services Act, R.S.P.E.I. 1988, Cap. H-1.6 provides the regulatory and administrative frameworks for improvements to the health care system in PEI by:

Within this governance structure Health PEI has the responsibility to:

In response to the COVID-19 global pandemic, The Department of Health and Wellness and Health PEI introduced several measures to help keep Islanders safe and stop the spread of COVID-19 in Island communities. Examples of these measures include:

1.0 Public Administration

1.1 Health Care Insurance Plan and Public Authority

The Hospital Services Insurance Plan, under the authority of the Minister of Health and Wellness (the Minister), is the vehicle for delivering hospital care insurance in Prince Edward Island (PEI). The enabling legislation is the Hospital and Diagnostic Services Insurance Act R.S.P.E.I. 1988, Cap. H-8. The Medical Services Insurance Plan provides for insured physician services under the authority of the Health Services Payment Act R.S.P.E.I. 1988, Cap. H-2. Together, the plans insure services as defined under section 2 of the Canada Health Act. The Department of Health and Wellness (the Department) is responsible for providing policy, strategic and fiscal leadership for the health care system, while Health PEI is responsible for service delivery and the operation of hospitals, health centres, manors and mental health facilities. Health PEI is responsible for the hiring of physicians, while the Public Service Commission of PEI hires nurse practitioners, nurses and all other health related workers.

1.2 Reporting Relationship

An annual report is submitted by the Department to the Minister who tables it in the Legislative Assembly. The report provides information about the operating principles of the Department and its legislative responsibilities, as well as an overview and description of the operations of the departmental divisions and statistical highlights for the year. The Health PEI annual report for 2019-2020 was published on October 28, 2020.

Health PEI prepares an annual business plan which functions as a formal agreement between Health PEI and the Minister responsible, and documents accomplishments to be achieved over the coming fiscal year.

1.3 Audit of Accounts

The provincial Auditor General conducts annual audits of the public accounts of PEI. The public accounts of the province include the financial activities, revenues and expenditures of the Department of Health and Wellness.

The provincial Auditor General, through the Audit Act, R.S.P.E.I. 1988, c A-24, has the discretion to conduct further audit reviews on a comprehensive or program specific basis.

2.0 Comprehensiveness

2.1 Insured Hospital Services

Insured hospital services are provided under the Hospital and Diagnostic Services Insurance Act. The accompanying Regulations define the insured in-patient and out-patient hospital services available at no charge to a person who is eligible. Insured hospital services include, but are not limited to:

The process to add a new hospital service to the list of insured services involves extensive consultation and negotiation between the Department of Health and Wellness (the Department), Health PEI and key stakeholders. The process involves the development of a business plan which, when approved by the Minister of Health and Wellness, would be taken to Treasury Board for funding approval. Executive Council (Cabinet) has the final authority in adding new services.

2.2 Insured Physician Services

The enabling legislation that provides for insured physician services is the Health Services Payment Act. Insured physician services are provided by medical practitioners licensed by the College of Physicians and Surgeons. The total number of practicing practitioners who billed the Medical Services Insurance Plan as of March 31, 2020, was 416. This includes all physicians (complement, locums, visiting specialists, and other non-complement physicians). Under section 10 of the Health Services Payment Act, a physician or practitioner who is not a participant in the Medical Services Insurance Plan is not eligible to bill the Plan for services rendered. When a non-participating physician provides a medically required service, section 10(2) requires that physicians advise patients that they are non-participating physicians or practitioners and provide the patient with sufficient information to enable recovery of the cost of services from the Department. Under section 10.1 of the Health Services Payment Act, a participating physician or practitioner may determine, subject to and in accordance with the Regulations and in respect of a particular patient or a particular basic health service, to collect fees outside the Plan or selectively opt out of the Plan. Before the service is rendered, patients must be informed that they will be billed directly for the service. Where practitioners have made that determination, they are required to inform the Minister thereof and the total charge is made to the patient for the service rendered.

As of March 31, 2020, no physicians had opted out of the Medical Services Insurance Plan.

All basic health services rendered by physicians that are medically required are covered by the Medical Services Insurance Plan. These include:

Services that are not covered as insured benefits include:

The process to add a physician service to the list of insured services involves negotiation between the Department, Health PEI and the Medical Society of Prince Edward Island (PEI). The process involves development of a business plan which, when approved by the Minister, would be taken to Treasury Board for funding approval. Insured physician services may also be added or deleted as part of the negotiation of a new Master Agreement with the Medical Society of PEI (Section 5.2). Cabinet has the final authority in adding new services.

2.3 Insured Surgical-Dental Services

Most dental services are not insured under the Medical Services Insurance Plan. Only oral maxillofacial surgeons are paid through the Plan. There are currently four surgeons in that category. Surgical-dental procedures included as basic health services in the Tariff of Fees are covered only when the patient's medical condition requires that they be done in hospital or in an office with prior approval, as confirmed by the attending physician.

Any new surgical-dental services added to the list of insured services covered by the Medical Services Insurance Plan is done through negotiations of the Dental Agreement between the Department, Health PEI and the Dental Association of PEI. In 2019–2020, no new services were added to the Dental Agreement.

2.4 Uninsured Hospital, Physician and Surgical-Dental Services

Services not covered by the Medical Services Insurance Plan include:

Hospital services not covered by the Hospital Services Insurance Plan include:

The process to de-insure services covered by the Medical Services Insurance Plan is done in collaboration with the Department, Health PEI and the Medical Society of PEI. No services were de-insured during the 2019–2020 fiscal year.

All Prince Edward Island residents have equal access to services. Third parties such as private insurers or the Workers' Compensation Board of PEI do not receive priority access to services through additional payment.

Prince Edward Island has no formal process to monitor compliance; however, feedback from physicians, hospital administrators, medical professionals and staff allows the Department and Health PEI to monitor usage and service concerns.

3.0 Universality

3.1 Eligibility

The Health Services Payment Act and the Hospital and Diagnostic Services Insurance Act, define eligibility for the Medical Services Insurance Plan and the Hospital Services Insurance Plan respectively. These plans are designed to provide coverage for eligible Prince Edward Island (PEI) residents. A resident is anyone legally entitled to remain in Canada and who makes his or her home and is ordinarily present on an annual basis for at least six months plus a day in PEI. While there is no formal appeal process, an individual can seek clarification regarding their eligibility determination.

All new residents must register with Health PEI in order to become eligible. Persons who establish permanent residence in PEI from elsewhere in Canada will become eligible for insured hospital and medical services on the first day of the third month following the month of arrival. PEI currently does not have a process where a resident can opt out of the health care insurance plan.

Residents who are ineligible for insured hospital and medical services coverage in PEI are those who are eligible for certain services under other federal or provincial government programs, such as members of the Canadian Forces, inmates of federal penitentiaries, and clients of Workers' Compensation or the Department of Veterans Affairs' programs.

Ineligible residents may become eligible in certain circumstances. For example, members of the Canadian Forces become eligible on discharge or completion of rehabilitative leave. Penitentiary inmates become eligible upon release. In such cases, the province where the individual in question was stationed at the time of discharge or release, or release from rehabilitative leave, would provide initial coverage during the customary waiting period of up to three months. Parolees from penitentiaries will be treated in the same manner as discharged prisoners.

New or returning residents must apply for health coverage by completing a registration application from Health PEI. The application is reviewed to ensure that all necessary information is provided. A health card is issued and sent to the resident within two weeks of becoming eligible. Renewal of coverage takes place every five years and residents are notified by mail six weeks before renewal.

The number of residents registered with the Medical Services Insurance Plan and the Health Services Insurance Plan in PEI as of March 31, 2020, was 154,728.

3.2 Other Categories of Individuals

Foreign students, tourists, transients or visitors to PEI do not qualify as residents of the province and are, therefore, not eligible for hospital and medical insurance benefits.

Temporary workers, refugees and Minister's Permit holders are not eligible for hospital and medical insurance benefits.

4.0 Portability

4.1 Minimum Waiting Period

Insured persons who move to Prince Edward Island (PEI) from another province or territory in Canada are eligible for health insurance on the first day of the third month following the month of arrival in the province.

4.2 Coverage during Temporary Absences in Canada

Residents absent each year for any reasons must reside in PEI for at least six months plus a day each year in order to be eligible for sudden illness and emergency services while absent from the province, as allowed under section 11 of the Health Services Payment Act Regulations. A person, including a student, who is temporarily absent from the province for up to 182 days in a 12 month period must notify Health PEI before leaving.

PEI participates in the Hospital Reciprocal Billing Agreements and the Medical Reciprocal Billing Agreements along with other jurisdictions across Canada.

4.3 Coverage during Temporary Absences outside Canada

The Health Services Payment Act is the enabling legislation that defines portability of health insurance during temporary absences outside of Canada, as allowed under section 11 of the regulations thereunder.

Persons must reside in PEI for at least six months plus a day each year in order to be eligible for sudden illness and emergency services while absent from the province, as allowed under section 11 of the Health Services Payment Act Regulations.

Insured residents may be temporarily out of the country for up to a 12 month period in some circumstances.

Students attending a recognized learning institution in another country must provide proof of enrollment from the educational institution on an annual basis. Students must notify Health PEI upon returning from outside the country.

For PEI residents leaving the country for work purposes for longer than one year, coverage ends the day the person leaves.

For PEI residents travelling outside Canada, coverage for emergency or sudden illness will be provided at PEI rates only, in Canadian currency. Residents are responsible for paying the difference between the full amount charged and the amount paid by Health PEI.

4.4 Prior Approval Requirement

Prior approval is required from Health PEI before receiving non-emergency, out-of-province medical or hospital services. Island residents seeking such required services may apply for prior approval through a PEI physician. If approval is not granted, a letter can be submitted to Health PEI to appeal a medical insurance decision. Full coverage may be provided for (PEI insured) non-emergency or elective services, provided the physician completes an application to Health PEI. Prior approval is required from the Medical Director of Health PEI to receive out-of-country hospital or medical services not available in Canada.

5.0 Accessibility

5.1 Access to Insured Health Services

Both of Prince Edward Island's (PEI) Hospital Services Insurance Plan and the Medical Services Insurance Plan provide services on uniform terms and conditions on a basis that does not impede or preclude reasonable access to those services by insured persons. While there is no formal complaints process for inappropriate charges, an individual can seek clarification on the appropriateness of any charges through the Department of Health and Wellness (the Department). The Department can be contacted at:

Prince Edward Island Department of Health and Wellness
P.O. Box 2000
Charlottetown, PE
C1A 7N8
(902) 368-6414

PEI has a publicly administered and funded health system that guarantees universal access to medically necessary hospital and physician services as required by the Canada Health Act.

The Government of PEI recognizes that the health system must constantly adapt and expand to meet the needs of residents.

Several examples of initiatives from the 2019–2020 fiscal year include:

5.2 Physician Compensation

A collective bargaining process is used to negotiate physician compensation. Bargaining teams are appointed by both physicians and the government to represent their interests in the process. The last five-year Master Agreement between the Medical Society of PEI, the Department and Health PEI covered the period of April 1, 2019, to March 31, 2024.

Many physicians continue to work on a fee-for-service basis; however, alternate payment plans have been developed and some physicians receive salary, contract and sessional payments. Alternate payment modalities are expanding and seem to be the preference for new graduates. Currently, 67 per cent of PEI's physicians (excluding locums and visiting specialists) are compensated under an alternate payment method (non-fee-for-service) as their primary means of remuneration.

The legislation governing payments to physicians and dentists for insured services is the Health Services Payment Act. Health PEI is responsible for auditing physician claims for compliance with legislative requirements and the Master Agreement tariff, as permitted under the Health Services Payment Act and delegated by the Minister. The Health Services Payment Act allows for audits of physician payments to assist in efficient and effective use of resources. Health PEI's audit rights are affirmed in the Master Agreement with the Medical Society of PEI. Health PEI approved its Practitioner Claims Monitoring, Compliance, and Recovery Policy on December 22, 2015, and continues to conduct physician payment audits on a go-forward basis. The policy information was communicated to physicians in January 2016.

Physicians submit bills for services provided to insured residents to Health PEI's Claims Payment System (CPS). The CPS contains billing rules aligned with the Master Agreement which help to ensure billings which do not meet Master Agreement criteria are rejected or flagged for review. As part of Health PEI's monitoring process, physicians are randomly selected and requested to provide Health PEI with documentation to support sample billings. Overall physician billings are periodically reviewed to identify unusual billing profiles when compared to peers, significant increases in fee code billings and irregularities in the use of new fee codes. Any irregularities discovered may trigger an audit.

The audits include specific steps for:

The Health Services Payment Act allows for recovery of overpayments and provides for appeal of adjustments to claims. The initial stage for appeal is a discussion with the Executive Director, Medical Affairs or designate. If no agreement can be reached, the matter is appealed to the Health Services Payment Advisory Committee which will provide a recommendation to the Minister.

5.3 Payments to Hospitals

Payments (advances) to provincial hospitals and community hospitals for hospital services are approved for disbursement by the Department in line with cash requirements and are subject to approved budget levels.

The usual funding method includes using a global budget adjusted annually to take into consideration increased costs related to such items as labour agreements, drugs, medical supplies and facility operations.

6.0 Recognition Given To Federal Transfers

The Government of Prince Edward Island (PEI) strives to recognize the federal contributions provided through the Canada Health Transfer whenever appropriate. Over the past year, this has included reference in public documents such as the Province of PEI 2019–2020 Annual Budget and in the 2019–2020 Public Accounts, both of which were tabled in the Legislative Assembly and are publicly available to Prince Edward Island residents.

It is also the intent of the Department of Health and Wellness to recognize this important contribution in the 2019–2020 Annual Report.

Registered Persons
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
1. Number as of March 31st 146,930 150,194 150,990 153,861 154,728
Insured Hospital Services Within Own Province or Territory
Public Facilities 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
2. Number 7 7 7 7 7
3. Payments for insured health services ($)           210,797,200 218,043,400 222,523,865 227,859,554 235,449,936
Private For-Profit Facilities 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
4. Number of private for-profit facilities providing insured health services 0 0 0 0 0
5. Payments to private for-profit facilities for insured health services ($) 0 0 0 0 0
Insured Hospital Services Provided to Residents in Another Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
6. Total number of claims, in-patient 2,616 2,612 2,683 2,736 2,853
7. Total payments, in-patient ($) 28,867,047 28,644,094 27,621,152 27,458,162 30,439,891
8. Total number of claims, out-patient 20,397 19,166 20,008 19,522 19,373
9. Total payments, out-patient ($) 7,930,682 8,234,123 8,866,851 8,667,961 8,670,798
Insured Hospital Services Provided Outside CanadaPEI Table 4 Footnote 1
Pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
10. Total number of claims, in-patient (#) Not applicable Not applicable Not applicable 0 3
11. Total payments, in-patient ($) Not applicable Not applicable Not applicable 0 34,465
12. Total number of claims, out-patient (#) Not applicable Not applicable Not applicable 0 6
13. Total payments, out-patient ($) Not applicable Not applicable Not applicable 0 642
Non pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
14. Total number of claims, in-patient (#) Not applicable Not applicable Not applicable 22 30
15. Total payments, in-patient ($) Not applicable Not applicable Not applicable 121,344 110,913
16. Total number of claims, out-patient (#) Not applicable Not applicable Not applicable 100 95
17. Total payments, out-patient ($) Not applicable Not applicable Not applicable 36,992 50,255
PEI Table 4 Footnote 1

Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report, but did not require provinces or territories to report on previous years.

PEI Table 4 Return to footnote 1 referrer
Insured Physician Services Within Own Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
18. Number of participating physicians 357 367 382 412 416
19. Number of opted-out physicians 0 0 0 0 0
20. Number of non-participating physicians 0 0 0 0 0
21. Total payments for services provided by physicians paid through all payment methods ($) 98,070,004 102,691,590 104,240,026 107,814,785 85,915,289
22. Total payments for services provided by physicians paid through fee-for-service ($) 64,477,376 65,226,925 69,491,809 72,228,583 73,456,751
Insured Physician Services Provided to Residents in Another Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
23. Number of services 107,666 113,338 111,377 115,918 124,520
24. Total payments ($) 11,973,879 11,782,835 11,366,710 11,498,714 12,740,969
Insured Physician Services Provided Outside CanadaPEI Table 7 Footnote 1
Pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
25. Number of services Not applicable Not applicable Not applicable 11 10
26. Total payments ($) Not applicable Not applicable Not applicable 2,584 1,641
 Non pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
27. Number of non pre-approved services Not applicable Not applicable Not applicable 441 262
28. Total payments ($) Not applicable Not applicable Not applicable 26,316 59,715
PEI Table 7 Footnote 1

Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report,but did not require provinces or territories to report on previous years.

PEI Table 7 Return to footnote 1 referrer
Insured Surgical-Dental Services Within Own Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
29. Number of participating dentists 2 2 3 4 4
30. Number of opted-out dentistsPEI Table 8 Footnote 1 - 0 0 0 0
31. Number of non-participating dentistsPEI Table 8 Footnote 1 - 0 0 0 0
32. Number of services provided 373 365 481 401 401
33. Total payments ($) 129,361 127,385 171,255 145,910 164,239
PEI Table 8 Footnote 1

Health Canada requested this data as of the 2016-2017 report, but did not require provinces or territories to report data for 2015-16.

Return to footnote 1 referrer

Nova Scotia

The Nova Scotia Department of Health and Wellness' (the Department) vision and mission are:

The health and wellness system includes the delivery of health care as well as the prevention of disease and injury and the promotion of health and healthy living. The Health Authorities Act establishes roles and responsibilities of the Department, the Nova Scotia Health Authority and the IWK Health Centre.

The Department is responsible for providing leadership and ensuring accountability for funding for the health system.

The Nova Scotia Health Authority and the IWK Health Centre are responsible for governing, managing and providing health services in the province and engaging with the communities they serve.

Insured services in Nova Scotia cover hospital services and physician services. Services such as home care, long-term care, and pharmaceuticals are also provided.

Nova Scotia continues to be committed to the delivery of hospital services and medically required services consistent with the principles of the Canada Health Act.

Additional information related to health care in Nova Scotia may be obtained from the Department of Health and Wellness website.

Covid-19 Measures

Due to the Covid-19 pandemic, the Nova Scotia government put several measures into place in the health care system in 2019-20. These include:

Measures to assist with expanding Health Human Resources:

Measures to increase or expand services for Nova Scotians:

Measures to increase patient safety:

Measures to support vulnerable populations:

1.0 Public Administration

1.1 Health Care Insurance Plan and Public Authority

Two plans cover insured health services in Nova Scotia: The Hospital Insurance and the Medical Services Insurance (MSI) Plans, which both operate under the Health Services and Insurance Act.

The Nova Scotia Department of Health and Wellness (the Department) administers the Hospital Insurance Plan and the MSI Plan is administered and operated by Medavie Blue Cross (MBC) on behalf of the Minister.

Section 8 of the Health Services and Insurance Act gives the Nova Scotia Minister of Health and Wellness (the Minister), with approval of the Governor in Council, the power to enter into agreements and vary, amend or terminate the same agreements with such person or persons as the Minister deems necessary to establish, implement and carry out the MSI Plan.

The Department and MBC entered into a service level agreement, effective August 1, 2005. Under the agreement, MBC is responsible for operating and administering programs contained under MSI, Pharmacare Programs and Health Card Registration Services.

In 2019-2020, no amendments were made to either the Health Services Insurance Act or the Medical Services Insurance Regulations.

1.2 Reporting Relationship

A. Hospital Insurance

Section 17(1)(i) of the Health Services and Insurance Act, and sections 11(1) and 12(1) of the Hospital Insurance Regulations, under this Act, set out the terms for reporting by hospitals and hospital boards to the Minister of Health and Wellness.

B. Medical Insurance

In the service level agreement between MBC and the Department, MBC is obliged to provide reports to the Department under various Statements of Requirements as listed in the contract. MBC is audited every year on various areas of reporting. MBC provides audited financial statements for the fiscal year ending March 31st and the statements are provided within 4 months of the fiscal year end.

1.3 Audit of Accounts

The Auditor General audits all expenditures of the Department. Under its service level agreement with the Department, MBC provides audited financial statements of MSI costs to the Department. The Auditor General and the Department have the right to perform audits of the administration of the agreement with MBC.

Within the Physician Services program there are various programs that are audited by third parties and that submit financial statements to the Department. This includes financial statements from the Dalhousie Family Medicine training sites and the Practice Ready Assessment program. Additionally, MBC conducts audits of the Academic Funding Plans (AFP).

On behalf of the Minister, the service provider that operates Nova Scotia’s out-of-hospital emergency medical services (Emergency Health Services (EHS) 911 Ground Ambulance, EHS Critical Care Transport, and non-emergent EHS Mobile Integrated Health Services) and 811 Telehealth services is required to submit audited financial statements each year and they are due 90 days after year-end of March 31st. The Department also receives audited financial statements from various other service providers including Nova Scotia Hearing and Speech Centres, Canadian Blood Services, Society of Deaf and Hard of Hearing Nova Scotia but there is no set deadline for these statements.

Under section 36(4) of the Health Authorities Act, a health authority is required to submit to the Minister, no later than June 30 each year, an audited financial statement for the preceding fiscal year.

In addition to the annual audit of the Provincial Financial Statements, the Auditor General conducts performance audits on a variety of programs. The most recent Auditor General audits on the Department of Health and Wellness were follow-up reports, specifically:

For further details please visit the Auditor General’s website.

1.4 Designated Agency

MBC administers monies to pay physician accounts as per the service agreement with the Department of Health and Wellness. Physician rates of pay are set based on the Master Agreement negotiated with Doctors Nova Scotia (the sole negotiating body for physicians in Nova Scotia) and the Clinical Academic Funding Plan, which is negotiated with Doctors Nova Scotia, Dalhousie University, the Nova Scotia Health Authority and the IWK Health Centre.

MSI is the provincial plan of insured medical services. It is designed to pay for a wide range of medically necessary physicians’ services, as well as certain dental and optometric services.

The Department and the Office of the Auditor General, have the right, under the terms of the service level agreement, to audit all MSI and Pharmacare transactions.

Green Shield Canada administers and has the authority to receive monies to pay dentists under a service level agreement with the Department. The tariff of dental fees is negotiated between the Nova Scotia Dental Association and the Department.

As part of an agreement with the Department, Green Shield Canada also provides monthly, quarterly and annual reports with regard to dental programs in Nova Scotia. This includes hospital dental services when the hospital setting is required for the safe performance of the procedure. These reports address provider claims and payment, program utilization, and audit. A complete list of reports can be obtained from the Department.

Green Shield is required to submit their audited financial statements annually.

MBC is responsible for providing a number of regular and ad hoc reports to the Department pertaining to health card administration, physician claims activity, financial monitoring, provider management, audit activities and program utilization. These reports are submitted on a monthly, quarterly, or annual basis. A complete list of reports can be obtained from the Department.

2.0 Comprehensiveness

2.1 Insured Hospital Services

The enabling legislation that provides for insured hospital services in Nova Scotia is the Health Services and Insurance Act (HSIA). Hospital Insurance Regulations were made pursuant to the Act. No amendments were made to this legislation in fiscal year 2019-2020.

Under the Hospital Services Insurance Plan, in-patient services include:

Out-patient services include:

Each year, the Nova Scotia Health Authority and the IWK Health Centre submit business plans outlining budgets and priorities for the coming year to ensure safe and high-quality access to care. Under the Health Authorities Act, business plans are to be submitted on November 1 every year and will be approved by the Minister of Health and Wellness.

The Department is aware of the operation of a private MRI clinic that is operating outside of HSIA and the Hospital Insurance Plan Regulations. The Department is currently reviewing options for how to address the situation.

2.2 Insured Physician Services

The legislation covering the provision of insured physician services in Nova Scotia is the Health Services and Insurance Act, sections 3(2), 5, 8, 13, 13A, 17(2), 22, 27–31, 35, and the Medical Services Insurance Regulations. No amendments were made to this legislation in 2019-2020.

As of March 31, 2020, 2,801 physicians were paid through the MSI Plan.

Physicians retain the ability to opt in or out of the MSI Plan. To opt out, a physician notifies MSI and relinquishes their billing number. MSI reimburses patients who pay the physician directly due to opting out. As of March 31, 2020, no physicians had opted-out of the MSI plan to pursue this method of remuneration.

Insured services include those that are medically necessary. Payment is provided for the following physicians’ services, when medically necessary:

If, in the opinion of the physician, a patient requires the services of a specialist for either consultation or care, a referral to the specialist is made. Payment at the specialist tariff is based on a valid referral by the attending physician.

Additional services were added to the list of insured physician services in 2019–2020, including Body Mass Index surgical premium, Mohs Micrographic Surgery, Head and Neck Surgery, Endobronchial Ultrasound, and Autistic Diagnostic Assessment.

The Fee Committee is outlined in Article 4.1(c) of the 2019 Master Agreement. The Fee Committee is a collaborative structure made up of the Department, Nova Scotia Health Authority, and Doctors Nova Scotia. The Committee reviews requests for new fees, amendments to current fees, and for additions, revision, or clarification of the Preamble to the MSI Physician manual. The Fee Committee provides advice and recommendations to the Master Agreement Management Group on all matters pertaining to the fee schedule, based on consensus and available budget. If the fee is approved, Medavie Blue Cross is directed to add the new fee to the schedule of insured services payable by the MSI Plan.

Public consultations are not generally undertaken when listing or delisting insured medical services.

2.3 Insured Surgical-Dental Services

To provide insured surgical-dental services under the Health Services and Insurance Act, dentists must be registered members of the Nova Scotia Dental Association, must be certified competent in the practice of dental surgery, and must also have privileges from the health authorities to deliver services at specific hospitals. The Health Services and Insurance Act is written so that a dentist may choose not to participate in the MSI Plan. To participate, a dentist must register with MSI. A participating dentist who chooses not to participate must advise MSI in writing and is then no longer eligible to submit claims to MSI. In 2019 –2020, 18 dentists were paid through the MSI Plan for providing insured surgical-dental services.

Insured surgical-dental services must be provided in a public health care facility. Insured surgical-dental services are detailed in the Department’s Dentists Guide and are reviewed annually. Services under this program are insured when the condition of the patient is such that it is medically necessary for the procedure to be done in a public hospital and the procedure is of a surgical nature.

Generally included as insured surgical-dental services are extractions and oral and maxillofacial surgery. Requests for an addition to the list of surgical-dental services are accomplished through the Nova Scotia Dental Association which submits a proposal to the Department. Then, in consultation with experts in the field, the Department renders a decision on the addition of the procedure as an insured service. Public consultations are not undertaken during the consideration of additions to the list of insured services.

Insured services in the “Other extraction services” (routine extractions) category are approved for the following groups of patients: cardiac patients, transplant patients, immunocompromised patients, and radiation patients. This is the case only when patients are undergoing active treatment in a hospital setting and the medical procedure must require the removal of teeth in a manner that would otherwise be considered routine extractions.

Currently, there are no opted-out dentists and no non-participating dentists providing insured surgical-dental services.

2.4 Uninsured Hospital, Physician and Surgical-Dental Services

Uninsured hospital services include:

Uninsured Physician Services include:

Major third-party agencies currently purchasing medically required health services in Nova Scotia include Workers’ Compensation Board and the Department of National Defence.

All residents of the province are entitled to services covered under the Health Services and Insurance Act. If enhanced goods and services, such as fibreglass casts, are offered as an alternative, the specialist or physician is responsible to ensure that the patient is aware of their responsibility for the cost. Patients are not denied service based on their inability to pay. The province provides alternatives to any of the enhanced goods and services.

The Department carefully reviews all patient complaints or public concerns that may indicate that the general principles of insured services are not being followed.

If a service or procedure is deemed by the Department not to be medically required, it is removed from the physician fee schedule and will no longer be reimbursed to physicians as an insured service. Once a service has been de-insured, all procedures and testing relating to the provision of that service also become de-insured. The same also applies to dental services and hospital services. Public consultations are not undertaken during the determination of medical necessity and de-listing of insured services. Consultation with the Nova Scotia Dental Association has preceded past de-listing of dental services. The last time there was any significant de-insurance of services was in 1997.

3.0 Universality

3.1 Eligibility

Eligibility for insured health care services in Nova Scotia is outlined under section 2 of the Hospital Insurance Regulations made pursuant to section 17 of the Health Services and Insurance Act. All residents of Nova Scotia are eligible. A resident is defined as anyone who is legally entitled to stay in Canada and who makes their home and is ordinarily present in Nova Scotia. Registration for the hospital and medical insurance plans is voluntary and residents may choose not to register.

In 2019-2020, a person was considered to be "ordinarily present" in Nova Scotia if the person:

Children born out-of-country to Nova Scotia residents are eligible for coverage provided their parents meet the Nova Scotia residency requirements.

Persons moving to Nova Scotia from another Canadian province will normally be eligible for Medical Services Insurance on the first day of the third month following the month of their arrival. Persons moving permanently to Nova Scotia from another country are eligible on the date of their arrival in the province, provided they are Canadian citizens or hold "Permanent Resident" status as defined by IRCC.

Individuals insured under the Workers’ Compensation Act or any other act in the Legislature or of the Parliament of Canada or under any statute or law of any other jurisdiction either within or outside of Canada are not eligible for MSI Coverage (such as members of the Canadian Forces, federal inmates and some classes of refugees). Once individuals are no longer covered under any of the acts, statutes or laws noted above, they are then eligible to apply for and receive Nova Scotia health insurance coverage, provided that they are either a Canadian Citizen, a permanent resident as defined by IRCC or meet the Nova Scotia residency requirements. An administrative review may be requested for individuals who are deemed ineligible.

In 2019-2020, the total number of residents registered with the health insurance plan was 1,043,849.

No amendments were made to the Nova Scotia Health Insurance Policy in 2019-2020.

3.2 Other Categories of Individuals

Other individuals may be eligible for insured health care services in Nova Scotia if they meet specific eligibility criteria listed below:

Immigrants: Persons moving from another country to live permanently in Nova Scotia are eligible for health care on the date of arrival if they arrive as a permanent resident, as determined by Immigration, Refugees and Citizenship Canada.

Non-Canadians married to Canadian Citizens or Permanent Residents (copy of marriage certificate required), who possess the required documentation from IRCC indicating they have applied for permanent residency, will be eligible for coverage on the date of arrival in Nova Scotia (if applied prior to their arrival to Nova Scotia), or the date of application for permanent residency (if applied after their arrival in Nova Scotia).

Convention refugees or persons in need of protection who possess the required documentation from IRCC indicating they have applied for permanent residency will be eligible for coverage on the date of application for permanent residency.

In 2019-2020, there were 57,575 permanent residents registered with the health care insurance plan.

Refugees: Refugees are eligible for MSI once they have been granted permanent residency status by IRCC, or if they possess either a work permit or study permit.

Work Permits: Persons moving to Nova Scotia from outside the country who possess a work permit can apply for coverage on the date of arrival in Nova Scotia, provided they will be remaining in Nova Scotia for at least one full year. A declaration must be signed to confirm that the worker will not be outside Nova Scotia for more than 31 consecutive days, unless required in the course of employment. MSI coverage is extended for a maximum of 12 months at a time. Each year, a copy of their renewed immigration document must be presented, and a declaration signed. Dependants of such persons, who are legally entitled to remain in Canada, are granted coverage on the same basis. Seasonal Workers are eligible for the same coverage as those with work permits.

Once coverage has terminated, the person is to be treated as never having qualified for health services coverage as herein provided and must comply with the above requirements before coverage will be extended to them or their dependants.

In 2019-2020, there were 7,694 individuals with work permits covered under the health care insurance plan.

Study Permits: Persons moving to Nova Scotia from another country and who possess a study permit (Student Authorization) will be eligible for MSI on the first day of the thirteenth month following the month of their arrival, provided they have not been absent from Nova Scotia for more than 31 consecutive days, unless required in the course of their studies. MSI coverage is extended for a maximum of 12 months at a time and only for services received within Nova Scotia. Each year, a copy of their renewed immigration document must be presented, and a declaration signed. Dependants of such persons, who are legally entitled to remain in Canada, will be granted coverage on the same basis once the student has gained entitlement.

In 2019-2020, there were 1,985 individuals with study permits covered under the health care insurance plan.

4.0 Portability

4.1 Minimum Waiting Period

Persons moving to Nova Scotia from another Canadian province or territory will normally be eligible for Medical Services Insurance on the first day of the third month following the month of their arrival.

4.2 Coverage during Temporary Absences in Canada

The Interprovincial Agreement on Eligibility and Portability is followed in all matters pertaining to the portability of insured services.

Generally, the Nova Scotia Medical Services Insurance (MSI) Plan provides coverage for residents of Nova Scotia who move to other provinces or territories for a period of three months, per the Eligibility and Portability Agreement. Students and their dependants, who are temporarily absent from Nova Scotia and in full-time studies at an educational institution may remain eligible for MSI on a yearly basis. To qualify for MSI, the student must provide to MSI a letter directly from the educational institution which states that they are registered as a full-time student. MSI coverage will be extended on a yearly basis pending receipt of this letter.

Workers who leave Nova Scotia to seek employment elsewhere will still be covered by MSI for up to 12 months, provided they do not establish residence in another province or territory. Services provided to Nova Scotia residents in other provinces or territories are covered by reciprocal agreements. Nova Scotia participates in the Hospital Reciprocal Billing Agreement and the Medical Reciprocal Billing Agreement. Quebec is the only province that does not participate in the Medical Reciprocal Billing Agreement. Nova Scotia pays for services provided by Quebec physicians to Nova Scotia residents at Quebec rates if the services are insured in Nova Scotia. The majority of such claims are received directly from Quebec physicians. In-patient hospital services are paid through the interprovincial reciprocal billing arrangement at the standard ward rate of the hospital providing the service. Nova Scotia pays the host province rates for insured services in all reciprocal billing situations.

The total amount paid by the plan in 2019-2020 for in-patient and out-patient hospital services received in other provinces and territories was $37,085,112.

Nova Scotia residents remain eligible to receive MSI during vacation outside of the province for up to seven months in each calendar year and will continue to be deemed a resident if the following conditions are met:

No amendments were made to the Nova Scotia Health Insurance Policy in 2019-2020.

4.3 Coverage during Temporary Absences Outside Canada

Nova Scotia adheres to the Agreement on Eligibility and Portability for dealing with insured services for residents temporarily outside Canada. Provided a Nova Scotia resident meets eligibility requirements, out-of-country services will be paid, at a minimum, on the basis of the amount that would have been paid by Nova Scotia for similar services rendered in this province. In order to be covered, procedures of a non-emergency nature must have prior approval before they will be covered by MSI.

Residents receiving haemodialysis outside Canada are eligible for reimbursement to a maximum of $496 per day, provided they submit the original service invoice.

Nova Scotia residents remain eligible to receive MSI during vacation out-of-country for up to seven months in each calendar year and continue to be deemed a resident if the above stated conditions are met.

Students and their dependants who are temporarily absent from Nova Scotia and in attendance at an educational institution outside Canada may remain eligible for MSI on a yearly basis. To qualify for MSI, the student must provide to MSI a letter obtained from the educational institution that verifies the student's attendance there in each year for which MSI coverage is requested.

Persons who engage in employment (including volunteering, missionary work or research) outside Canada, which does not exceed 24 months, are still covered by MSI, providing the person has already met the residency requirements.

The total amount spent in 2019-2020 for insured in-patient services provided outside of Canada was $7,327,272. Nova Scotia does not cover out-patient services out-of-country.

In 2019-2020, the total number of residents registered with the health insurance plan was 1,043,849.

No amendments were made to the Nova Scotia Health Insurance Policy in 2019-2020.

4.4 Prior Approval Requirement

Prior approval must be obtained, if residents wish to be reimbursed for elective services outside the country. Application for prior approval is made to the medical consultant of the MSI Plan by a specialist in Nova Scotia on behalf of an insured resident. The medical consultant reviews the terms and conditions and determines whether or not the service is available in the province, or if it can be provided in another province or only out-of-country. The decision of the medical consultant is relayed to the patient's referring specialist. If approval is given to obtain service outside the country, the full cost of that service will be covered under MSI. An administrative review may be requested for individuals who are deemed ineligible.

5.0 Accessibility

5.1 Access to Insured Health Services

Section 3 of the Health Services and Insurance Act states that “subject to this Act and the regulations, all residents of the Province are entitled to receive insured hospital services from hospitals upon uniform terms and conditions.” As well, all residents of the province are insured on uniform terms and conditions in respect of the payment of insured professional services to the extent of the established tariff. There are no user charges or extra charges allowed under the plan. In Nova Scotia, there is not a dedicated number or website to report cases of patient charges.

Complaints generally come directly to the Department of Health and Wellness via telephone or e-mail; are received by Medavie Blue Cross and then directed to the Department; or are directed to the College of Physicians and Surgeons of Nova Scotia (CPSNS). Complaints are investigated and addressed.

The Department of Health and Wellness General Inquiry contact information is as follows:

By phone: 902-424-5818
1-800-387-6665 (toll-free in Nova Scotia)
1-800-670-8888 (TTY/TDD)

By mail: Department of Health and Wellness
PO Box 488
Halifax, Nova Scotia B3J 2R8

E-mail questions or feedback on-line.

Nova Scotia continually monitors and reviews situations around access to insured health services across Canada to ensure equity of access.  

5.2 Physician Compensation

The Health Services and Insurance Act, RS Chapter 197 governs payment to physicians and dentists for insured services. Physician payments are made in accordance with a negotiated agreement between Doctors Nova Scotia (the sole bargaining agent for physicians) and the Province of Nova Scotia, as represented by the Minister.

Fee-for-service is the most prevalent method of payment for physician services; however, there is growth in the share of total physician payments made through alternative payment arrangements. Alternative payment arrangements facilitate the delivery of medical care that may not be compatible with the fee-for-service funding model and are often used to support physician recruitment and retention, and the funding of group-based care in rural areas where service volumes are expected to be less. Additionally, within the academic funding context, payments may include compensation for non-medical activities such as teaching, research, and administration.

The 2019 Master Agreement committed the province to developing a blended capitation model; this work is underway. Other funding programs such as emergency agreements, sessional funding, and locum funding are also utilized by the province.

In Nova Scotia, payment and payment monitoring are part of Medical Services Insurance’s (MSI) deliverables. Section 9 of the 2019 Master Agreement lays out the Department’s right to conduct audits of Physicians with respect to insured medical service being claimed. Schedule E of the Master Agreement outlines billing audit processes including an Audit Committee of the Master Agreement Management Group to review the audit process and make recommendations. Annually, MSI develops an audit plan and conducts monitoring of claims to determine whether:

Payment rates for dental services in the province are negotiated between the Department and the Nova Scotia Dental Association following a process similar to physician negotiations. Dentists are generally paid on a fee-for-service basis. Pediatric dentists at the IWK Health Centre receive remuneration through an Academic Funding Plan.

5.3 Payments to Hospitals

The Department establishes budget targets for health care services. It does this by receiving business plans from the Nova Scotia Health Authority and the IWK Health Centre and other non-district health authority organizations. Approved provincial estimates form the basis on which payments are made to these organizations for service delivery.

The Health Authorities Act establishes the Nova Scotia Health Authority and the IWK Health Centre as the bodies responsible for overseeing the delivery of health services in the province of Nova Scotia and requires them to work collaboratively to do so.

Section 10 of the Health Services and Insurance Act and sections 9 through 13 of the Hospital Insurance Regulations define the terms for payments by the Minister of Health and Wellness to hospitals for insured hospital services.
In 2019-2020 there were 2,828 hospital beds in Nova Scotia (2.9 beds per 1,000 population). Department direct expenditures for insured hospital services operating costs were $2,033,885,945.

6.0 Recognition Given to Federal Transfers

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

The Government of Nova Scotia also recognized the federal contribution under the Canada Health Transfer in various published documents, including the following documents:

Registered Persons
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
1. Number as of March 31st 1,008,726 1,012,642 1,020,007 1,034,476 1,043,849
Insured Hospital Services Within Own Province or Territory
Public Facilities 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
2. Number 35 35 35 35 35
3. Payments for insured health services ($)Nova Scotia Table 2 Footnote 1 1,720,856,746 1,790,425,313 1,862,969,024 1,917,181,492 2,033,885,945
Private For-Profit Facilities 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
4. Number of private for-profit facilities providing insured health servicesNova Scotia Table 2 Footnote 2 0 0 0 0 0
5. Payments to private for-profit facilities for insured health services ($) Not applicable Not applicable Not applicable Not applicable Not applicable
Nova Scotia table 2 Footnote 1

Reflects payments made to the public facilities noted for indicator 2.

Nova Scotia table 2 Return to footnote 1 referrer

Nova Scotia table 2 Footnote 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.

Nova Scotia table 2 Return to footnote 2 referrer
Insured Hospital Services Provided to Residents in Another Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
6. Total number of claims, in-patient 2,019 1,882 2,995 2,934 1,986
7. Total payments, in-patient ($) 19,022,461 19,801,011 19,474,523 19,879,822 21,568,883
8. Total number of claims, out-patient 40,344 37,910 39,706 40,361 38,929
9. Total payments, out-patient ($) 14,174,680 14,428,730 15,209,411 15,715,186 15,516,229
Insured Hospital Services Provided Outside CanadaNova Scotia Table 4 Footnote 1
Pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
10. Total number of claims, in-patient Not applicable Not applicable Not applicable Not Available Not Available
11. Total payments, in-patient ($) Not applicable Not applicable Not applicable 2,386,348 7,327,272
12. Total number of claims, out-patient Not applicable Not applicable Not applicable Not Available Not Available
13. Total payments, out-patient ($) Not applicable Not applicable Not applicable Not Available Not Available
Non pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
14. Total number of claims, in-patient Not applicable Not applicable Not applicable Not Available Not Available
15. Total payments, in-patient ($) Not applicable Not applicable Not applicable 331,879 352,994
16. Total number of claims, out-patient Not applicable Not applicable Not applicable Not Available Not Available
17. Total payments, out-patient ($) Not applicable Not applicable Not applicable Not Available Not Available
Nova Scotia Table 4 Footnote 1

Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report, but did not require provinces or territories to report on previous years.

Nova Scotia Table 4 Return to footnote 1 referrer
Insured Physician Services Within Own Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
20. Number of non-participating physicians Not applicable Not applicable Not applicable Not applicable Not applicable
21. Total payments for services provided by physicians paid through all payment methods ($) 740,465,887 735,418,537 769,657,951 800,367,900 834,933,109
22. Total payments for services provided by physicians paid through fee-for-service ($) 378,290,569 377,118,049 352,410,103 357,558,840 352,279,973
Insured Physician Services Provided to Residents in Another Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
23. Number of services 222,026 220,932 215,616 221,096 226,834
24. Total payments ($) 9,304,321 9,167,527 9,023,845 9,292,479 9,522,757
Insured Physician Services Provided Outside CanadaNova Scotia Table 7 Footnote 1
Pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
25. Number of services Not applicable Not applicable Not applicable 38 47
26. Total payments ($) Not applicable Not applicable Not applicable 119,968 110,315
Non pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
27. Number of services Not applicable Not applicable Not applicable 1,971 1,391
28. Total payments ($) Not applicable Not applicable Not applicable 121,608 91,170
Nova Scotia Table 7 Footnote 1

Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report,but did not require provinces or territories to report on previous years.

Nova Scotia Table 7 Return to footnote 1 referrer
Insured Surgical-Dental Services Within Own Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
29. Number of participating dentists 28 26 19 18 18
30. Number of opted-out dentistsNova Scotia Table 8 Footnote 1 Not applicable 0 0 1 0
31. Number of non-participating dentistsNova Scotia Table 8 Footnote 1 Not applicable 0 0 0 0
32. Number of services providedNova Scotia Table 8 Footnote 2 8,591 8,518 8,123 6,642 6,381
33. Total payments ($)Nova Scotia Table 8 Footnote 3 1,401,379 1,470,674 1,422,086 1,427,177 1,460,699
Nova Scotia Table 8 Footnote 1

Health Canada requested this data as of the 2016-2017 report, but did not require provinces or territories to report data for 2015-16.

Nova Scotia Table 8 Return to footnote 1 referrer

Nova Scotia Table 8 Footnote 2

Total services includes block funded dentists. This also inclued maxillofacial and cleft palate surgeries.

Nova Scotia Table 8 Return to footnote 2 referrer

Nova Scotia Table 8 Footnote 3

Total payments does not include block funded dentists.

Nova Scotia Table 8 Return to footnote 3 referrer

New Brunswick

As with the rest of Canada, in March 2020, New Brunswick was faced with the unique challenges posed by the COVID-19 virus. Taking immediate steps, such as expanding the virtual provision of care at a time when physical contact put both patients and providers at risk, New Brunswick initiated actions to continue to ensure that citizens receive the care that they need, while preserving capacity to fight the pandemic.

We are proud of the way care New Brunswick’s health providers and citizens, and civil servants from all Orders of Government have risen to this challenge, showing an admirable combination of competence, courage, determination, and compassion.

1.0 Public Administration

1.1 Health Care Insurance Plan and Public Authority

In New Brunswick, the formal name for Medicare is the Medical Services Plan. The Minister of Health (Minister) has the mandate and responsibility for operating and administering the plan by virtue of the Medical Services Payment Act and its Regulations. The Act and Regulations set out who is eligible for Medicare coverage, the rights of the patient, and the responsibilities of the Department of Health (the Department). This law establishes a Medicare plan, and defines which Medicare services are covered and which are excluded. It also stipulates the type of agreements the Department may enter into. As well, it specifies the rights of a medical practitioner; how the amounts to be paid for medical services will be determined; how assessment of accounts for medical services may be made; and confidentiality and privacy issues as they relate to the administration of the Act.

1.2 Reporting Relationship

The Medicare and Physician Services Branch of the Department are mandated to administer the Medical Services Plan. The Minister reports to the Legislative Assembly through the Department’s annual report and through regular legislative processes.

The Regional Health Authorities Act establishes the regional health authorities (RHA) and sets forth the powers, duties, and responsibilities of the same. The Minister is responsible for the administration of the Act, provides direction to each RHA, and may delegate additional powers, duties or functions to the RHA.

The Department of Health prepares and submits an Annual Report to the Legislature, and also provides information to the Office of the Comptroller for inclusion in their Public Accounts documents. The Minister and Department of Health executive team are accountable to answer questions of members of the Legislature pursuant to those Public Accounts documents. The most current Department of Health Annual Report can be found here.

1.3 Audit of Accounts

Three groups have a mandate to audit the Medical Services Plan.

The Office of the Auditor General: In accordance with the Auditor General Act, the Office of the Auditor General conducts the external audit of the accounts of the province of New Brunswick, which includes the financial records of the Department. The Auditor General also conducts management reviews on programs as they see fit. Chapter 2 of the Auditor General’s June 2019 report reviewed the way in which Medicare Cards are renewed. The report’s key findings and the Department’s responses can be found here.

The Office of the Comptroller: The Comptroller is the chief internal auditor for the province of New Brunswick and provides accounting, audit and consulting services in accordance with responsibilities and authority set out in the Financial Administration Act. Annual financial statements and supplementary information submitted to the Legislature by the Office of the Comptroller for all publicly funded purposes including those associated with insured services under the Canada Health Act) can be found here. 

Monitoring and Compliance Team: This team is tasked with managing compliance with the Medical Services Payment Act and Regulations, as well as the Negotiated Fee Schedule.

2.0 Comprehensiveness

2.1 Insured Hospital Services

Legislation providing for insured hospital services as described in the Canada Health Act includes the Hospital Services Act, section 9 of Regulation 84–167, and the Hospital Act. Under Regulation 84–167 of the Hospital Services Act, New Brunswick residents are entitled to the following insured hospital services.

Insured in-patient services include:

Insured out-patient services include:

In 2019-2020 no amendments were made to the Acts or Regulations noted above, nor were any insured services added or deleted.

The publicly funded New Brunswick health system is rich in medical imaging resources, and imaging deemed by a referring physician to be medically necessary is conducted swiftly, without patient comments or concerns respecting accessibility. There is no evidence in New Brunswick of unmet patient need for timely access to CHA insurable imaging services.

Accordingly, New Brunswick finds no present need to legislate or regulate such private businesses. While in 2019-2020 there was one clinic in New Brunswick soliciting private clients for diagnostic imaging, the Department has no relationship with the organization, and does not foresee entering into one.

2.2 Insured Physician Services

The Medical Services Payment Act and corresponding regulations provide for insured physician services. As of March 31, 2020, there were 1,748 participating physicians in New Brunswick. While any practitioner licensed in New Brunswick who has not affirmatively “opted-in” is deemed to have “opted out” (and no further action is required to have opted-out status), no physicians rendering health care services in this fiscal year so chose. Opted-out practitioners are not paid directly by Medicare for the services which they render, must bill their patients in all cases, and the patients are not entitled to a reimbursement from Medicare. Further, practitioners can elect to opt-out for any given patient only for the total management of the patient’s condition under care, including any complications which may develop within a reasonable length of time, and they must advise the patient in advance of rendering service that they are opting-out for those services.

The services which residents are entitled to under Medicare include:

A physician or the Department of Health may request the addition of a new service. All requests are considered by the New Service Items Committee, which is jointly managed by the New Brunswick Medical Society and the Department. The decision to add a new service is based on conformity to the definition of “medically necessary” and whether the service is considered generally acceptable practice (not experimental) within New Brunswick and/or Canada. Considerations under the term “medically necessary” include services required for maintaining health, preventing disease and/or diagnosing or treating an injury, illness or disability. No public consultation process is used.

In May 2019, Regulation 2019-9 added audiologists to the lists in Section 11(2.1) and 11(2.2) of those who may refer to a medical practitioner or oral and maxillofacial surgeon. Apart from this, there were no changes to the Medical Services Payment Act or Regulation during the period of this report.

2.3 Insured Surgical-Dental Services

Schedule 4 of Regulation 84–20 under the Medical Services Payment Act identifies the insured surgical- dental services that can be provided by a qualified dental practitioner in a hospital, providing the condition of the patient requires services to be rendered in a hospital.

In addition, a general dental practitioner may be paid to assist another dentist for medically required services under some conditions. In addition to Schedule 4 of Regulation 84–20, oral maxillofacial surgeons (OMS) have added access to approximately 300 service codes in the Physician Manual and can admit or discharge patients and perform physical examinations, including those performed in an out-patient setting. OMS may also see patients for consultation in their office.

As of March 31, 2020, there were 11 dentists and oral maxillofacial surgeons who provided services insured under the Medical Services Plan.

There is not a formally defined process through which new dental services may be added to the list of insured services; however, oral maxillofacial surgeons may approach government with such a request if they deem it appropriate. In 2019-2020 there were no such additions.

2.4 Uninsured Hospital, Physician and Surgical-Dental Services

Uninsured hospital services include:

The services listed in Schedule 2 of New Brunswick Regulation 84–20 under the Medical Services Payment Act are specifically excluded from the range of entitled medical services under Medicare. They are as follows:

Dental services not specifically listed in Schedule 4 of the Dental Schedule are not covered by the Plan. Those listed in Schedule 2 are considered the only non-insured medical services.

There are no specific policies or guidelines, other than the Act and Regulations, to ensure that charges for uninsured medical goods and services (e.g., fibreglass casts), provided in conjunction with an insured health service, do not compromise reasonable access to insured services.

The decision to de-insure physician or surgical-dental services is based on the conformity of the service to the definition of “medically necessary,” a review of medical service plans across the country, and the previous use of the particular service. Once a decision to de-insure is reached, the Medical Services Payment Act dictates that the government may not make any changes to the Regulation until the advice and recommendations of the New Brunswick Medical Society are received or until the period within which the Society was requested by the Minister to furnish advice and make recommendations has expired. Subsequent to receiving their input and resolution of any issues, a regulatory change is completed. Physicians are informed in writing following notification of approval. The public is usually informed through a media release. No public consultation process is used.

In 2019–2020, no services were removed from the insured services list.

3.0 Universality

3.1 Eligibility

Sections 3 and 4 of the Medical Services Payment Act and Regulation 84–20 define eligibility for the health care insurance plan in New Brunswick. Residents are required to complete a Medicare application and provide proof of identity, proof of residency, and proof of Canadian citizenship or a valid Canadian immigration document. A resident is defined as a person lawfully entitled to be, or to remain, in Canada, who makes their home and is ordinarily present in New Brunswick, but does not include a tourist, transient, or visitor to the province.

As of March 31, 2020, there were 782,398 persons registered in New Brunswick.

All persons entering or returning to New Brunswick (excluding children adopted from outside Canada) have a waiting period before becoming eligible for Medicare coverage. Coverage commences on the first day of the third month following the month of arrival.

Exceptions are as follows:

Residents who were not eligible for Medicare coverage during this reporting period included:

Persons who are discharged or released in New Brunswick from the Canadian Armed Forces, or a federal penitentiary, become eligible for coverage on the date of their discharge or release. An application must be completed and signed, and the applicant must provide proof of Canadian citizenship, proof of residency and the official date of release.

3.2 Other Categories of Individuals

Non-Canadian new hires coming to Canada under a work permit must have a permit valid for a minimum of one year (or two six-month permits within a few months of each other). The Department of Health also requires a copy of their passport (including a copy of the last entry date stamp), and proof of residency in New Brunswick.

Children born out-of-country to Canadian citizens will take the eligibility status of the parent upon return to the province.

Should an individual disagree with a decision of the Department of Health, including a decision respecting eligibility to receive services, they may petition the Insured Services Appeal Committee, which shall provide advice to the Minister.

There were no amendments made to eligibility provisions in 2019-2020.

4.0 Portability

4.1 Minimum Waiting Period

A person is eligible for New Brunswick Medicare coverage on the first day of the third month following the month permanent residency has been established. The three month waiting period is legislated under New Brunswick’s Medical Services Payment Act. Refer to section 3.1 of this submission for exceptions; there were no amendments made to this section of the Act in 2019-2020.

4.2 Coverage during Temporary Absences in Canada

The legislation that defines portability of health insurance during temporary absences in Canada is the Medical Services Payment Act, Regulation 84–20, sub-sections 3(4) and 3(5). This portion of the Act was not amended in 2019-2020.

Medicare coverage may be extended upon request in the case of temporary absences to:

Students: Those in full-time attendance at a university or other approved educational institution, who leave the province to further their education in another province, will be granted coverage for a 12 month period that is renewable, provided the following terms are met:

Residents: Residents temporarily employed in another province or territory are granted coverage for up to 12 months, provided the following terms are met:

New Brunswick has formal agreements for reciprocal billing arrangements of insured hospital services with all provinces and territories. In addition, New Brunswick has reciprocal agreements with all provinces, except Quebec, for the provision of insured physician services. Services provided by Quebec physicians to New Brunswick residents are paid at Quebec rates provided the service delivered is insured in New Brunswick. The majority of such claims are received directly from Quebec physicians. Any claims submitted directly by a patient are reimbursed to the patient.

4.3 Coverage during Temporary Absences Outside Canada

The legislation that defines portability of health insurance during temporary absences outside Canada is the Medical Services Payment Act, Regulation 84–20, subsections 3(4) and 3(5).

Eligibility for New Brunswick residents temporarily absent outside of Canada is determined in accordance with the Medical Services Payment Act.

Residents temporarily employed outside Canada are granted coverage for 182 days. This may be extended up to 12 months within a three year period upon approval from the Director of Medicare Eligibility and Claims. Exceptions to this are mobile and contract workers.

Coverage for any absence over 212 days for vacation purposes requires approval from the Director of Medicare Eligibility and Claims. This approval can only be for up to 12 months in duration and will only be granted once every three years.

New Brunswick residents exceeding the 12 month extension have to reapply for New Brunswick Medicare upon their return to the province. In this instance, cases are reviewed on a case by case basis. Depending on the circumstances, some cases may be eligible for first day coverage while others who have been away from the province slightly beyond the 12 month period may be given a grace period.

Insured residents who receive insured emergency services out-of-country are eligible to be reimbursed $100 per day for in-patient stays and $50 per out-patient visit. The insured resident is reimbursed for physician services associated with the emergency treatment at New Brunswick rates. The difference in rates is the patient’s responsibility.

Mobile Workers: Mobile Workers are residents whose employment requires them to travel outside the province (e.g., pilots). The following guidelines must be met to receive Mobile Worker designation.

Mobile Worker status is assigned for a maximum of two years, after which the resident must reapply and submit documentation to confirm a continuation of Mobile Worker status.

Contract Workers: Any New Brunswick resident accepting a contract out-of-country must supply the following information and documentation:

Contract Worker status is assigned up to a maximum of two years. Any further requests for contract worker status must be forwarded to the Director of Medicare Eligibility and Claims for approval on an individual basis.

Students: Those in full-time attendance at a university or other approved educational institution in another country will be granted coverage for a 12 month period that is renewable, provided they comply with the following:

4.4 Prior Approval Requirement

Medicare may cover out-of-country services that are not available in Canada on a pre-approval basis only. Residents may opt to seek non-emergency out-of-country services; however, they are responsible for assuming the total cost.

New Brunswick residents may be eligible for reimbursement if they receive elective medical services outside the country, provided the following requirements are met:

If the above requirements are met, it is mandatory to request prior approval from Medicare in order to receive coverage. A physician, patient or family member may request prior approval to receive these services outside the country, accompanied by supporting documentation from a Canadian specialist or specialists.

A beneficiary who disagrees with a decision made by Medicare regarding their case or the case of an immediate family member can appeal to the Insured Services Appeal Committee. Beneficiary appeals can include decisions about eligibility, refusal of a claim payment for entitled services or the amount paid on a claim. The Committee includes members from the general public. It meets three to four times a year based on the number of cases. It reviews each case and presents recommendations to the Minister of Health who makes the final decision regarding an appeal.

Out-of-country insured services that are not available in Canada, are non-experimental, and receive prior approval are paid in full. Often the amount payable is negotiated with the provider by Global Medical Management on the province’s behalf.

Haemodialysis is exempt from the out-of-country coverage policy. Patients are required to obtain prior approval and Medicare will reimburse the resident at a rate equivalent to the current inter-provincial rate per session.

A New Brunswick patient may choose to receive an insured service paid by Medicare in any public hospital in Canada, without prior approval. Most of these services are covered by Interprovincial Reciprocal Billing Agreements, although some may be billed directly to the host province. Some procedures require prior Medicare approval before a patient will be accepted for treatment in another province (e.g. high cost procedures, residential addictions/mental health services, some plastic procedures etc.). Should such prior approval be required, the attending physician would write to the medical consultant with Medicare, providing pertinent documentation and the reason for the out-of-province referral. Travel is not covered by Medicare, but lodging may be considered if the patient meets Medicare’s Hostel Policy criteria.

5.0 Accessibility

5.1 Access to Insured Health Services

New Brunswick’s health care system delivers equitable, quality care to the public it serves. As indicated in section 13.1 of Medical Services Payment Act Regulation 84–20, New Brunswick does not permit user fees for insured health services as defined by the Canada Health Act. New Brunswick uses a robust “comment based” approach to identifying individual citizens’ concerns on a wide range of health issues. In a typical month in the 2019–2020 fiscal year, the Department of Health received, logged, and responded to 100–150 concerns from individual New Brunswickers on issues including access to primary or specialized care, pharmaceutical approvals, access to services in a citizen’s language of choice, wait times for specific services, the structure of specific programs, etc. The Department’s web page provides several mechanisms to make such comments, including mailing addresses, e-mail addresses, telephone numbers, and a web-based message service. One contact respecting a privately provided imaging service was received in the 2019–2020 fiscal year. Specifically prohibited for reimbursement by the Medical Services Payment Act when provided privately, review indicated that the patient experienced no access barrier – neither respecting geography, nor the scheduled date of the service.

Access in a resident’s official language of choice is not a limiting factor, regardless of where a resident receives services in the province.

Improving access to primary care and acute care is an ongoing focus within New Brunswick’s health system. To support this focus, Government announced a number of investments in 2019–2020 that will further improve access to health services. They include:

5.2 Physician Compensation

Payments to physicians and dentists are governed under the Medical Services Payment Act, Regulations 84–20, 93–143 and 2002–53.

The methods used to compensate physicians for providing insured health services in New Brunswick are fee-for-service, salary and sessional, alternate payment mechanisms or Family Medicine New Brunswick that may include a blended system.

5.3 Payments to Hospitals

The legislative authorities governing payments to hospital facilities in New Brunswick are the Hospital Act, which governs the administration of hospitals, and the Hospital Service Act, which governs the financing of hospitals. The Regional Health Authorities Act provides for the delivery and administration of health services in defined geographic areas within the province.

The Department mainly distributes available funding to New Brunswick’s regional health authorities (RHA) through a Current Service Level approach. The funding base of the RHA from the previous year is the starting point, to which approved salary increases and a global inflator for non-wage items are added. This applies to all clinical services provided by hospital facilities, as well as support services (e.g., administration, food services, etc.).

Funding for Service New Brunswick, a shared services agency that manages the information technology, materials management, laundry and clinical engineering components of the hospital facilities in New Brunswick, is also based on the Current Service Level approach.

Any requests for funding for new programs or services are submitted to the Deputy Minister of Health for approval. Funding for approved new programs or services is based on requirements identified through discussions between Department of Health and RHA staff. These amounts are added to the RHA funding base once there is agreement on the funding requirements.

6.0 Recognition given to Federal Transfers

New Brunswick recognizes the federal role regarding its contributions under the Canada Health Transfer in public documentation presented through legislative and administrative processes. Federal transfers are identified in the Main Estimates document and in the Public Accounts of New Brunswick. Both documents are published annually by the New Brunswick government.

Registered Persons
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
1. Number as of March 31st 754,522 761,157 767,562 775,093 782,398
Insured Hospital Services Within Own Province or Territory
Public Facilities 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
2. Number 62 62 62 64 64
3. Payments for insured health services ($) 1,666,482,214 1,704,602,299 1,778,140,499 1,933,194,385 1,942,617,634
Private For-Profit FacilitiesNew Brunswick Table 2 Footnote 1 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
4. Number of private for-profit facilities providing insured health services 0 0 0 0 0
5. Payments to private for-profit facilities for insured health services ($) 0 0 0 0 0
New Brunswick Table 2 Footnote 1

There are no private for-profit facilities providing health insured services operating in New Brunswick.

New Brunswick Table 2 Return to footnote 1 referrer
Insured Hospital Services Provided to Residents in Another Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
6. Total number of claims, in-patient 4,972 4,552 4,524 4,517 4,506
7. Total payments, in-patient ($) 52,181,789 46,528,311 50,506,502 47,646,790 48,739,305
8. Total number of claims, out-patient 53,344 50,434 49,939 50,858 51,004
9. Total payments, out-patient ($) 20,046,048 20,857,748 21,199,404 21,711,066 22,677,309
Insured Hospital Services Provided Outside CanadaNew Brunswick Table 4 Footnote 1
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
10. Total number of claims, pre-approved in-patient Not applicable Not applicable Not applicable 5 4
11. Total payments, pre-approved in-patient ($) Not applicable Not applicable Not applicable 12,555 273,499
12. Total number of claims, pre-approved out-patient Not applicable Not applicable Not applicable 16 78
13. Total payments, pre-approved out-patient ($) Not applicable Not applicable Not applicable 37,319 1,126,040
Non pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
14. Total number of claims, non pre-approved in-patient Not applicable Not applicable Not applicable 101 74
15. Total payments, non pre-approved in-patient ($) Not applicable Not applicable Not applicable 68,869 535,056
16. Total number of claims, non pre-approved out-patient Not applicable Not applicable Not applicable 624 524
17. Total payments, non pre-approved out-patient ($) Not applicable Not applicable Not applicable 245,165 972,707
News Brunswick Table 4 Footnote 1

Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report, but did not require provinces or territories to report on previous years.

New Brunswick Table 4 Return to footnote 1 referrer
Insured Physician Services Within Own Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
18. Number of participating physiciansNew Brunswick Table 5 Footnote 1 1,652 1,666 1,742 1,734 1,748
19. Number of opted-out physicians 0 0 0 0 0
20. Number of non-participating physicians 0 0 0 0 0
21. Total payments for services provided by physicians paid through all payment methods ($)New Brunswick Table 5 Footnote 2 589,156,558 598,757,372 616,104,222 637,821,346 631,179,766
22. Total payments for services provided by physicians paid through fee-for-service ($) 362,601,062 373,715,908 381,321,118 393,236,955 405,341,277
New Brunswick Table 5 Footnote 1

These are the number of physicians with an active physician status on March 31st of each year.

New Brunswick Table 5 Return to footnote 1 referrer

New Brunswick Table 5 Footnote 2

The total payment for all payment methods.

New Brunswick Table 5 Return to footnote 2 referrer
Insured Physician Services Provided to Residents in Another Province or TerritoryNew Brunswick Table 6 Footnote 1
Private For-Profit Facilities 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
23. Number of services 247,273 226,812 225,177 218,578 212,579
24. Total payments ($) 24,675,343 23,067,671 22,061,956 22,167,200 21,681,383
New Brunswick Table 6 Footnote 1

These are all physician services provided to residents and dispensed in another province.

New Brunswick Table 6 Return to footnote 1 referrer
Insured Physician Services Provided Outside CanadaNew Brunswick Table 7 Footnote 1
Pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
25. Number of pre-approved services Not applicable Not applicable Not applicable 547 622
26. Total pre-approved payments ($) Not applicable Not applicable Not applicable 25,142 103,403
Non pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
27. Number of non pre-approved services Not applicable Not applicable Not applicable 2,955 1,933
28. Total non pre-approved payments ($) Not applicable Not applicable Not applicable 296,008 175,131
New Brunswick Table 7 Footnote 1

Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report,but did not require provinces or territories to report on previous years.

New Brunswick Table 7 Return to footnote 1 referrer
Insured Surgical-Dental Services Within Own Province
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
29. Number of participating dentistsNew Brunswick Table 8 Footnote 1 9 11 13 10 11
30. Number of opted-out dentistsNew Brunswick Table 8 Footnote 2 Not applicable Not applicable Not applicable Not applicable Not applicable
31. Number of non-participating dentistsNew Brunswick Table 8 Footnote 2 Not applicable Not applicable Not applicable Not applicable Not applicable
32. Number of services provided 1,607 1,623 1,788 1,601 1,747
33. Total payments ($) 273,686 343,764 379,857 314,903 331,722
New Brunswick Table 8 Footnote 1

These are the number of dentists and oral maxillofacial surgeons (OMS) participating in New Brunswick's Medical Services Plan during a fiscal year. Routine dental services are not covered by New Brunswick Medicare therefore few dentists and OMSs are registered - only some emergency dental services done in hospital are covered by the Medical Services Plan.

New Brunswick Table 8 Return to footnote 1 referrer

New Brunswick Table 8 Footnote 2

Health Canada requested this data as of the 2016-2017 report, but did not require provinces or territories to report data for 2015-16. In general, NB Medicare does not keep track of dentists in the province.

New Brunswick Table 8 Return to footnote 2 referrer

Quebec

COVID-19

COVID-19 testing is covered for all persons in Quebec, whether or not they have a health insurance card.

Health care coverage by client category, as of March 30, 2020
Client category COVID-19 test Health care (professional and hospital services) for Covid-19 Health care (professional and hospital services) unrelated to COVID-19

Person with an expired card

Covered

Covered (easing – expired card honoured)

Covered under the usual terms of the plan, expired card honoured

Person repatriated by the Government of Canada during the pandemic

Covered

Covered

Covered under the usual terms of the plan, but without a waiting period

Person temporarily residing outside Quebec returning to Quebec after more than 183 days abroad

Covered

Covered

Covered under the usual terms of the plan,
but Presence in Québec rule of 183 days is suspended

Homeless person

Covered

Covered (easing – authentification and photo card are not required)

Covered under the usual terms of the plan

Person temporarily residing outside of Quebec, currently in Canada

Not applicable

Covered under the usual terms of the legal and regulatory framework

Covered under the usual terms of the legal and regulatory framework

Person temporarily residing outside of Quebec, currently outside of Canada

Not applicable

Covered under the usual terms of the legal and regulatory framework

Covered under the usual terms of the legal and regulatory framework

Person with refugee status

Covered

Covered

Covered under the usual terms of the plan

Newcomer (person who has recently settled in Quebec on a permanent basis)

Covered

Covered
Pursuant to memo 2014-030 (01.01.10.03) of the Quebec department of health and social services– services required for health problems of an infectious nature affecting public health – these services are covered during the waiting period

Covered under the usual terms of the plan, with a 3‑month waiting period

Foreign worker or student from a country that is signatory to a social security agreement with Quebec (person who has recently arrived in Quebec as a temporary resident to work or study, with a valid residency permit)
The signatory countries are: Belgium, Denmark, Finland, France, Greece, Luxembourg, Norway, Portugal, Romania, Sweden

Covered

Covered (without waiting period)

Covered under the usual terms of the plan (without waiting period)

Foreign worker (person who has recently arrived in Quebec as a temporary resident to work, with a valid residency permit)

Covered

Covered
Pursuant to memo 2014-030 (01.01.10.03) of the Quebec department of health and social services– services required for health problems of an infectious nature affecting public health – these services are covered during the waiting period

Covered under the usual terms of the plan, with a 3‑month waiting period

Foreign worker or student (person who is a temporary resident in Quebec, to work or study, with an expired residency permit)

Covered

Covered if there is no coverage provided by the person's country of origin, a federal program, or an insurance policy

Not covered

Refugee protection claimant (including persons crossing the Canada – United States border irregularly)

Covered

Covered under the Interim Federal Health Program (IFHP)

Covered under the Interim Federal Health Program (IFHP)

Person without status or undocumented person

Covered

Covered if there is no coverage provided by the person's country of origin, a federal program, or an insurance policy

Not covered

Traveller, tourist and any other category of persons who are not eligible to obtain a health insurance card (includes students who are not from a country that is signatory to a social security agreement with Quebec)

Covered

Covered if there is no coverage provided by the person's country of origin, a federal program, or an insurance policy

Not covered

1.0 Public Administration

1.1 Health Insurance Plan and Public Authority

Quebec’s hospital insurance plan, the Régime d’assurance hospitalisation du Québec, is administered by the Ministère de la Santé et des Services sociaux (MSSS) [the Quebec Department of Health and Social Services].

Quebec’s health and drug insurance plans are administered by the Régie de l’assurance maladie du Québec (the Régie), a public body established by the provincial government which reports to the Minister of Health and Social Services.

RAMQ is responsible for the sound management of the Québec Health Insurance Plan and of the Public Prescription Drug Insurance Plan. As part of its mission, it manages the eligibility of persons for the plans, monitors the remuneration of health professionals and facilitates access to health care. Find out more about RAMQ through its mission, services, values, services and publications.

1.2 Reporting Relationships

The Public Administration Act (R.S.Q., c. A-6.01) sets forth government criteria for preparing reports on the planning and performance of public authorities, including the MSSS and the Régie.

The Board must, not later than 15 October each year, produce a report showing the sums it has paid out to physicians in the course of the preceding fiscal year under the Health Insurance Act (chapter A-29). The report must indicate, on the one hand, the proportion of budget variance between expenditures and estimates and on the other, the reasons for such variance.

Not later than 31 July each year, the Board shall submit to the Minister of Health and Social Services a report of its activities for its previous fiscal year; such report shall also contain all the information which the Minister of Health and Social Services may prescribe.

In a separate section of the report, the Board shall state, in particular, the number of inspections and investigations conducted and, as regards the latter, their class and the number of them having lasted more than one year, as well as the sums recovered following those inspections and investigations.

Such report shall be laid before the National Assembly if it is in session or, if it is not, within thirty days of the opening of the next session.

The Board shall give the Minister of Health and Social Services any information he may require respecting its operations.

1.3 Audit of Accounts

The Quebec Hospital Insurance Plan and the Quebec Health and Drug Insurance Plans are administered by the public authorities on a non-profit basis. All books and accounts are audited by the auditor general of the province.

The books and accounts of the Board shall be audited by the Auditor General each year and also whenever so ordered by the Government; his reports shall accompany the annual report of the Board.

The QC Ombudsperson released their 2019-2020 annual report in September 2020, which includes commentary on RAMQ, and can be accessed at the following site: https://publications.virtualpaper.com/protecteur-citoyen/annual_report_2020/#2/

2.0 Comprehensiveness

2.1 Insured Hospital Services

Insured in-patient services include the following:

Out-patient services include the following:

Other insured services are:

The Ministère de la Santé et des Services sociaux (MSSS) administers a free ambulance transportation program for persons aged 65 and older, in accordance with the parameters described in the Quebec policy on user transportation. It should be noted that this policy will be revised in the coming year.

In addition to basic insured health services, the Régie de l’assurance maladie du Québec (the Régie) also covers:

It also covers, for Quebec residents within the meaning of the Health Insurance Act (R.S.Q. c. A-29) who meet the eligibility criteria for each program:

This coverage applies only to aids and appliances covered in the Regulations. Financial aid is granted for external breast prostheses, ocular prostheses, devices provided to ostomies, and compression clothing for people with lymphedema.

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 otherwise would not have access to a private drug insurance plan. In 2019-2020, the public drug insurance plan covered 4.1 million insured persons.

2.2 Insured Physician Services

Services insured under this plan include medical and surgical services that are provided by physicians participating in the plan and are medically necessary.

Also included are:

2.3 Insured Surgical-Dental Services

Services insured under this plan include surgery performed by dental surgeons and specialists in oral and maxillofacial surgery, in a prescribed hospital centre or university institution.

2.4 Uninsured Hospital, Physician and Surgical-Dental Services

Uninsured hospital services include:

The following services are not insured:

3.0 Universality

3.1 Eligibility

Registration with the Hospital Insurance Plan is not required. Registration with the Régie de l’assurance maladie du Québec (RAMQ) is sufficient to establish an individual’s eligibility. Any individual residing or staying in Quebec as defined in the Health Insurance Act must be registered with RAMQ to be eligible for hospital services.

A person whose eligibility has been denied or who is dissatisfied with a decision of the RAMQ may request a review of the decision. The request for a review must be submitted to the RAMQ in a written notice setting out the reasons for the request. The request must be submitted within the six-month period following the date when the requester was informed of the decision.

As a last resort, within 60 days of being notified of the decision, a person may contest before the Tribunal administrative du Québec the decision for which the person has requested a review.

No relevant amendments to eligibility were made in 2019-2020.

3.2 Other Categories of Individuals

Inmates in federal penitentiaries are not covered by the Quebec Health Insurance Plan.

Certain categories of residents, notably permanent residents under the Immigration Act and persons returning to live in Canada, become eligible under the plan following a waiting period of up to three months. Persons from another country receiving last-resort financial assistance benefits are eligible upon registration. 

Canadian Forces personnel and their family members posted to Quebec from another Canadian province or territory who have status permitting them to settle there are eligible on the date of their arrival. Those who have not acquired Quebec resident status, and inmates of federal penitentiaries, become insured the day they are discharged or released.

Immediate coverage is provided for certain seasonal workers, repatriated Canadians, persons from outside Canada who are living in Quebec under an official bursary or internship program of the Ministère de l’Éducation [the Quebec Department of Education], persons from outside Canada who are eligible under an agreement or accord reached with a country or an international organization, and refugees. 

Persons from outside Canada who have work permits and are living in Quebec for the purpose of holding an office or employment for a period of more than six months may be eligible for the plan following a waiting period of up to three months.

4.0 Portability

4.1 Minimum Waiting Period

Persons settling in Quebec after moving from another province of Canada are entitled to coverage under the Quebec Health Insurance Plan when they cease to be entitled to benefits from their province of origin, provided they register with the Régie and meet certain conditions.

4.2 Coverage during Temporary Absences from Quebec

If living outside Quebec in another province or territory for 183 days or more and provided they so notify the Régie, students and full-time unpaid trainees may retain their status as residents of Quebec:

This is also the case for persons living outside Quebec who are temporarily employed or working on contract there. Their resident status can be maintained for no more than two consecutive calendar years. 

Persons who are directly employed or working on contract outside Quebec for a company or corporate body with its headquarters or a place of business in Quebec to which they report directly, or who are employed by the federal government and posted outside Quebec, also retain their status as a resident of the province. The same is true of persons who remain outside the province for 183 days or more, but less than 12 months within a calendar year, provided such absence occurs only once every seven years.

Insured persons who leave Quebec to live in another province or territory in Canada remain eligible for health insurance for up to three months after their departure, but their eligibility for the Quebec drug plan ends on the day of their departure.

However, coverage for insured persons who leave Quebec to permanently move abroad terminates the day of their departure.

4.3 Reimbursement of Professional Services Received Outside Quebec

The costs of insured services provided by health professionals to an insured person in another province or territory of Canada are reimbursed for the amount actually paid or at the rate that would have been paid by the Régie for such services in Quebec, whichever is lower. Exceptionally, for the Outaouais region, Quebec has negotiated a permanent arrangement with Ontario to pay Ottawa medical specialists at the Ontario fee rate for specialized services that are not available in the Outaouais region. This agreement came into effect on November 1, 1989. The Régie covers the amount it would have paid for the same services in Quebec. The Centre intégré de services de santé et de services sociaux de l’Outaouais [Outaouais integrated health and social services centre] pays the difference between the cost invoiced by Ontario and the amount initially reimbursed by the Régie. A similar agreement was signed in December 1991 between the Centre de santé Témiscaming [Témiscaming Health Centre] and the North Bay Regional Health Centre.

The service provided must be an insured service within the meaning of the Act. Services that are experimental in nature are not reimbursed.

4.4 Reimbursement of Hospital Services Received in Canada

Costs for hospital services provided to an insured person in another province or territory of Canada are paid in accordance with the terms and conditions of the Hospital Reciprocal Billing Agreement regarding hospital insurance agreed to by the provinces and territories of Canada. These costs are paid either at the established per diem for hospitalization in a standard ward or in intensive care proposed by the host province and approved by all the provinces and territories or, in cases of out-patient services or expensive procedures, at the approved interprovincial rates. Services that are excluded from interprovincial agreements but covered under the provincial program are reimbursed at the rate in force. 

4.5 Reimbursement of Hospital Services Outside Canada

During a temporary stay outside Canada, the Régie reimburses the full cost of emergency hospital services and 75 per cent of the cost in other cases to students, unpaid trainees, Quebec government employees posted abroad and employees of non-profit organizations working in international aid or co-operation programs recognized by the Minister of Health and Social Services (the Minister). However, when such persons go on holiday outside their place of study, training or work, this coverage is no longer in force, and regular coverage for hospital services applies.

Residents of Quebec who are working or studying abroad are covered by the plan in effect in that country when the stay falls under a social security agreement reached between the Minister and the country in question. 

For residents who are not in one of the above situations and receive insured services in a hospital outside Canada, the Régie reimburses the cost of such services, when they become necessary due to an emergency or sudden illness, to a maximum of: $100 CAD per day if the patient was hospitalized, including for day surgery, or to a maximum of $50 CAD per day for out-patient services. However, haemodialysis treatments are covered to a maximum of $220 CAD per treatment. The services must be rendered in a hospital or hospital centre recognized and accredited by the appropriate authorities. No reimbursements are made for nursing homes, spas or similar establishments.

4.6 Prior Approval Requirement

To receive full reimbursement for professional and hospital services elsewhere in Canada or in another country not covered under an agreement, a written request signed by two physicians with expertise in the field of the pathology of the person on whose behalf the request is made must first be sent to the Régie. The request must be accompanied by a summary of the insured person’s medical file, describe the specialized services required by the insured person, attest to the unavailability of the said services in Quebec or Canada, and contain information about the treating physician and the name and address of the hospital where the services are to be provided. Following an evaluation of the request by the Régie, authorization to receive the services is either given or denied. No authorization will be given if the service is available in Quebec or if it is an experimental service.

A person whose request has been denied or who is dissatisfied with a decision of the Régie de l’assurance maladie du Québec (RAMQ) may request a review of the decision. The request for a review must be submitted to the RAMQ in a written notice setting out the reasons for the request. The request must be submitted within the six-month period following the date when the requester was informed of the decision.

As a last resort, within 60 days of being notified of the decision, a person may contest before the Tribunal administrative du Québec the decision for which the person has requested a review.

5.0 Accessibility

5.1 Access to Insured Health Services

Everyone has the right to receive adequate health care services without any kind of discrimination. In Quebec, the Health Insurance Act does not allow user fees to be imposed. It also prohibits any person from demanding or receiving any payment from a person for incidental fees related to an insured service, except in cases prescribed by regulation and the conditions mentioned therein. If anyone thinks that the person has been incorrectly billed fees, the person may request reimbursement from the Régie de l’assurance maladie du Québec (the Régie), which will determine whether any amounts have been unjustifiably paid. If appropriate, the Régie will reimburse the insured person and will recover the amount reimbursed from the health-care professional or the clinic involved. It is also possible to reimburse insured persons who have not made reimbursement requests if the Régie finds that fees have been charged to them illegally.

A situation that appears to be illegal with respect to fees charged to an insured person may also be reported to the Régie which, after verification, will follow up appropriately. These follow-ups may include an inspection or an investigation of the clinics or the professionals involved. Residents who have reason to believe that they have been subject to patient charges can contact the Régie.

Improving access to health and social services for the population is a government priority. In order to achieve this objective, Quebec undertook a transformation of the Health and Social Services Network (the network) and its governance in 2015.

For most health and social services regions, this transformation has established an integrated health and social services centre or an integrated university health and social services centre which generally encompasses all of the health missions.

In more detail, as of March 31, 2020, the health and social services network had 141 institutions: 51 public and 90 private. These institutions administer 1,624 facilities or physical spaces providing health and social services to the Quebec population. 

The 51 public institutions are administered by 34 president-CEOs or CEOs. They include Integrated Health and Social Services Centres (CISSS) and Integrated University Health and Social Services Centres (CIUSSS), hereafter referred to as integrated centres, as well as grouped institutions and other institutions that have been neither grouped nor merged. 

As of April 1, 2015, each of the 22 integrated centres is the result of the merger of all or some of the public institutions in a given health and social services region, as the case may be, with the health and social services agency. Nine of the 22 integrated centres call themselves “centre intégré universitaire de santé et de services sociaux” because they are located in a health and social services region in which a university offers a complete predoctoral program of study in medicine or because they operate a centre designated as a university institute in the field of social services.

For their part, the 29 remaining public institutions are distributed as follows:

In addition, as of March 31, 2020, Quebec had 42 public and five private facilities under agreement with a hospital centre (CH) mission providing diagnostic services and general and specialized medical care in the physical health (CHSGS) and mental health (CHPSY) sectors. As of that date, there were 20,983 beds with a CH mission, i.e., 19,854 general and specialized care beds and 1,129 psychiatric care beds. According to the most recent available data:

In conclusion, Quebec also has four integrated university health networks (réseaux universitaires intégrés de santé or RUISS) which promote co-operation, complementarity and integration of the care, teaching and research missions of the health facilities and universities with which they are affiliated. In addition to the services provided by public facilities, the population also has access to the services of private facilities which offer accommodation, long-term care and other services.

Since 2002, Family Medicine Groups (GMF) have served as flagships for the organization of front-line health care and services in Quebec. GMF promote teamwork, collaboration among professions, institutional responsibility to the population, and the development of trust and close collaboration between patients and clinicians. Review of the GMF management framework led to the creation of the Programme ministériel de financement et de soutien professionnel [departmental funding and professional support program] (The program). The Program came into force on November 16, 2015. It offers financial and professional support tailored to the realities of clinicians and the needs of patients. It has introduced equitable, patient-centred funding, additional professional support (in addition to nursing personnel, social workers, pharmacists and other health professionals), a more balanced service offer, less burdensome administrative procedures, and mandatory use of electronic health records. These features have the voluntary support of physicians and the benefit of a team funding structure.

The core of the model continues to be the registration of patients with a group physician and a service offering that allows registered patients to take advantage of accessible services. The elementary structure of the GMF ensures that registered patients have reasonable and timely access, as is demonstrated by the addition of a measurement of patients’ attendance at the GMF in which they are registered. The Program updates terms of funding and resource allocation, and is designed to be more flexible to implement. It relies on the professional commitment of clinical communities to provide accessible, continuous and quality services.

As of March 31, 2020, Quebec had 358 accredited GMF in the province. As of the same date, there were 52 GMF networks (of which 35 were former network clinics).

5.2 Physician Compensation

Physicians are remunerated in accordance with the negotiated fee schedule. The Minister may enter into an agreement with the organizations representing any class of health professional.
The Health Insurance Act (A-29) governs the compensation of health professionals (physicians, dentists, optometrists and pharmacists). While the majority of physicians practise within the provincial plan, Quebec allows two other options:

To become a non-participant, a health professional must notify the Régie by registered or certified mail. The non-participation takes effect the thirtieth (30th) day from the date of mailing, and re-enrollment takes effect the eighth (8th) day following the date of mailing of the notice (Regulation respecting the application of the Health Insurance Act, s. 29).

There are various modes of remuneration:

According to the most recent data available, in 2019-2020 the Régie paid an estimated $7.8 billion for professional services provided to Quebec residents. Professional services (including reimbursements to insured persons and payments to professionals) received outside Quebec were estimated at $44.7 million.

The Régie is responsible for enforcing health-care professional compensation agreements and for controlling compensation paid to health-care professionals. It has established a framework that enables it to enhance its controls on the basis of the risks identified, in order to ensure that the compensation paid to health-care professionals complies with the terms and conditions in the agreements negotiated. The Régie has various control measures as follows:

Awareness-Raising Mechanisms

The Régie issues notifications to the Quebec Department of Health and Social Services with respect to issues and risks associated with controlling the payment of health-care professionals on the basis of the agreements negotiated. Thus, based on its analyses, the Régie’s findings may result in the issuance of notifications on different issues even if they apply more to medical practice or the organization of services.

Systematic Controls

These measures are aimed at the overall billing of health-care professionals or agreement situations. The controls are carried out manually, by computer, by taking samples, or by monitoring. Systematic controls may be followed by specific controls if the Régie deems it necessary to do an in-depth analysis of a situation with a professional or a limited group of professionals.

Specific Controls (inspections, investigations, service audits performed)

These measures are aimed at the billings of a professional or a limited group of professionals for whom practices have been identified as at risk of being non-compliant or potentially abusive or fraudulent. A specific audit may also be initiated following a complaint or a tip.

The Régie recovers the amounts that have been inappropriately paid by means of a compensation or recovery mechanism.

The Régie has a monitoring mechanism to ensure that professionals with non‑compliant, abusive or fraudulent billings are subject to monitoring.

5.3 Payments to Hospitals

The Minister of Health and Social Services funds hospitals through payments directly related to the cost of insured services provided.

Ontario

Ontario has one of the largest and most complex publicly funded health care systems in the world. Administered by the province's Ministry of Health (MOH)Footnote 6, Ontario's health care system was supported by over $63.7 billion (including capital) in spending during 2019–2020.

COVID-19 Measures

In response to the COVID-19 outbreak, Ontario implemented the following temporary funding changes related to its health insurance program:

The emergence of COVID-19 and resulting constrained global supply chain impeded Health Service Provider (HSP) access to Personal Protective Equipment (PPE) and other critical supplies. HSPs that typically procured supplies independently via public funding were unable to effectively procure critical inventory required for the provision of key health services. In response to these challenges, the Ministry of Health began supplementing regular funding mechanisms with the direct, centralized procurement and distribution of PPE and other critical supplies to HSPs.

1.0 Public Administration

1.1 Health Care Insurance Plan and Public Authority

Ontario Health Care and Health Care Planning

The Ontario Health Insurance Plan (OHIP) is administered on a non-profit basis by the MOH. OHIP was established in 1972 and is continued under the Health Insurance Act (HIA), Revised Statutes of Ontario, 1990, c. H-6, to provide insurance in respect of the cost of insured services provided to Ontario residents (as defined in the HIA) in hospitals and health facilities, and by physicians and other health care practitioners.

The MOH provides services to the public through programs such as health insurance, drug benefits, assistive devices, forensic mental health and supportive housing, home care, community and public health, and health promotion and disease prevention. It also regulates hospitals and nursing homes, medical laboratories and specimen collection centres, and coordinates emergency health services.

Local Health Integration Networks (LHIN) were established under the Local Health System Integration Act, 2006 (LHSIA). Since April 1, 2007, Ontario's fourteen (14) LHINs have served as Ontario's regional health authorities and have had responsibility for funding, planning and integrating health care services at the local level. This included services delivered by hospitals, community care access centres, community health centres, community support service agencies, and mental health and addictions agencies.

In 2017, the LHINs' role was expanded to include the management and delivery of home and community care services. To support their expanded mandate, the roles and responsibilities of the former 14 community care access centres were transferred to the LHINs.

On February 26, 2019, Ontario announced its long-term plan to build a modern and sustainable health care system that starts and ends with the patient. Ontario is creating an integrated public health care system by coordinating the work of existing provincial health agencies and programs. Ontario will have one single health agency—Ontario Health (OH), a Crown agency, has the mandate to oversee health care delivery, improve clinical guidance and provide support for providers to ensure better quality care for patients. OH will also support or provide value-oriented supply chain management services to health service providers, and work together with patients, providers and the health sector to build an integrated, patient-focused supply chain for health care products and services.

On December 2, 2019, as part of the first phase of transitions, the following five health agencies were transferred into OH:

The 14 LHINs were clustered into five interim geographical regions, and five Transitional Regional Leads were appointed. The Transitional Regional Leads are responsible for the ongoing management of the LHIN operations in their regions and also report to the President and CEO of OH to support planning for the eventual transition of LHIN functions and oversight responsibilities into OH. The government also transferred non-home and community care executives of the LHINs into OH.

On March 31, 2020, the five health agencies transferred into OH, existing then only as corporate shells, were dissolved by Minister's order. By April 1, 2020 the second phase of transitions were in effect including the transfer of the Ontario Telemedicine Network to OH and its formal dissolution, and the assignment of oversight of two digital health transfer payment agreements (Electronic Child Health Network and OntarioMD) to OH.

As the COVID-19 pandemic continued to evolve rapidly in Ontario in Spring 2020, and recognizing the critical role of OH and the Local Health Integration Networks in the health system response, the Ministry decided to delay the transfer of select LHIN non-patient care functions into OH until a later date.

As the COVID-19 response begins to stabilize and plans are underway to reopen the economy, the Ministry has resumed planning for the next phase of OH transfers and transformation work without negatively impacting the COVID-19 efforts and compromising patient care. The transformation will take place over a number of years. It will continue to roll out in carefully planned phases to ensure patient care is not interrupted.

1.2 Reporting Relationship

Section 2 of the HIA stipulates that the Minister of Health is responsible for the administration and operation of OHIP, and is Ontario's public authority for the purposes of the Canada Health Act.

Annually, the MOH reports on its plans, results and outcomes via a published plan and annual report. The MOH's published plan and annual report are tabled in the legislature and published on the MOH's website.

1.3 Audit of Accounts

Every year the Auditor General of Ontario reports on the results of their examination of government resources and administration. The Auditor General's report is tabled by the Speaker of the Legislative Assembly, usually in the fall, at which time it becomes available to the public. Audit reports on select areas of the MOH chosen for review by the Auditor General are included within this annual report, the last of which was released on December 4, 2019.

The MOH's accounts are published annually in the Public Accounts of Ontario. The 2019-2020 Public Accounts of Ontario were tabled and released on September 23rd, 2020.

2.0 Comprehensiveness

2.1 Insured Hospital Services

Insured in-patient and out-patient hospital services in Ontario are prescribed in sections 7 and 8 of Regulation 552 under the Health Insurance Act (HIA).

In keeping with the provisions of the Canada Health Act, Ontario insures all medically necessary hospital services. Hospital services are all services that are medically required to be performed in hospital. These are described in the regulations as follows:

Insured in-patient hospital services include medically required:

Insured out-patient services include medically required:

Each individual hospital service is not specifically listed in Regulation 552 ; rather, the Regulation lists the above broad categories of services so that new medical and technological advances are automatically included as they become accepted standards of practice.

Regulatory changes are approved by Cabinet and generally there is a public consultation process by way of Ontario's Regulatory Registry.

No regulation changes to insured hospital services were completed in fiscal year 2019-2020.

2.2 Insured Physician Services

Insured physician services are prescribed in Regulation 552 under the HIA.

Under Regulation 552 of the HIA, a service provided by a physician in Ontario is an insured service if it:

Physicians provide medical, surgical and diagnostic services, including primary health care services. Services are provided in a variety of settings, including: physician offices, community health centres, hospitals, mental health facilities, licensed independent health facilities, and long-term care homes.

In general terms, insured physician services include:

Physicians must be registered to practice medicine in Ontario by the College of Physicians and Surgeons of Ontario, and be located in Ontario when rendering the service in order for their services to be covered under OHIP.

During 2019–2020, most physicians submitted claims for all insured services rendered to insured persons directly to OHIP, and a small number of physicians billed the insured person. Physicians who do not bill OHIP directly are commonly referred to as having opted-out of the Plan. When a physician has opted-out of the Plan the physician bills the patient an amount not exceeding the amount payable for the service under the Schedule of Benefits—Physician Services (this was permitted on a 'grandparented' basis following proclamation of the Commitment to the Future of Medicare Act [CFMA] in 2004). The patient then recoups that amount from the Plan.

There were approximately 33,245 physicians who submitted claims to OHIP in 2019–2020. This figure includes physicians submitting both fee-for-service claims and physicians included in an alternative payment plan who submitted tracking or shadow-billed claims. In 2019–2020, there were 15 opted-out physicians in Ontario.

The Schedule of Benefits — Physician Services is regularly reviewed and revised to reflect current medical practice and new technologies. In 2019-2020, numerous changes were made that included new services added, existing services revised, or obsolete services removed through regulatory amendment. This process involved consultation with the Ontario Medical Association (OMA) and negotiation of payments with the OMA under the Binding Arbitration Framework.

Additional changes were also made in March 2020 by way of Ministerial Order, to address the provision of physician services during the COVID-19 pandemic. This included temporarily listing as insured services new fee codes for the provision of assessments of, or counselling to, insured persons by telephone or video, or advice and information to patient representatives by telephone or video, and certain services provided within eligible assessment centres that would differentiate physician payment for services provided after-hours, weekend hours and holidays in these centres.

2.3 Insured Surgical-Dental Services

In accordance with the Canada Health Act, certain surgical-dental services are prescribed as insured services under Regulation 552 in the HIA and listed in the Schedule of Benefits— Dental Services. The Act authorizes OHIP to pay for a limited number of procedures when r the procedure is i performed in a public hospital graded under the Public Hospitals Act as Group A, B, C or D, by a dental surgeon who has been appointed to the dental staff of the public hospital.

Generally, insured dental services include:

With respect to insured surgical-dental services, the MOH consults with the Ontario Dental Association in making changes to the Schedule of Benefits - Dental Services.

Regulatory changes are approved by Cabinet and generally there is a public consultation process by way of Ontario's Regulatory Registry.

In Ontario, in the fiscal year 2019–2020, 880 dentists had active billing numbers and 276 dentists billed OHIP. There were 599 dentists who had active billing numbers but did not bill OHIP. Following proclamation of the CFMA in 2004, dentists are required to submit claims for all insured surgical-dental services to OHIP, i.e. are prohibited from charging the patient for insured services. No dentists are 'opted-out' or exempt under 'grandparented' provisions.

2.4 Uninsured Hospital, Physician and Surgical-Dental Services

Uninsured hospital services include but are not limited to:

Section 24 of Regulation 552 details some specified physician and supporting services that are not insured services.

Uninsured physician services may include:

Under section 24, treatment for a medical condition that is generally accepted within Ontario as experimental is also not insured.

Additionally, “add ons” to insured services that are considered non-medically necessary and optional upgrades to a basic insured service (e.g. upgraded cataract lenses, specialized testing for cataract surgery, fibreglass casts, etc.) are uninsured services for which a patient may be charged.

Dental services provided in dentists’ offices are not insured and payment is the responsibility of the individual patient. Dental services not specifically listed in the Dental Schedule are also not insured including such services as prosthetic restorations (fixed bridges and dentures) for the replacement of teeth, orthodontic treatment, fillings and crowns.

In an effort to uphold requirements under the Canada Health Act to prohibit extra-billing and user charges (EBUC) for insured health care services, Ontario’s CFMA provides authority to investigate and take action related to allegations of EBUC. Specifically with respect to EBUC the CFMA makes it illegal:

For more fulsome information on the CFMA, please refer to section 5.1.

Under the Independent Health Facilities Act (IHFA), the MOH provides facility fee funding to cover overhead costs associated with the provision of insured services rendered in non-hospital facilities. Under this Act, facility fees are payable only by the Minister of Health, Cancer Care Ontario or a Local Health Integration Network and only to a licensed independent health facility, and charges to or receipt of a facility fee payment from a patient is an illegal facility fee.

The MOH reviews all possible violations of the CFMA and IHFA that come to its attention. Possible violations come to the MOH’s attention from various sources such as patient complaints, the media, advertisements, health care providers and their staff and Members of Provincial Parliament. In some cases, the MOH may also review possible violations of the CFMA and IHFA on a proactive basis (i.e., without receiving a complaint tied to a specific patient). If it is found that a patient has paid an unauthorized payment, the MOH ensures that patients are reimbursed in accordance with provisions of the CFMA.

Providers and facilities are legally permitted to charge patients for uninsured services, either on a fee-for-service basis, or through a block or annual fee, which covers a group of uninsured services rendered by a physician, practitioner or hospital over a specified time period.

The MOH does not regulate charges by physicians for uninsured services, or for services rendered to uninsured persons nor does the MOH set prices for uninsured services.

The College of Physicians and Surgeons of Ontario (CPSO), the body governing the practice of medicine in Ontario, is responsible for regulating charges by physicians for uninsured services, including block fees. The MOH’s interest in block fees is to ensure that they do not create a barrier to accessing insured services, do not include charges for insured services, do not confer preferential access to insured services, or constitute illegal facility fees contrary to Ontario law. However, the ministry does not regulate the amount charged for block fees or the types of uninsured services that may or may not be included in block fees.

The CPSO has established guidelines with respect to charging patients for uninsured services, and is responsible for investigating complaints against physicians, such as for excessive fees. It is professional misconduct under the Medicine Act for physicians to charge a fee that is excessive in relation to the services performed. The MOH directs patients who have complaints regarding charges for uninsured services to the CPSO.

A regulatory amendment is required for changes to OHIP insured services, including potential public consultation via the Regulatory Registry.

3.0 Universality

3.1 Eligibility

Section 11 of the Health Insurance Act (HIA) specifies that every person who is a resident of Ontario is entitled to become an insured person under the OHIP upon application. In order to be considered an Ontario resident, Regulation 552 under the HIA, with a few exceptions that are noted in the Regulation, requires that a person must:

Individuals who are not eligible for OHIP coverage are those who do not meet the definition of a resident, such as tourists, visitors to the province and those who do not hold an immigration or other similar status as defined in the Regulation. Services that a person is entitled to receive under federal legislation are not insured services, for example, those provided to federal penitentiary inmates and Canadian Forces members. Services that a person is entitled to receive under the Workplace Safety and Insurance Act are also not insured services in Ontario.

When it is determined that a person is not eligible, or is no longer eligible, for OHIP coverage, a request may be made by the person to the MOH to review the decision. Anyone may request that the MOH review the denial of their OHIP eligibility by making a request in writing to the OHIP Eligibility Review Committee (OERC). Those who are not satisfied with the OERC’s decision regarding their OHIP eligibility may request an appeal of their case by the Health Services Appeal and Review Board.

The MOH is the sole payor for OHIP insured physician, hospital and hospital surgical-dental services. An eligible Ontario resident may not obtain any benefits from another insurance plan for the cost of any insured service that is covered by OHIP (with the exception of during the OHIP waiting period).

Persons who were previously ineligible for OHIP coverage but whose status and/or residency situation has changed may be eligible upon application, subject to the requirements of Regulation 552. There were 14,295,514 valid and active health card users in Ontario as of March 31, 2020.

3.2 Other Categories of Individuals

The MOH provides health insurance coverage to a limited number of specified categories of residents of Ontario, other than Canadian citizens and permanent residents or landed immigrants.

These residents are required to provide acceptable original documentation to support their residence in Ontario and their identity in the same manner as Canadian citizens and permanent resident or landed immigrant applicants.

The individuals listed below who are residents in Ontario may be eligible for OHIP coverage in accordance with Regulation 552 of the HIA. Individuals are required to apply in person to ServiceOntario, which has the government-wide mandate for the delivery of front-facing services to the residents of Ontario, including the issuance of the Ontario Photo Health Card.

As of March 19, 2020, the province has removed the three-month waiting period requirement for OHIP coverage.

Applicants for Permanent Residence: These are persons who have submitted an application for Permanent Resident status to Immigration, Refugees and Citizenship Canada (IRCC), and IRCC has confirmed that the person meets the eligibility requirements to apply for permanent residence in Canada and that the application has not yet been denied.

Protected Persons/Convention Refugees: These are persons who are determined to be Protected Persons/Convention Refugees under the terms of the federal Immigration and Refugee Protection Act. Members of this group are provided with immediate OHIP coverage.

Holders of Temporary Resident Permits: A Temporary Resident Permit is issued to an individual by IRCC when there are compelling reasons to admit an individual into Canada who would otherwise be inadmissible under the federal Immigration and Refugee Protection Act. Each Temporary Resident Permit has a case type or numerical designation on the permit that indicates the circumstances allowing the individual entry into Canada. Individuals who hold a permit with a case type of 86, 87, 88, 89, 90, 91, 92, 93, 94, 95 or 80 (if for adoption) are eligible for OHIP coverage.

Foreign Clergy, Foreign Workers and their Accompanying Family Members: An eligible foreign clergy is a person who is sponsored by a religious organization or denomination if the member has finalized an agreement to minister to a religious congregation or group in Ontario for at least six months, as long as the member is legally entitled to stay in Canada.

A foreign worker is eligible for OHIP if the individual has been issued a Work Permit or other document by IRCC that permits the person to work in Canada, and if the person also has a formal agreement in place to work full-time for an employer in Ontario. The work permit or other document issued by IRCC, or a letter provided by the employer, must set out the employer's name, state the person's occupation with the employer, and state that the person will be working for the employer for no less than six consecutive months.

A spouse and/or dependent (under 22 years of age; or 22 years of age or older if dependent due to a mental or physical disability) of an eligible foreign clergy or an eligible foreign worker is also eligible for OHIP coverage as long as the spouse or dependent is legally entitled to stay in Canada.

Applicants for Canadian Citizenship: These individuals are eligible for OHIP coverage if they have submitted an application for Canadian citizenship under section 5.1 of the federal Citizenship Act, even if the application has not yet been approved, provided that IRCC has confirmed that the person meets the eligibility requirements to apply for citizenship under that section and the application has not yet been denied.

Children Born Out-of-Country: A child born to an OHIP-eligible woman who was transferred from Ontario to receive insured health services that were pre-approved for payment by OHIP is eligible for immediate OHIP coverage provided that the mother was pregnant at the time of departure from Ontario.

Seasonal Agricultural Farm Workers: are persons who have a Work Permit issued under the Seasonal Agricultural Worker Program administered by the Government of Canada. Due to the special nature of their employment, migrant farm workers do not have to meet any other residency requirement and are provided with immediate OHIP coverage.

3.3 Premiums

No premiums are required to obtain OHIP coverage. There is an Ontario Health Premium that is collected through the provincial income tax system but it is not connected to OHIP registration or eligibility in any way. Responsibility for the administration of the Ontario Health Premium lies with the Ontario Ministry of Finance.

4.0 Portability

4.1 Minimum Waiting Period

Prior to March 19, 2020, in accordance with section 5 of Regulation 552 under the Health Insurance Act (HIA), individuals who moved to Ontario were typically entitled to Ontario Health Insurance Plan (OHIP) coverage three months after establishing residency in the province unless listed as an exception in sections 6, 6.1, 6.2, or 6.3 of Regulation 552, or subsection 11(2.1) of the HIA.

Assessment of whether or not an individual was subject to the waiting period occurred at the time of their application for OHIP coverage. Examples of those who are exempt from the three- month waiting period included newborn babies, eligible military family members, and insured residents from another province or territory who move to Ontario and immediately become residents of an approved long-term care home in Ontario.

In accordance with Regulation 552 under the HIA and as provided for in the Interprovincial Agreement on Eligibility and Portability, persons who permanently moved to Ontario from another Canadian province or territory where they are insured were typically be eligible for OHIP coverage after the last day of the second full month following the date residency is established, in other words, an interprovincial waiting period.

Effective March 19, 2020, in response to the COVID 19 pandemic, Regulation 552 under the HIA was amended to remove the waiting period for OHIP for all new and returning residents of Ontario. Currently no waiting period for OHIP coverage exists.

4.2 Coverage during Temporary Absences in Canada

Ontario adheres to the terms of the Interprovincial Agreement on Eligibility and Portability (EPA), as per section 1.6 of Regulation 552, and in accordance with the EPA, an insured person who leaves Ontario temporarily to travel within Canada, without establishing residency in another province or territory, may continue to be covered by OHIP for a period of up to 12 months.

An insured person who temporarily seeks or accepts employment in another province or territory may continue to be covered by OHIP for a period of up to 12 months. If the individual plans to remain outside Ontario beyond the 12-month maximum, he or she should apply for coverage in the province or territory where that person has been working or seeking work.

As per section 1.8 of Regulation 552, and in accordance with the EPA, insured students who are temporarily absent from Ontario, but remain within Canada, may be eligible for continuous health insurance coverage for the duration of their full-time studies, provided they do not establish permanent residency elsewhere during this period. To ensure that they maintain continuous OHIP eligibility, a student should provide the MOH with documentation or information from their educational institution confirming registration as a full-time student. Insured family members (spouses and dependents) of students who are studying in another province or territory are also eligible for continuous OHIP eligibility while accompanying students for the duration of their studies.

Also, in accordance with section 1.6 and 1.8 of Regulation 552 of the HIA, most insured residents who want to travel, work or study outside Ontario, but within Canada, and maintain OHIP coverage, must have resided in Ontario for at least 153 days in the last 12 month period immediately prior to departure from Ontario.

Payments for insured out-of-province services are prescribed under sections 28, 28.0.1, 28.0.2, and 29 of Regulation 552 of the HIA. Insured residents who are temporarily outside of Ontario can use their valid Ontario health card to obtain insured physician (except in Quebec) and hospital services generally at no direct cost.

Ontario participates in Reciprocal Hospital Billing Agreements with all other provinces and territories for payment of insured in-patient and out-patient hospital services. For the 2019-2020 fiscal year, rates were set and approved by the Interprovincial Health Insurance Agreements Coordinating Committee. Payment for in-patient services depends on the hospital's approved in-patient per diem rate. Payment for out-patient services is at the standard approved out-patient rate.

Ontario is also party to the Reciprocal Medical Billing Agreements with all other provinces and territories, except Quebec (which does not participate in reciprocal medical billing). Ontario residents who have been directly billed for insured physician or hospital services in another province or territory can submit their receipts to MOH for reimbursement. Reimbursement of insured physician services is at the rates payable in the Ontario Schedule of Benefits for Physician Services or the amount billed, whichever is less. Reimbursement of insured hospital services is at the established rates or the amount billed, whichever is less.

Out-of-Province (Within Canada)

Out-of-province (but within Canada) authorized laboratory tests performed outside of a publicly funded hospital require prior approval of funding in accordance with Section 28.0.2 of Regulation 552. In addition, certain medical services that require prior approval of funding in Ontario (as prescribed in the Schedule of Benefits for Physician Services for services including breast reduction and panniculectomy) must be prior approved if the service is sought in another province or territory.

4.3 Coverage during Temporary Absences outside Canada

Residents may be temporarily outside of Canada for a total of 212 days in any 12 month period and still maintain OHIP coverage as long as their primary place of residence remains Ontario.

Extended Absences:

Health insurance coverage for insured Ontario residents during extended absences (longer than 212 days) outside Canada is governed by Regulation 552 of the HIA.

The MOH requests that residents apply to MOH to confirm this coverage before their departure and provide documents explaining the reason for their absence.

In accordance with regulations and MOH policy, most applicants must also have been residents in Ontario for at least 153 days in each of the two consecutive 12 month periods before their expected date of departure.

The length of time that a person can receive continuous Ontario health insurance coverage during an extended absence outside Canada varies depending on the reason for the absence as follows:

Reasons and lengths of time a person can receive continuous Ontario Health Insurance coverage during an extended absence
Reason OHIP coverage
Study Duration of full-time academic studies (unlimited)
Work Five-year terms (specific residency requirements must be met for two years between absences)
Charitable Worker Five-year terms (specific residency requirements must be met for two years between absences)
Vacation/Other Two-year terms (specific residency requirements must be met for five years between absences)

Spouses and dependents may also qualify for continuous OHIP coverage while accompanying the primary applicant on an extended absence outside Canada.

Out-of-Country Coverage for Ontario Residents who are Temporarily Absent

Until December 31, 2019, Regulation 552 under the HIA set out eligibility criteria and payment authority for funding emergency health care costs incurred by eligible Ontarians who were temporarily absent from Canada, such as for travel, work, and studying.

The provisions under this program provided reimbursement at very limited rates for medical treatment required to treat illnesses, diseases, conditions or injuries that were acute, unexpected, arose outside of Canada and required immediate treatment.

OHIP reimbursed patients at the following rates:

These provisions were intended and designed to provide a very limited amount of funding for the medical treatment of insured residents of Ontario if they incurred an unexpected illness, disease, condition or injury while they are outside of Canada and not if the illness, disease, condition or injury arose before the patient left Canada, or if it was not acute or unexpected, no payment could be made.

Effective January 1, 2020 OHIP no longer provided coverage for emergency health care costs incurred by eligible Ontarians while temporarily absent from Canada, such as for travelling, working and studying. On September 23, 2020, pursuant to a challenge by the Canadian Snowbirds Association, the Ontario Superior Court of Justice (Divisional Court) quashed the regulation that ended this program. As a result, the Ministry intends that the OOC emergency Travellers program will be re-established retro active to January 1, 2020.

4.4 Prior Approval Requirement

As set out in Regulation 552 under the HIA, payment for non-emergency health services provided outside of Canada requires written prior approval from the General Manager of OHIP before the services are rendered.

With written prior approval, full funding for out-of-country medical services is paid directly to out-of-country hospitals, health facilities and physicians as well as laboratories for medically necessary insured services that are not performed in Ontario or, with the exception of laboratory services, for services that cannot be obtained in Ontario without medically significant delay.

In accordance with the requirements of Regulation 552 under the HIA, the requested out-of- country medical services are eligible for funding as insured services only if they are:

Requests for prior approval of funding require written confirmation from a physician who is a specialist in the type of services for which prior approval has been requested to confirm that the regulatory criteria for the funding of out-of-country medical services are met. This requirement does not apply to emergency services or services that are within a general practitioner’s scope of practice.

There are also other specified requirements in section 28.4 of Regulation 552 depending on the nature of the service for which funding is requested.

Funding requirements for non-emergency authorized laboratory tests performed outside Canada are described in section 28.5 of Regulation 552 of the HIA.

In the case of a denial of funding, the referring Ontario physician and the patient are advised that the decision may be reviewed if new medical information is submitted for consideration. Internal reviews may be requested as often as needed, provided new additional supporting medical documentation is submitted. In addition, the patient may appeal an out-of-country funding decision to the Health Services Appeal and Review Board.

5.0 Accessibility

5.1 Access to Insured Health Services

Funding for all insured hospital, physician, and designated practitioner services provided to insured Ontario residents is in accordance with the HIA and Regulations. Access to insured services without charges is protected under Part II of the Commitment to the Future of Medicare Act (CFMA), “Health Services Accessibility.” The CFMA prohibits extra-billing by including a provision that prohibits any physician or designated practitioner from charging or accepting payment or other benefit for rendering an insured service to an insured person for more than the amount that is paid by OHIP. The CFMA also prohibits a physician or designated practitioner from accepting payment or benefit for an insured service rendered to an insured person except from OHIP (subject to a few specified exceptions) and generally prohibits any person or entity from charging or accepting payment or other benefit for an insured service rendered to an insured person except as outlined above or as specified in the regulations.

The CFMA further prohibits queue-jumping through a provision that prohibits any person or entity from paying, charging, or accepting payment or other benefit in exchange for conferring upon an insured person a preference in obtaining access to an insured service. In addition, the CFMA prohibits physicians, practitioners and hospitals from refusing to provide an insured service if an insured person chooses not to pay a “block” or “annual” fee for uninsured services.

The CFMA contains provincial offence provisions, where individuals and corporations in violation of the Act may be subject to fines under the Provincial Offence Act (POA).

The MOH reviews all possible contraventions of the CFMA that come to its attention. For situations in which it is determined that an unauthorized payment has occurred, the MOH takes steps to ensure that the amount is repaid to the payee. When a CFMA review identifies possible inappropriate OHIP billing or fraud, the matter is subsequently referred to either the ministry’s Payment Accountability Unit or to the Ontario Provincial Police fraud investigation unit for more serious cases.

For complaints regarding charges for insured services, the CFMA program of the ministry can be reached at 1-888-662-6613 or by email at: protectpublichealthcare@ontario.ca.

Health Card Validation (HCV) assists health care providers with access to information requested for claims payment. HCV allows the provider to determine the point-in-time status of a patient’s Ontario health number (and version code) indicating eligibility or ineligibility for provincially funded health care services, thereby reducing claim rejects. A health care provider may subscribe for validation services if they have a valid and active billing number as assigned by the MOH. If patients require access to insured services and do not have a valid health card in their possession, upon obtaining patient consent, the provider may obtain the necessary information by utilizing the accelerated health number release service provided by ServiceOntario’s Health Number Look Up service which is offered 24 hours a day, 365 days per year to physicians or hospitals registered for this service.

Acute care priority services are designated, highly specialized, hospital-based services that deal with life-threatening conditions such as organ transplants, cancer surgery and treatments, and neuro services. These services are often high-cost and are rapidly growing, which has made access a concern. Generally, these services are managed provincially, on an ongoing basis by continually monitoring demand and adjusting funding as needed.

Acute care priority services include:

Primary Health Care: The various primary health care physician compensation models encourage access to comprehensive primary health care services for Ontario as a whole, as well as for targeted population groups and remote underserviced communities.

Interprofessional Care Models:

Family Health Teams (FHT) are independent, non-profit organizations that provide interdisciplinary team-based primary health care; they are staffed by providers such as nurse practitioners, nurses, social workers and dieticians. Physician groups that can affiliate with and participate in FHTs are funded by one of three compensation options: Blended Capitation (such as FHN or FHO), Complement Based Models (RNPGA or other specialized agreements) and BSM (for community sponsored FHTs). FHT are located across Ontario, in both urban and rural settings, ranging in size, structure, scope and governance.

Nurse Practitioner-Led Clinics (NPLCs) have been created throughout Ontario to provide comprehensive, accessible and coordinated family health care services by targeting Ontarians who have difficulty accessing primary care. NPLCs are contributing to a number of local and provincial health care priorities by providing faster access to care through same day and next day appointments and collaborating with other community partners to improve quality and better coordinate care for their patients.

Community Health Centres (CHCs) are models of primary health care delivery that play a key role delivering primary health care services to priority populations across Ontario and support the province’s overarching efforts to transform primary care. CHCs are not-for-profit community governed organizations with a primary focus to improve the health and well-being of populations who have traditionally faced barriers accessing health services, including those who are low income, new immigrants, those with complex mental health issues and individuals who do not have health insurance. CHCs are mandated to deliver comprehensive primary health care services, health promotion, and disease prevention services to individuals and families. CHCs develop partnerships that focus on broader health and social issues, such as inadequate housing, literacy, pollution and other social determinants of health.

Aboriginal Health Access Centres (AHACs) are Aboriginal-led, primary health care organizations that provide a combination of traditional healing, primary care, cultural programs, health promotion programs, community development initiatives, and social support services to First Nations, Métis and Inuit Communities. AHACs are closely modelled after Ontario’s Community Health Centres and provide the mechanisms to improve the health and well-being of communities in Ontario facing various barriers in accessing health care. AHACs serve as a key contributor to Ontario’s commitment to improve and expand access to comprehensive primary care by providing clinical care services, integrated chronic disease prevention and management, family focused maternal/child health care and addictions counselling and mental health care.

Health Care Connect (HCC): refers Ontarians who are seeking a primary health care provider (family doctor or nurse practitioner) to a provider who is accepting new patients in their community. Insured persons without a primary health care provider who register with HCC may be referred to a family doctor or a nurse practitioner if there is a participating provider who is accepting new patients in their community. HCC is voluntary for both patients and providers and there is no guarantee that a referral will be made for each program registrant.

During 2019-2020, MOH continued to administer various initiatives to improve access to health care services across the province. Ontario's physician supply has stabilized due to past medical school expansion and ongoing evidence-informed planning, and the province is working to enhance the retention and distribution of physicians through measures, such as:

There are a number of existing initiatives to improve access across Ontario, including but not limited to the Northern and Rural Recruitment and Retention Initiative, the Northern Physician Retention Initiative, and the Northern Health Travel Grant Program.

Northern and Rural Recruitment and Retention Initiative (NRRRI): The NRRRI supports the recruitment and retention of physicians in rural and northern communities. The NRRRI provides financial recruitment incentives to physicians who establish a fulltime practice in an eligible community. Community eligibility for the NRRRI is based on a Rurality Index for Ontario score of 40 or more. Also eligible are the five Northern Ontario Census Urban Referral Centre census metropolitan areas (Thunder Bay, Sudbury, North Bay, Sault Ste. Marie and Timmins).

Northern Physician Retention Initiative (NPRI): The NPRI provides physicians who have completed a minimum of four years of continuous full-time practice in Northern Ontario with a retention incentive paid at the end of each fiscal year in which they continue to practise full-time in Northern Ontario. NPRI supports retention of physicians in Northern Ontario and encourages them to maintain active hospital privileges. Northern Ontario is defined as the districts of Algoma, Cochrane, Kenora, Manitoulin, Nipissing, Parry Sound, Muskoka, Rainy River, Sudbury, Thunder Bay and Timiskaming.

Northern Health Travel Grant (NHTG) Program: The NHTG Program helps defray travel-related costs for residents of Northern Ontario who must travel long distances to access insured medical specialist services, or designated health care facility-based procedures that are not locally available, within a radius of 100 kilometres. In addition to travel grants based on kilometric rate, the program provides an accommodation allowance of $100-$550 (dependent on the number of lodging nights) per eligible treatment trip to patients whose one-way road distance to a specialist is at least 200 kilometers. In 2017–2018, a $9.9 million enhancement was introduced to move from a $100 flat rate accommodation allowance to a maximum of $550, dependent on the number of medically necessary lodging nights. The NHTG Program also promotes using specialist services located in Northern Ontario, which encourages more specialists to practice and remain in the north.

5.2 Physician Compensation

Physicians are paid for the services they provide through a number of mechanisms. Many physician payments are provided through fee-for-service arrangements. Fee-for-service remuneration is based on the Schedule of Benefits - Physician Services under the HIA. Other physician payment models include Primary Health Care Models (such as blended capitation models), Alternate Payment Plans, and funding arrangements for physicians in Academic Health Science Centres.

Physicians that belong to these other payment models may also bill fee-for-service when providing services that are outside of the scope of these models.

The MOH undertakes payment accountability activities to ensure physicians receive the payment to which they are entitled. Pre-payment activities include monitoring and system controls, such as automated payment rules in the OHIP fee-for-service claims payment system.

Post-payment activities may include claims reviews, audits, and educating and assisting physicians in meeting OHIP billing requirements. If payments for inappropriate claims are identified, the MOH attempts to work with the physician to resolve the issue. The MOH may also use remedies outlined in the HIA or IHFA. Post-payment reviews are identified through monitoring such as data analytics, as a result of concerns reported to the MOH, such as through the fraud hotline or other mechanisms.

In 2018-2019, 95 per cent of General Practitioners received fee-for-service payments from OHIP, but fewer than 30 per cent of them were paid solely on a fee-for-service basis. The majority (65 per cent) of primary care physicians in Ontario received funding through one of the primary health models: Comprehensive Care (CCM), Family Health Group (FHG), Family Health Network (FHN), Family Health Organization (FHO), Community Health Centres (CHC), Rural and Northern Physician Group Agreement (RNPGA), Group Health Centre (GHC), Blended Salary Model (BSM) and specialized agreements.

The MOH negotiates physician compensation with the Ontario Medical Association (OMA) in accordance with the OMA Representation Rights and Joint Negotiation and Dispute Resolution Agreement. In 2017, the MOH and the OMA successfully negotiated a Binding Arbitration Framework, an agreement that governs the process for PSA negotiations, mediation, and arbitration.

On February 19, 2019, a board of arbitration released its award establishing the parameters for physician compensation for the period of April 1, 2017 to March 30, 2021.

5.3 Payments to Hospitals

Ontario hospitals are funded through a combination of global funding, volume-based funding, and Patient-Based Funding—which provides funding on a spectrum between activity-based, and performance- based approaches.

Since April 1, 2012, Ontario shifted hospital funding from a predominantly global budget system towards a patient-based funding (PBF) system. PBF ensures that patients get the right care, at the right place, at the right time, and at the right price. PBF offers an integrated approach to health system funding and puts the patient at the centre through adopting a 'funding follows the patient' principle.

For purposes of funding, publicly funded hospitals are classified based on whether they receive funding through the Growth and Efficiency Model (GEM) or not. In addition, GEM hospitals are further classified based on whether they provide specialized care (e.g. teaching, pediatric) or by their size (e.g. large, medium).

Stand-alone psychiatric and small-sized hospitals do not receive GEM funding. Instead, they rely primarily on global budgets for their operational funding.

Hospital Funding Sources

Global funding: Non-targeted base funding that is carried over year-to-year. This funding is not tied to the delivery of specific procedures.

Growth and Efficiency Model (GEM) (Formerly Health-Based Allocation Model [HBAM]): This is an evidence-based funding formula that uses clinical and financial information to redistribute about $5.135 billion annually among all modeled hospitals, based on the number of patients treated and the complexity of their care. The model also takes into account the efficiency of hospitals.

In 2019-2020, the redistribution of HBAM was suspended, pending development of a long-term plan that considers a consolidated approach to address growth in services, which resulted in the introduction of the Growth and Efficiency Model (GEM). GEM is used to allocate incremental growth funding, rather than re-distributing existing funds.

Quality Based Procedures (QBP): QBP are episodes of care (e.g. hip/knee replacement surgery, stroke) for which evidence-based best practices have been defined and providers are compensated for providing the services included in the episode based on an established price.

Funding is allocated by assigning a number of cases (volumes) and a provincial price that is specific to identified surgical or medical procedures. The provincial price is adjusted to reflect patient cohort differences at each hospital using a measure of acuity, known as the Case Mix Index (CMI).

The funding amount for QBP is based on historical utilization, population growth projections and other risk factors and is intended to address the demands of a growing and aging population.

Bundled Care: Like QBP, Bundled Care funding is allocated by an assigned number of cases and a price. However, a Bundled QBP encompasses services that cross providers, specifically including hospital and post-acute community care like home care. Bundled QBP provide a single payment for an episode of care across multiple settings and providers, like hip/knee replacement surgery and post-surgical rehabilitation.

Funding is allocated to a Bundle Holder (a health service provider) who is responsible for partnering with and transferring funds to other service providers for surgical care and/or post- acute rehabilitation, providing a more integrated service from the time patients enter hospital for surgery to their recovery at home and in the community. Bundle Holders must ensure that patients are receiving the full scope of care in an integrated pathway, regardless of where the patient lives.

Bundled care is being implemented for hip and knee replacement surgery and chronic kidney disease, and being tested in other clinical areas.

Priority Programs and Services: Funding for life-saving procedures and specialized services (i.e. cardiovascular, neurosurgical, bariatric, critical care) as well as maternal/newborn health programs.

Funding rates are pre-set, and volume amounts are determined using a number of data points, including: historical utilization information, changes in the population of interest for the catchment area, and direct discussions with the hospitals and Local Health Integration Networks (LHIN), regarding their respective projections.

Post Construction Operating Plan (PCOP): PCOP funding provides operating funds to hospitals for clinical service and space expansions incurred after the completion of an approved capital project.

Post Construction Operating Plan funding may be provided for service volume increases, one-time start up and transition costs, equipment amortization and/or incremental facility costs.

Wait Times: Allocated to support additional diagnostic imaging (e.g. Magnetic Resonance Imaging [MRI] & Computerized Axial Tomography [CT] Hours) and select surgical procedures (price per procedure). Funding allocation is determined based on prior year performance, current capacity and wait lists.

Pay for Results (P4R): Provides annual one-time performance-related funding incentives to hospitals with high volume Emergency Departments with over 30,000 annual visits.

6.0 Recognition Given To Federal Transfers

The Government of Ontario publicly acknowledged the federal contributions provided through the Canada Health Transfer in its Public Accounts of Ontario 2019-2020.

Registered Persons
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
1. Number as of March 31st (#):Ontario Table 1 Footnote 1 13,723,465 13,829,743 14,042,917 14,231,376 14,295,514
Ontario table 1 Footnote 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)

Ontario table 1 Return to footnote 1 referrer
Insured Hospital Services Within Own Province or Territory
Public Facilities 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
2. Number (#):Ontario table 2 Footnote 1 143 143 141 141 140
3. Payments for insured health services ($):Ontario table 2 Footnote 2 16,386,982,327 16,784,015,574 17,356,176,130 18,024,589,979 18,400,652,198
Private For-Profit Facilities 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
4. Number of private for-profit facilities providing insured health services (#):Ontario table 2 Footnote 3 Not available Not available Not available Not available Not available
5. Payments to private for-profit facilities for insured health services ($):Ontario table 2 Footnote 3 Not available Not available Not available Not available Not available
Ontario table 2 Footnote 1

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.

Ontario table 2 Return to footnote 1 referrer

Ontario table 2 Footnote 2

Amount represents funding for all public and private hospitals excluding specialty psychiatric hospitals.

Ontario table 2 Return to footnote 2 referrer

Ontario table 2 Footnote 3

Data are not collected in a single system in MOH. Further, the MOH is unable to categorize providers/facilities as "for-profit" as MOH does not have financial statements detailing service providers' disbursement of revenues from the Ministry.

Ontario table 2 Return to footnote 3 referrer
Insured Hospital Services Provided to Residents in Another Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
6. Total number of claims, in-patient (#): 7,160 6,337 6,473 6,230 5,809
7. Total payments, in-patient ($): 66,194,339 61,781,960 61,748,658 59,696,706 54,158,972
8. Total number of claims, out-patient (#): 129,182 120,710 119,325 122,863 119,206
9. Total payments, out-patient ($): 42,834,485 43,097,597 43,821,288 46,325,610 45,498,572
Insured Hospital Services Provided Outside CanadaOntario table 4 Footnote 1Ontario table 4 Footnote 2
Pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
10. Total number of claims, pre-approved in-patientOntario table 4 Footnote 3 Not applicable Not applicable Not applicable 805 800
11. Total payments, pre-approved in-patient ($)Ontario table 4 Footnote 3 Not applicable Not applicable Not applicable 49,236,770 76,038,140
12. Total number of claims, pre-approved out-patient Not applicable Not applicable Not applicable Not applicable Not applicable
13. Total payments, pre-approved out-patient ($) Not applicable Not applicable Not applicable Not applicable Not applicable
Non pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
14. Total number of claims, non pre-approved in-patientOntario table 4 Footnote 3 Not applicable Not applicable Not applicable 4,343 4,419
15. Total payments, non pre-approved in-patient ($)Ontario table 4 Footnote 3 Not applicable Not applicable Not applicable 3,936,420 3,986,091
16. Total number of claims, non pre-approved out-patientOntario table 4 Footnote 3 Not applicable Not applicable Not applicable 13,693 13,891
17. Total payments, non pre-approved out-patient ($)Ontario table 4 Footnote 3 Not applicable Not applicable Not applicable 1,393,745 1,385,304
Ontario table 4 Footnote 1

Indicators 10 & 11 include both in-patient and out-patient for insured hospital and physician services provided outside Canada

Ontario table 4 Return to footnote 1 referrer

Ontario table 4 Footnote 2

Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report,but did not require provinces or territories to report on previous years.

Ontario table 4 Return to footnote 2 referrer

Ontario table 4 Footnote 3

Data pertains to hospital services to out-of-country travellers for emergency services that are acute, unexpected, arose outside of Canada and require immediate treatment.

Ontario table 4 Return to footnote 3 referrer
Insured Physician Services Within Own Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
18. Number of participating physicians (#): 30,177 30,893 31,718 32,566 33,245
19. Number of opted-out physicians (#): 21 20 19 17 15
20. Number of non-participating physicians (#):Ontario table 5 Footnote 1 0 0 0 0 0
21. Total payments for services provided by physicians paid through all payment methods ($):Ontario table 5 Footnote 2 11,918,882,881 12,113,803,206 13,199,726,871 13,024,319,815 13,910,893,530
22. Total payments for services provided by physicians paid through fee-for-service ($) 7,803,728,926 8,028,037,940 13,199,726,871 8,469,716,136 9,013,952,400
Ontario table 5 Footnote 1

Ontario has no non-participating physicians, only opted-out physicians who are reported under item #20

Ontario table 5 Return to footnote 1 referrer

Ontario table 5 Footnote 2

Total payments includes payments made to Ontario physicians through Fee-for-Service, Primary Care, Alternate Payment Programs, Academic Health Science Centres, the Hospital On Call Program and Health Care Connect. Services and payments related to Other Practitioner Programs, Out-of-Country/ Out-of-Province Programs, Nurse Practitioners, Interprofessional Shared Care, NP Led Clinics, ECHO & Chronic Pain, Fertility Services, Family Health Teams and Community Labs are excluded.

Ontario table 5 Return to footnote 2 referrer
Insured Physician Services Provided to Residents in Another Province or Territory
Private For-Profit Facilities 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
23. Number of services (#):Ontario table 6 Footnote 1 589,688 585,353 539,598 573,828 506,698
24. Total payments ($):Ontario table 6 Footnote 1 29,524,980 30,851,717 28,646,930 30,818,175 28,626,840
Ontario table 6 Footnote 1

Data pertains to physician services for out-of-country travellers for emergency services that are acute, unexpected, arose outside of Canada and require immediate treatment

Ontario table 6 Return to footnote 1 referrer
Insured Physician Services Provided Outside CanadaOntario 7 Footnote 1
Pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
25. Number of pre-approved services Not applicable Not applicable Not applicable Not applicable Not applicable
26. Total pre-approved payments ($) Not applicable Not applicable Not applicable Not applicable Not applicable
Non pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
27. Number of non pre-approved servicesOntario table 7 Footnote 2 Not applicable Not applicable Not applicable 80,534 79,937
28. Total non pre-approved payments ($)Ontario table 7 Footnote 2 Not applicable Not applicable Not applicable 2,750,057 2,771,990
Ontario table 7 Footnote 1

Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report,but did not require provinces or territories to report on previous years.

Ontario table 7 Return to footnote 1 referrer

Ontario table 7 Footnote 2

Data pertains to physician services for out-of-country travellers for emergency services that are acute, unexpected, arose outside of Canada and require immediate treatment

Ontario table 7 Return to footnote 2 referrer
Insured Surgical-Dental Services Within Own Province
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
29. Number of participating dentists (#): 278 281 276 280 276
30. Number of opted-out dentists (#):Ontario table 8 Footnote 1 Not applicable Not applicable Not applicable Not applicable Not applicable
31. Number of non-participating dentists (#):Ontario table 8 Footnote 1 Not applicable Not applicable Not applicable Not applicable Not applicable
32. Number of services provided 99,570 98,823 105,438 106,109 101,668
33. Total payments ($): 12,442,618 13,124,123 12,981,062 13,131,908 12,527,790
Ontario table 8 Footnote 1

Health Canada requested this data as of the 2016-2017 report, but did not require provinces or territories to report data for 2015-16

Return to footnote 1 referrer

Manitoba

Manitoba Health, Seniors and Active Living (MHSAL) provides leadership and support to protect, promote and preserve the health of all Manitobans. MHSAL continues efforts to improve access, service delivery, capacity, innovation, sustainability and improve the health status of Manitobans while reducing health disparities. The roles and responsibilities of the department include policy, program and standards development; fiscal and program accountability; and evaluation. In addition, some direct services continue to be provided through Selkirk Mental Health Centre, Cadham Provincial Laboratory, public health inspections, and provincial nursing stations.

COVID-19 Measures

Steps have been taken in relation to the COVID-19 pandemic, to ensure that newcomers to Manitoba and other applicants for coverage have expedited access to registration for health care benefits under the Provincial Health Insurance Plan, including the temporary relaxation of documentation requirements, extensions of benefits in instances where delays due to travel or processing of immigration or other government documents may impact the application process, and other similar extensions and exceptions.

1.0 Public Administration

1.1 Health Care Insurance Plan and Public Authority

The Manitoba Health Services Insurance Plan (MHSIP) is administered by Manitoba Health, Seniors and Active Living (MHSAL) under the Health Services Insurance Act, R.S.M. 1987, c. H35.

The MHSIP is administered under this Act, and insures the costs of hospital, personal care, and medical and other health services referred to in acts of the legislature or related regulations.

The Minister of Health, Seniors and Active Living (the Minister) is responsible for administering and operating the MHSIP. The Minister may also enter into contracts and agreements with any person or group that he or she considers necessary for the purposes of the Act.

The Minister may also make grants to any person or group for the purposes of the Act on such terms and conditions that are considered advisable. Also, the Minister may, in writing, delegate to any person any power, authority, duty or function conferred or imposed upon the Minister under the Act or under the Regulations.

There were no legislative amendments to the Act or the Regulations in the 2019-2020 fiscal year that affected the public administration of the MHSIP.

1.2  Reporting Relationship

Section 6 of the Health Services Insurance Act requires the Minister to have audited financial statements of the MHSIP showing separately the expenditures for hospital services, medical services and other health services. The Minister is required to prepare an annual report, which must include the audited financial statements, and to table the report before the Legislative Assembly within 15 days of receiving it, if the Assembly is in session. If the Assembly is not in session, the report must be tabled within 15 days of the beginning of the next session.

1.3 Audit of Accounts

Section 7 of the Health Services Insurance Act requires that the Office of the Auditor General of Manitoba (or another auditor designated by the Office of the Auditor General of Manitoba) audit the accounts of the MHSIP annually and prepare a report on that audit for the Minister. The most recent audit reported to the Minister and available to the public is for the 2019-2020 fiscal year and is contained in the Manitoba Health, Seniors and Active Living Annual Report.

2.0 Comprehensiveness

2.1 Insured Hospital Services

Sections 46 and 47 of the Health Services Insurance Act, as well as the Hospital Services Insurance and Administration Regulation (M.R. 48/93), provide for insured hospital services.

There were no amendments to Sections 46 and 47 of the Health Services Insurance Act or the Hospital Services Insurance and Administration Regulation in 2019-2020.

As of March 31, 2019, there were 96 facilities providing insured hospital services to both in-and out-patients. Hospitals are designated by the Hospitals Designation Regulation (M.R. 47/93) under the Act.

Services specified by the Regulation as insured in-patient and out-patient hospital services include:

The Regulation states that hospital in-patient services include routine medical and surgical supplies, thereby ensuring reasonable access for all residents. The regional health authorities and Manitoba Health, Seniors and Active Living (MHSAL) monitor compliance.

No additional services were added to the list/schedule of insured hospital services in 2019-2020.

Manitoba Health, Seniors and Active Living (MHSAL), for the period of 2019-2020, had no formal evidence, investigations or actions against any diagnostic clinics where there was an assertion of inappropriate charging of patients for services that would be considered insured if provided in a hospital. Manitoba Health, Seniors and Active Living (MHSAL), do not have any recent or upcoming legislative or regulatory changes in this regard.

Manitoba residents maintain high expectations for quality health care and insist that the best available medical knowledge and service be applied to their personal health situations.

2.2 Insured Physician Services

The enabling legislation that provides for insured physician services is the Medical Services Insurance Regulation (M.R. 49/93) made under the Health Services Insurance Act.

Physicians providing insured services in Manitoba must be lawfully entitled to practice medicine in Manitoba, and be registered and licensed under the Medical Act. As of April 30, 2020, there were 3,029 physicians registered in Manitoba, with 2,678 participating in the Manitoba Health Services Insurance Plan.

A physician, by giving notice to the Minister of Health, Seniors and Active Living (the Minister) in writing, may elect to collect the fees other than from the Minister for medical services rendered to insured persons, in accordance with section 91 of the Act and section 5 of the Medical Services Insurance Regulation. The election to opt out of the health care insurance plan takes effect on the first day of the month following a 90-day period from the date the Minister receives the notice.

Before rendering a medical service to an insured person, physicians must give the patient reasonable notice that they propose to collect any fee for the medical service from them or any other person except the Minister. The physician is responsible for submitting a claim to the Minister on the patient's behalf and cannot collect fees in excess of the benefits payable for the service under the Act or Regulations. No physicians opted-out of the medical plan in 2019-2020.

The range of physician services insured by MHSAL is listed in the Payment for Insured Medical Services Regulation (M.R. 95/96). Coverage is provided for all medically required personal health care services that are not excluded under the Excluded Services Regulation (M.R. 46/93) of the Act, rendered to an insured person by a physician.

During fiscal year 2019-2020, a number of new insured services were added to a revised fee schedule. The Physician's Manual can be found on the Health, Seniors and Active Living website.

The process for a medical service to be added to the list of those covered by MHSAL is that physicians must put forward a proposal to their specific section of Doctors Manitoba. Doctors Manitoba will negotiate the item, including the fee, with MHSAL. MHSAL may also initiate this process, which may include stakeholder and public consultation.

2.3 Insured Surgical-Dental Services

Insured surgical and dental services are listed in the Hospital Services Insurance and Administration Regulation (M.R. 48/93) under the Health Services Insurance Act. Surgical services are insured when performed by a certified oral and maxillofacial surgeon or a licensed dentist in a hospital, when hospitalization is required for the proper performance of the procedure. This Regulation also provides benefits relating to the cost of insured orthodontic services in cases of cleft lip and/ or palate for persons registered under the program by their 18th birthday, when provided by a registered orthodontist.

Providers of dental services, by giving to the minister at any time notice in writing, may elect to collect their fees directly from the patient in the same manner as physicians in accordance with section 91(1) of the Health Services Insurance Act and may not charge to, or collect from, an insured person a fee in excess of the benefits payable under the Act or Regulations. No providers of dental services opted-out in 2019-2020.

In order for a dental service to be added to the list of insured services, a dentist must put forward a proposal to the Manitoba Dental Association (MDA) for discussion with MHSAL, which may include stakeholder and public consultation. The MDA negotiates the item and fee with MHSAL.

2.4 Uninsured Hospital, Physician and Surgical-Dental Services

The Excluded Services Regulation (M.R. 46/93) made under the Health Services Insurance Act sets out those services that are not insured. These include:

The Hospital Services Insurance and Administration Regulation states that hospital in-patient services include routine medical and surgical supplies, thereby ensuring reasonable access for all residents. The regional health authorities and MHSAL monitor compliance.

All Manitoba residents have equitable access to services. Third parties such as private insurers or the Workers Compensation Board do not receive priority access to services through additional payment. Manitoba has no formalized process to monitor compliance; however, feedback from physicians, hospital administrators, medical professionals and staff allows regional health authorities and MHSAL to monitor usage and service concerns.

To de-insure services covered by MHSAL, the Ministry prepares a submission for approval by Cabinet. The need for public consultation is determined on an individual basis depending on the subject.

No services were removed from the list of those insured by Manitoba Health in 2019-2020.

3.0 Universality

3.1 Eligibility

The Health Services Insurance Act defines the eligibility of Manitoba residents for coverage under the provincial health care insurance plan.

Section 2(1) of the Act states that a resident is a person who is legally entitled to be in Canada, makes his or her home in Manitoba, is physically present in Manitoba for at least six months in a calendar year, and includes any other person classified as a resident in the Regulations, but does not include a person who holds a temporary resident permit under the Immigration and Refugee Protection Act (Canada), unless the Minister of Health, Seniors and Active Living (the Minister) determines otherwise, or is a visitor, transient or tourist.

The Residency and Registration Regulation (M.R. 54/93) extends the definition of residency. The extensions are found in sections 7(1) and 8(1). Section 7(1) allows missionaries, individuals with out-of-country employment and individuals undertaking sabbatical leave to be outside Manitoba for up to two years while still remaining residents of Manitoba. Students are deemed to be Manitoba residents while in full-time attendance at an accredited educational institution. Section 8(1) extends residency to individuals who are legally entitled to work in Manitoba and have a work permit of 12 months or more under the Immigration and Refugee Protection Act (Canada). Additionally, section 8.1.1 of the Residency and Registration Regulation extends deemed residency to temporary foreign workers (and their dependents) in the province to provide agricultural services on the basis of a work permit, regardless of the duration of their work permit.

No amendments were made to the Residency and Registration Regulation (M.R. 54/93) in 2019-2020.

The Residency and Registration Regulation, section 6, defines Manitoba’s waiting period as follows:

“A resident who was a resident of another Canadian province or territory immediately before his or her arrival in Manitoba is not entitled to benefits until the first day of the third month following the month of arrival.”

Section 6 of the Residency and Registration Regulation stipulates that there is no waiting period for dependents of members of the Canadian Armed Forces.

There are currently no other waiting periods in Manitoba.

The Manitoba Health Services Insurance Plan (MHSIP) excludes residents covered under any federal plan, including the following federal statutes:

These residents become eligible for health services insurance coverage upon discharge from the Canadian Forces, or in the case of an inmate of a penitentiary, upon discharge if the inmate has no resident dependents. Upon change of status, these persons have one month to register with Manitoba Health, Seniors and Active Living (MHSAL) (Residency and Registration Regulation (M.R. 54/93, subsection 2[3]).

RCMP members are insured persons in Manitoba and are eligible for benefits under the MHSIP.

The process of issuing health insurance cards requires that individuals inform and provide documentation to MHSAL that they are legally entitled to be in Canada, and that they intend to be physically present in Manitoba for six months in a calendar year. They must also provide a primary residence address in Manitoba. Upon receiving this information, Manitoba Health, Seniors and Active Living will provide a registration card for the individual and all qualifying dependents.

Manitoba has two health-related numbers. The registration number is a six-digit number assigned to an individual 18 years of age or older who is not classified as a dependent. The six-digit number may be shared by all members of a family including a spouse and dependents. A nine-digit Personal Health Identification Number is used for payment of all medical service claims and hospital services.

As of June 1, 2020, there were 1,385,225 residents registered with the Manitoba Health Services Insurance Plan.

Individuals may appeal decisions of MHSAL with respect to eligibility before the Manitoba Health Appeal Board, an independent quasi-judicial tribunal established pursuant to The Health Services Insurance Act.

There is no provision for a resident to opt out of the Manitoba Health Services Insurance Plan.

3.2 Other Categories of Individuals

The Residency and Registration Regulation (M.R. 54/93, sub-section 8[1]) requires that temporary workers possess a work permit issued by Immigration, Refugees and Citizenship Canada for at least 12 consecutive months, be physically present in Manitoba for six months in a calendar year, and be legally entitled to be in Canada before receiving MHSIP coverage.

Section 8.1.1 of the Residency and Registration Regulation extends deemed residency to temporary foreign workers (and their dependents) in the province to provide agricultural services on the basis of a work permit, regardless of the duration of their work permit.

4.0 Portability

4.1 Minimum Waiting Period

The Residency and Registration Regulation (M.R. 54/93, section 6) identifies the waiting period for insured persons from another province or territory. A resident who lived in another Canadian province or territory immediately before arriving in Manitoba is entitled to benefits on the first day of the third month following the month of arrival.

4.2 Coverage during Temporary Absences in Canada

The Residency and Registration Regulation (M.R. 54/93 section 7[1]) defines the rules for portability of health insurance during temporary absences in Canada.

Students are considered residents and will continue to receive health coverage for the duration of their fulltime enrollment at any accredited educational institution. The additional requirement is that they intend to return and reside in Manitoba after completing their studies.

Manitoba has formal agreements with all Canadian provinces and territories for the reciprocal billing of insured hospital services.

In-patient costs are paid at standard rates approved by the host province or territory. Payments for in-patient, high-cost procedures and out-patient services are based on national rates agreed to by provincial and territorial health plans. These include all medically necessary services as well as costs for emergency care.

Except for Quebec, medical physician services incurred in all provinces or territories are paid through a reciprocal billing agreement at host province or territory rates. Claims for physician medical services received in Quebec are submitted by the patient or physician to Manitoba Health, Seniors and Active Living (MHSAL) for payment at host province rates.

4.3 Coverage during Temporary Absences outside Canada

The Residency and Registration Regulation (M.R. 54/93, sub-section 7[1]) defines the rules for portability of health insurance during temporary absences from Canada.

Section 7(1)(g) of the Residency and Registration Regulation extends the period during which a person may be temporarily absent from Manitoba for the purpose of residing outside of Canada from six months to a maximum of seven months in a 12-month period.

Residents on full-time employment contracts outside Canada will receive health services insurance coverage for up to 24 consecutive months. Individuals must return and reside in Manitoba after completing their employment terms. Individuals serving as humanitarian aid workers or missionaries on behalf of a religious organization approved as a registered charity under the Income Tax Act (Canada) will be covered by MHSAL for up to 24 consecutive months. Students are considered residents and will continue to receive health coverage for the duration of their full-time enrollment at an accredited educational institution. The additional requirement is that they intend to return and reside in Manitoba after completing their studies. Residents on sabbatical or educational leave from employment will be covered by MHSAL for up to 24 consecutive months. These individuals also must return and reside in Manitoba after completing their leave.

Manitoba residents receiving coverage under the provincial health insurance plan who receive medical and hospital services outside of Canada are eligible to be reimbursed at the rates set out in the Medical Services Insurance Regulation and the Hospital Services Insurance and Administration Regulation. Emergency doctors' services outside of Canada are reimbursed at a rate equal to what a Manitoba doctor would receive for a similar service. Emergency hospital care is paid on an average daily rate established by MHSAL.

4.4 Prior Approval Requirement

Prior approval is not required for procedures that are covered under the interprovincial reciprocal agreements with other provinces. Prior approval by MHSAL is required for high cost items or procedures that are not included in the reciprocal agreements.

In order to be eligible for reimbursement, all non-emergency hospital and medical care provided outside Canada requires prior approval from MHSAL. Manitobans requiring medically necessary medical and/or hospital services unavailable in Manitoba or elsewhere in Canada may be eligible for reimbursement of costs incurred outside of Canada, pursuant to the Medical Services Insurance Regulation, by providing MHSAL with a recommendation from a specialist stating that the patient requires a specific, medically necessary service.

Individuals may appeal decisions of MHSAL with entitlement to medical benefits before the Manitoba Health Appeal Board, an independent quasi-judicial tribunal established pursuant to The Health Services Insurance Act.

5.0 Accessibility

5.1 Access to Insured Health Services

Manitoba Health, Seniors and Active Living (MHSAL) ensures that medical services are equitable and reasonably available to all Manitobans. Effective January 1, 1999, the Surgical Facilities Regulation (M.R. 222/98) under the Health Services Insurance Act came into force to prevent private surgical facilities from charging additional fees for insured medical services.

The Health Services Insurance Act and The Private Hospitals Act include definitions and other provisions to ensure:

The Accessibility for Manitobans Act includes definitions and principles to ensure accessibility by preventing and removing barriers that disable people with respect to receiving health care services including:

In the event that a Manitoba resident feels that they have been inappropriately charged for a service that is insured under the provincial health insurance plan (i.e., a potential incidence of extra-billing or a user charge), the resident is encouraged to contact Manitoba to report this occurrence at the following coordinates:

Manitoba Health Seniors and Active Living
300 Carlton Street
Winnipeg, MB R3B 3M9
1-800-392-1207

Inquiries are made by the Insured Benefits Branch of Manitoba Health, Seniors and Active Living into the specifics of the fee(s) charged to assess whether the service provided was an insured service, and any required further action. Generally, contact from MHSAL to the medical service provider, advising that the provider must reimburse the patient and submit a claim to MHSAL, is sufficient to address the concern. Further incidents on the part of the same service provider may result in an investigation by MHSAL's Audit and Investigation Unit. Concerns regarding the professional conduct of medical service providers are referred to the appropriate regulatory agency.

Manitoba Health, Seniors and Active Living remains committed to the principles of Medicare and improving the health status of all Manitobans. In 2019-2020, Manitoba continued to support these commitments through a number of activities including the following:

System Transformation

As recommended in the KPMG Health System Sustainability and Innovation Review, the government of Manitoba announced the creation of a Transformation Management Office in order to guide the integration of structural and organizational reform of the health system between government, regional health authorities and health-care facilities to ensure fiscal sustainability while addressing wait times. The government is now focused on the implementation of the review's recommendations to ensure the realization of sustainable benefits over the 2019-2020 year and moving forward.

Additionally, Shared Health Manitoba, a new provincial health organization announced in 2017–2018, continues to focus on patient-centred planning to ensure consistent standards across the province for the provision of care. Input was sought from over 10 provincial clinical teams comprised of health-care providers with varied professional backgrounds and experience across rural, urban and northern Manitoba communities with the objective of developing of a multi-year clinical and preventive services plan for Manitoba. A strategic plan, known as the Manitoba Clinical and Preventative Services Plan was created, and published publicly. An implementation plan was in its early stages of development.

The province also continued its focused efforts on the implementation of the provincial mental health and addictions strategy by aligning the needs identified in the Improving Access and Coordination of Mental Health and Addictions Services: A Provincial Strategy for all Manitobans report (the Virgo report) with the provincial clinical services plan, to ensure alignment with the broader health care system—a key recommendation within the Virgo report.

Additionally, Manitoba continued to implement the patient centred medical home model through two complementary and aligned initiatives—MyHealth Teams and Home Clinic. The goal of these is to improve access and demonstrate achievement of quality primary care standards for Manitobans and to build a more integrated primary care system. Adoption rate of home clinics remained high, representing approximately 70 per cent of all primary care providers. Both initiatives remain aligned with the broader provincial preventive and clinical services plan.

Facilities

As an ongoing component of Healthcare System Transformation, a Provincial ICT Governance model was integrated within Shared Health Manitoba with the intent of ensuring that a more equitable and provincial perspective was taken when considering investments focused on improving and where possible enhancing access and quality of services.

Manitoba Health provided strategic guidance for infrastructure investment to establish expectations and conditions to enable success for stakeholders to progress a cross-functional approach to planning and delivery of infrastructure including investments in repair, renovation and construction of buildings, specialized equipment and ICT.

Manitoba Health established a multi-year infrastructure plan which supports provincial population health objectives and is sustainable and sufficiently flexible to meet the changing needs of the population, as well as requirements of innovation in service delivery. This included a review of prioritized requests for major capital and on-going repairs/replacement related to infrastructure, ICT and specialized equipment repairs and replacement received from regional health authories (RHA's) / service delivery organizations (SDO's) as well as providing advice to inform government decision making for investment.

Manitoba Health planned, developed and completed infrastructure based projects across the multi-year strategic capital plan to address the operation service needs of the provincial health system. For the 2019-2020 fiscal year, 18 major projects within capital and ICT plus over 300 individual projects with the infrastructure repair and upgrades and specialized equipment categories. Projects with an estimated $401.9 million were submitted to MHSAL and progressed.

Manitoba secured and sustained government funding to support the execution of the provincial strategic infrastructure/ICT capital plan that is defined and implemented in accordance with government direction and with regional need and best practices, appropriate standards (program, design and construction), approved scope and timeline, and negotiated costs limits. Oversight for the implementation of investments of approximately $227 million in infrastructure, ICT, specialized equipment was provided and five innovative health-related initiatives targeted at improving health care processes and health outcomes were approved for implementation.

Manitoba applied policies related to procurement practices, infrastructure development, infrastructure sustainment, departmental funding and community cost-sharing and provided oversight and guidance to ensure that requirements were known to and complied with by RHA's and SDO's.

Manitoba provided efficient and accurate information on the department's infrastructure program including accurate forecasting of maintenance requirements, emerging program standards and models, capital financing and development of appropriate program and policy options. Oversight was provided for 31 Infrastructure/ICT major capital projects valued at approximately $356 million, of these four ICT projects with a total estimated value of $52 million were completed.

Manitoba provided upgrades and functional changes to existing infrastructure in a timely, prioritized sequence and continued to oversee the annual ICT Infrastructure Renewal Program managed by Digital Health, which focuses and on the execution of a risk-based approach to replacing and upgrading old, obsolete and failing technical infrastructure in Manitoba's health information systems operating environment. Policy, planning and project management oversight was provided to support department initiatives to ensure appropriate resourcing and solution delivery including significant efforts to update and sustain departmental ICT systems supporting critical administrative systems and information management and analytical capability. Continued oversight for the annual safety and security program including the review of the prioritized list of potential projects from the regional health authorities / service delivery organizations and the monitoring of the projects to completion as well as the oversight of the annual specialized equipment program including monitoring expenditures and completion of delivery/installation.

Manitoba provided necessary data and information for department staff to achieve corporate goals and objectives and consulted with other department branches/areas to ensure that all proposed projects fit with the department's planned priorities as well as managing, maintaining and provide security of the department systems and processes in support of user's access to information and in compliance with required availability targets.

Manitoba regularly reviewed and updated existing websites, which include new web-based information developed to provide ongoing support to the department, with the intent of increasing public access to the department’s online information, as measured by website analytics.

Health Professionals

In 2019-2020, the province provided funding for the following complement of medical and nursing professionals registered to practice in Manitoba:

The transition to the Regulated Health Professions Act (RHPA) continues to be a significant undertaking for the province. The RHPA came into effect in January 2014 to ensure all regulated health professions are governed by consistent, uniform regulations with enhanced focus on patient safety and accountability. The legislation includes a list of activities and procedures called reserved acts, that regulated health professionals may be authorized to perform when providing health care based on their competence and training.

The RHPA sets out consistent rules and processes for governance, registration, complaints and discipline, as well as regulation and bylaw making authority. To date audiologists and speech language pathologists, physicians and surgeons, and registered nurses have transitioned to self-regulation under the RHPA. It is expected that the profession of para-medicine will be next to transition to self-regulation with the new College of Paramedics of Manitoba commencing operations in fall 2020. Psychologists and Registered Psychiatric Nurses are the next two health care professions that will be transitioning to self-regulation under the RHPA. The transition of other health professions to the RHPA will continue to be a focus for the province, as it will have a significant long-term impact on the provincial health workforce.

In 2019-2020 the province provided funding to increase the number of medical and nursing professionals registered in Manitoba as follows:

The number of Registered Nurses decreased by 166 (from 13,522 to 13,356).

5.2 Physician Compensation

Manitoba continues to employ the following methods of payment for physicians:

The Health Services Insurance Act governs remuneration to physicians for insured services. There were no amendments to the Health Services Insurance Act related to physician compensation during the 2019-2020 fiscal year.

Fee-for-service remains the primary method of payment for physician services. Alternate payment arrangements constitute a significant portion of the total compensation to physicians in Manitoba. Alternate-funded physicians are those who receive non fee-for-service compensation, including through a salary (employment relationship) or those who work on an independent contract basis. Manitoba also uses blended payment methods where appropriate. As well, physicians may receive sessional payments for providing medical services on a time based arrangement, as well as stipends for on-call and other responsibilities.

In 2019-2020 MHSAL, in collaboration with Shared Health, represented Manitoba in its negotiations with Manitoba physicians. The physicians are typically represented by Doctors Manitoba with some exceptions, such as oncologists engaged by CancerCare Manitoba.

Doctors Manitoba and Manitoba reached a four-year agreement in July of 2019, to renew the physician Master Agreement. The new physician Master Agreement took effect on April 1, 2019, and will expire on March 31, 2023.

The Manitoba Physician’s Manual lists all of the fee tariff descriptions, rates, rules of application and the dispute resolution process in relation to fee-for-service payments to physicians. This document is the Schedule of Benefits payable to physicians on behalf of insured persons in Manitoba pursuant to the Medical Services Insurance Regulation under the Health Services Insurance Act.

All fee-for-service claims must be submitted electronically. The submission of paper claims is permitted on a limited basis and only with the prior approval of MHSAL. Fee-for-service claims must be received within six months of the date upon which the physician rendered the service.

5.3 Payments to Hospitals

Division 3.1 of Part 4 of The Regional Health Authorities Act sets out the requirements for operating agreements between regional health authorities and the operators of hospitals and personal care homes, defined as “health corporations” under the Act.

Pursuant to the provisions of division 3.1, regional health authorities are prohibited from providing funding to a health corporation for operational purposes unless the parties have entered into a written agreement for this purpose that:

If the parties cannot reach an agreement, the Act enables them to request that the Minister appoint a mediator to help them resolve outstanding issues. If the mediation is unsuccessful, the Minister is empowered to resolve the matter or matters in dispute. The Minister’s resolution is binding on the parties.

There are three regional health authorities which have hospitals operated by health corporations in their health regions. The regional health authorities have required agreements with health corporations that enable the regional health authority to determine funding based on objective evidence, best practices and criteria that are commonly applied to comparable facilities. In all other regions, the hospitals are operated by regional health authorities. The allocation of resources by regional health authorities for providing hospital services is approved by MHSAL through the approval of regional health plans, which the regional health authorities are required to submit for approval pursuant to section 24 of the Regional Health Authorities Act. Section 23 of the Act requires that regional health authorities allocate their resources in accordance with the approved regional health plan.

Pursuant to subsection 50(2.1) of the Health Services Insurance Act, payments from the Manitoba Health Services Insurance Plan for insured hospital services are to be paid to the regional health authorities. In relation to those hospitals that are not owned and operated by a regional health authority, the regional health authority is required to pay each hospital in accordance with any agreement reached between the regional health authority and the hospital operator.

No legislative amendments to the Act or the Regulations in 2019-2020 had an effect on payments to hospitals.

6.0 Recognition Given To Federal Transfers

Manitoba regularly recognizes the federal role regarding the contributions provided under the Canada Health Transfer in public documents. Federal transfers are identified in the Estimates of Expenditures and Revenue (Manitoba Budget) document and in the Public Accounts of Manitoba. Both documents are published annually by the Manitoba government.

Registered Persons
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
1. Number as of March 31st 1,320,343 1,339,308 1,369,673 1,370,642Manitoba table 1 Footnote 1 1,385,225
Manitoba table 1 Footnote 1

Population as of June 1st, 2020.

Manitoba table 1 Return to footnote 1 referrer
Insured Hospital Services Within Own Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
2. Number 96 96 96 96 96
3. Payments for insured health services ($) Not available Not available Not available Not available Not available
Private For-Profit Facilities 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
4. Number of private for-profit facilities providing insured health services 0 0 0 0 0
5. Payments to private for-profit facilities for insured health services ($) 0 0 0 0 0
Insured Hospital Services Provided to Residents in Another Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
6. Total number of claims, in-patient 2,507 2,458 2,569 2,491 2,502
7. Total payments, in-patient ($) 27,875,311 28,194,575 31,845,644 33,989,616 35,646,832
8. Total number of claims, out-patient 30,485 30,412 30,843 31,401 30,616
9. Total payments, out-patient ($) 10,542,720 11,535,541 12,579,590 12,742,040 13,949,642
Insured Hospital Services Provided Outside CanadaManitoba table 4 Footnote 1
Pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
10. Total number of claims, pre-approved in-patient Not available Not available Not available Not available Not available
11. Total payments, pre-approved  in-patient ($) Not available Not available Not available Not available Not available
12. Total number of claims, pre-approved out-patient Not available Not available Not available Not available Not available
13. Total payments, pre-approved out-patient ($) Not available Not available Not available Not available Not available
Non pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
14. Total number of claims, non pre-approved in-patientManitoba table 4 Footnote 2 616 589 613 567 567
15. Total payments, non pre-approved in-patient ($)Manitoba table 4 Footnote 2 5,162,892 3,148,170 3,160,654 1,930,540 1,713,770
16. Total number of claims, non pre-approved out-patientManitoba table 4 Footnote 2 1,982 10,842 11,615 10,542 7,718
17. Total payments, non pre-approved out-patient ($)Manitoba table 4 Footnote 2 3,790,531 3,652,283 4,463,261 6,790,798 2,876,572
Manitoba table 4 Footnote 1

Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report,but did not require provinces or territories to report on previous years.

Manitoba table 4 Return to footnote 1 referrer

Manitoba table 4 Footnote 2

The claims in our data system cannot be separated into pre-approved or non pre-approved, therefore, the numbers reflect the total claims and payments as reported for previous years.

Manitoba table 4 Return to footnote 2 referrer
Insured Physician Services Within Own Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
18. Number of participating physicians 2,533 2,660 2,709 2,755 2,678
19. Number of opted-out physicians 0 0 0 0 0
20. Number of non-participating physicians Not applicable Not applicable Not applicable Not applicable Not applicable
21. Total payments for services provided by physicians paid through all payment methods ($) 1,204,757,000 1,283,742,000 1,252,850,000 1,339,598,000 1,333,152,000
22. Total payments for services provided by physicians paid through fee-for-service ($) 784,398,000 867,122,000 845,522,000 901,784,000 895,650,638
Insured Physician Services Provided to Residents in Another Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
23. Number of services 263,393 254,395 273,056 271,009 251,133
24. Total payments ($) 12,545,113 13,062,681 13,818,753 13,898,168 13,440,993
Insured Physician Services Provided Outside CanadaManitoba table 7 Footnote 1
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
25. Number of pre-approved services Not available Not available Not available Not available Not available
26. Total pre-approved payments ($) Not available Not available Not available Not available Not available
Non pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
27. Number of non pre-approved services 7,995 6,641 6,867 5,888 5,482
28. Total non pre-approved payments ($) 1,269,879 1,042,755 788,816 768,212 602,938
Manitoba table 7 Footnote 1

Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report,but did not require provinces or territories to report on previous years.

Manitoba table 7 Return to footnote 1 referrer
Insured Surgical-Dental Services Within Own Province
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
29. Number of participating dentists 207 227 222 247 273
30. Number of opted-out dentistsManitoba table 8 Footnote 1 Not applicable Not applicable 0 0 0
31. Number of non-participating dentistsManitoba table 8 Footnote 1 Not applicable Not applicable 515 495 473
32. Number of services provided 6,561 7,249 7,415 7,081 7,098
33. Total payments ($) 1,531,281 1,851,615 2,047,349 1,872,000 2,205,750
Manitoba table 8 Footnote 1

Health Canada requested this data as of the 2016-2017 report, but did not require provinces or territories to report data for 2015-2016.

Manitoba table 8 Return to footnote 1 referrer

Saskatchewan

Saskatchewan's Ministry of Health strives for a patient-centred health care system, focused on better health, better care, better value, and better health care teams for Saskatchewan people. The Ministry supports innovative approaches to meet the needs of patients and families and provide culturally sensitive services.

Saskatchewan continues to make progress in the long-term transition from 12 regional health authorities to the Saskatchewan Health Authority. Since 2017, the province has been working to improve frontline patient care for residents, by standardizing processes and policies to better coordinate health services across the province and help ensure patients receive high-quality, timely health care, regardless of where they live in Saskatchewan. This work has been invaluable in supporting a more coordinated provincial response to the COVID-19 pandemic.

Within Saskatchewan's health system, the Saskatchewan Health Authority is supported by the Saskatchewan Cancer Agency, eHealth Saskatchewan, 3S Health (Shared Services Saskatchewan), the Athabasca Health Authority, affiliated health care organizations, and a diverse group of professionals, many of whom are in private practice. There are 28 self-regulated health professions in the province, overseen by 26 regulatory bodies. An estimated 46,000 people provide a broad range of services across the health system.

The Ministry continues to assess how it is organized to provide effective strategic oversight for health system partners, and supports leadership from boards, management, and health professionals at all levels.

The Ministry maintains partnerships with local, regional, provincial, national and international organizations, to help ensure that all Saskatchewan residents have access to quality health care services.

Visit saskatchewan.ca for more information about Ministry programs and services.

COVID-19

The Government of Saskatchewan has worked closely with health organizations, First Nations and Métis, the federal government, regulatory bodies, other provincial ministries, local governments and others in response to COVID-19 pandemic. The Saskatchewan Health Authority, with the support of the Government of Saskatchewan, prepared the acute care hospital system for surges in in-patient admissions due to the coronavirus. Actions that have been taken include creating a system-wide acute care surge plan designed for rural and urban areas; a centralized bed management and tracking system; plans to reduce elective and non-urgent services to create capacity in the system for COVID-19 patients; preserving supplies and personal protective equipment; ensuring hospital care in the north remains safe and accessible; increasing urban hospital capacity by relocating patients who do not require acute care to more appropriate facilities; equipping additional spaces to provide patient care, including development of two field hospitals that are ready to receive patients; and rapidly increasing medical equipment, including ventilators.

Effective March 13, 2020, the Ministry of Health implemented two temporary pandemic virtual care fee codes for telephone and video assessments to compensate physicians for direct patient care provided over the telephone and secure video conferencing. Subsequently, the Ministry of Health also implemented eight additional temporary pandemic virtual care fee codes for telephone and secure video conferencing for specialist consultations and visits, psychotherapy, and other psychiatric services effective March 24, 2020. The ministry further amended the temporary pandemic fee codes to be payable for services performed by medical learners under the supervision of a physician. These temporary pandemic virtual care fee codes are not insured services – they were implemented to address service delivery gaps caused by COVID-19 and are not intended for permanent use post-pandemic. Planning for implementing permanent virtual care fee codes post-pandemic is occurring within the process between the Saskatchewan Medical Association and Ministry of Health.

1.0 Public Administration

1.1 Health Care Insurance Plan and Public Authority

The provincial government is responsible for funding and ensuring the provision of insured hospital, physician and surgical-dental services in Saskatchewan. Section 6.1 of the Health Administration Act authorizes that the Saskatchewan Minister of Health (the Minister) may:

Sections 8 and 9 of the Saskatchewan Medical Care Insurance Act provide the authority for the Minister to establish and administer a plan of medical care insurance for residents of Saskatchewan. The Provincial Health Authority Act, implemented in 2017, provided the authority to amalgamate the 12 regional health authorities to a single health authority.

Sections 3 and 9 of the Cancer Agency Act provide the authority for establishing a Saskatchewan Cancer Agency and for the Agency to coordinate a program for diagnosing, preventing and treating cancer.

The mandates of the Saskatchewan Ministry of Health, provincial health authority, and the Saskatchewan Cancer Agency are outlined in the Health Administration Act, the Provincial Health Authority Act and the Cancer Agency Act.

No amendments were made to these Acts during 2019-2020.

1.2 Reporting Relationship

The Ministry of Health is directly accountable, and regularly reports, to the Minister on the funding, and administering the funds, for insured physician, surgical-dental and hospital services.

Section 36 of the Saskatchewan Medical Care Insurance Act requires that the Minister submit an annual report concerning the medical care insurance plan to the Legislative Assembly.

The Provincial Health Authority Act requires that the provincial health authority submit to the Minister:

Pursuant to legislation, the Minister submits these reports and corresponding statements to the Legislative Assembly.

Section 7-4 of the Provincial Health Authority Act requires that the provincial health authority and the Cancer Agency submit any reports that the Minister may request from time to time. The provincial health authority and the Cancer Agency are required to submit various financial documents and a health service plan to the Ministry.

1.3 Audit of Accounts

The Provincial Auditor conducts an annual audit of government ministries and agencies, including the Ministry. The audit of the Ministry includes a review of Ministry payments including, but not limited to, payments made to the Saskatchewan Health Authority (SHA), the Saskatchewan Cancer Agency (SCA), and physicians and dental surgeons for insured physician and surgical-dental services.

Section 7-7 of the Provincial Health Authority Act requires that an independent auditor, who possesses the prescribed qualification and is appointed for that purpose by the SHA and the SCA, audit the accounts of the SHA or the SCA at least once in every fiscal year. The SHA and the SCA must annually submit to the Minister a detailed, audited set of financial statements.

The most recent audits were for the year ending March 31, 2020. The SHA and SCA each table annual reports in the Saskatchewan Legislature each year which include their audited financial statements. The Government of Saskatchewan tables its audited financial statements (Public Accounts) in the Legislature each year as well. The reports are available to the public directly from each entity and are available on their websites.

The Office of the Provincial Auditor for Saskatchewan provides independent assurance (audit reports) and advice on the Government's management of and accountability practices for the public resources entrusted to it. They inform the Legislative Assembly about the reliability of the Government's financial and operational information, the Government's compliance with legislative authorities and the adequacy of the Government's management of public resources. Their reports are available on the Provincial Auditor of Saskatchewan site. The most recent report was released December 8, 2020 and examined the SHA and eHealth Saskatchewan.

The SHA and Saskatchewan Cancer Agency each table annual reports in the Saskatchewan Legislature each year, which include their audited financial statements. The Government of Saskatchewan tables its audited financial statements (Public Accounts) in the Legislature each year as well. The reports are available to the public directly from each entity and are available on their websites. The annual reporting requirements for the provincial health authority are specified in Section 7.5 of the Provincial Health Authority Act. 

2.0 Comprehensiveness

2.1 Insured Hospital Services

Section 2-7 of the Provincial Health Authority Act gives the Saskatchewan Minister of Health (the Minister) the authority to provide funding to the provincial health authority or a health care organization for the purpose of the Act. There were no amendments made to the Act in 2019-2020.

Section 2-9 of the Act permits the Minister to designate facilities including hospitals, special care homes and health centres. Section 2-10 allows the Minister to prescribe standards for delivering services in those facilities in the provincial health authority, including health care organizations that have entered into service agreements with the provincial health authority.

The Act sets out the accountability requirements for the provincial health authority and health care organizations. These requirements include, for example, submitting annual financial and health service plans for ministerial approval (section 7-2), and reporting critical incidents (section 8-2). The Minister also has the authority to establish a provincial surgical registry to help manage surgical wait times (section 2-11). The Minister retains authority to inquire into matters (section 8-3), appoint a public administrator if necessary (section 8-4), and approve general and practitioner staff by-laws (sections 6-1 to 6-3).

Funding for hospitals is included in the funding provided to the provincial health authority. A comprehensive range of insured services is provided by hospitals. These may include:

Hospitals are grouped into the following six categories: community or northern, district, regional, provincial, rehabilitation, and field. The hospitals are grouped this way so that people know what they can expect at each hospital. While not all hospitals will offer the same services, reliability and predictability means:

The provincial health authority has the authority to change the manner in which they deliver insured hospital services based on an assessment of their population health needs, available health providers and financial resources.

The process for adding a hospital service to the list of services covered by the health care insurance plan involves a comprehensive review, which takes into account such factors as service need, anticipated service volume, health outcomes by the proposed and alternative services, cost and human resource requirements, including availability of providers as well as initial and ongoing competency assurance demands. Typically the provincial health authority initiates the process and, depending on the specific service request, it could include consultations involving several branches within the Ministry of Health as well as external stakeholder groups such as service providers and the public. No new hospital services were added to the health care insurance plan in 2019-2020.

2.2 Insured Physician Services

Sections 8 and 9 of the Saskatchewan Medical Care Insurance Act enable the Minister of Health to establish and administer a plan of medical care insurance for provincial residents. There were no amendments to the Act in 2019-2020. All insured fee items for physicians can be found in the Physician Payment Schedule. As of March 31, 2020, there were 2,622 physicians licensed to practise in the province and eligible to participate in the Medical Care Insurance Plan. Of these, 1,330 (50.7 per cent) were family practitioners and 1,292 (49.3 per cent) were specialists. Physicians may choose to not participate in the Medical Services Plan (known in Saskatchewan legislation as opting-out), but if doing so, they must fully opt out of all insured physician services. As per legislation the non-participating physician must also advise beneficiaries that the physician services to be provided are not insured and that the beneficiary is not entitled to be reimbursed for those services. Written acknowledgement from the beneficiary indicating that he or she understands the advice given by the physician is also required.

As of March 31, 2020, there were no non-participating physicians in Saskatchewan.

Insured physician services are those that are medically necessary, are covered by the Medical Services Plan of the Saskatchewan Ministry of Health, and are listed in the Physician Payment Schedule of the Saskatchewan Medical Care Insurance Payment Regulations (1994) of the Saskatchewan Medical Care Insurance Act.

A process of formal discussion and negotiation between the Medical Services Plan and the Saskatchewan Medical Association addresses new insured physician services and definition or assessment rule revisions to existing selected services. The Executive Director of the Medical Services Branch manages this process. When the Medical Services Plan covers a new insured physician service, or a change is made to an existing physician service, the changes are reflected in the Physician Payment Schedule. A regulatory amendment to the Saskatchewan Medical Care Insurance Payment Regulations is required to provide the authority to pay updated rates to physicians and new insured services.

Although formal public consultations are not held, any member of the public may make recommendations about physician services to be added to the Medical Services Plan.

2.3 Insured Surgical-Dental Services

Dentists may choose to not participate in the Medical Services Plan, but if doing so, they must opt out of all insured surgical-dental services. The non-participating dentist must also advise beneficiaries that the surgical-dental services to be provided are not insured and that the beneficiary is not entitled to reimbursement for those services, or advise the beneficiaries to seek services from a dental specialist who is participating. Written acknowledgement from the beneficiary indicating that he or she understands the advice given by the dentist is also required.

There was one non-participating general and specialist dentist in Saskatchewan as of October 15, 2020.

Insured surgical-dental services are limited to:

In addition, all dental anaesthetic for beneficiaries under age 14 is publicly funded.

Surgical-dental services can be added to the list of insured services covered under the Medical Services Plan through a process of negotiation with provincial dental surgeons. The Executive Director of the Medical Services Branch manages the process of adding a new service. Although formal public consultations are not held, any member of the public may recommend that surgical-dental services be added to the Medical Services Plan.

As of March 31, 2020, there were approximately 518 practicing dentists and dental surgeons located in all major centres in Saskatchewan. Seventy-six provided services insured under the Medical Services Plan.

2.4 Uninsured Hospital, Physician and Surgical-Dental Services

Uninsured hospital, physician and surgical-dental services in Saskatchewan include:

As a matter of policy and principle, insured hospital, physician and surgical-dental services are provided to residents on the basis of assessed clinical need. There are no charges allowed in Saskatchewan for insured hospital, physician or surgical-dental services. Charges for enhanced medical services or products are permitted only if the medical service or product is not deemed medically necessary and/or not deemed to be an insured service. Compliance is monitored through consultations with the provincial health authority, physicians and dentists, as well as via complaints from members of the public.

The Patient Choice Medical Imaging Act and The Medical Imaging Facilities Licensing Regulations authorize private MRI and CT facilities in Saskatchewan to accept payment directly from patients in exchange for MRI and CT services. However, for every scan that is paid for privately, the Regulations require private providers to provide a second scan, free of charge, to an individual who is waiting on the public list. Private-pay MRI service and its unique two-for-one provision gives patients more options in accessing MRI service and has added capacity to the publicly-funded system at no extra cost to the health system or the patient receiving the reciprocal scan. Along with increases in public capacity, through expanded hospital volumes, new CT and MRI scanners, and increased volumes in publicly funded contracts, these privately funded scans and second scans are assisting in the management of MRI wait times.

Insured hospital services are typically de-insured by the government if they were determined to be no longer medically necessary and/or clinically appropriate. The process involves discussions among stakeholders, practitioners, and officials from the Saskatchewan Ministry of Health.

Insured physician services could be de-insured if they were determined not to be medically required and/or clinically appropriate. The process involves consultations with the Saskatchewan Medical Association and managed by the Executive Director of the Medical Services Branch.

Insured surgical-dental services could be de-insured if they were determined not to be medically necessary and/or clinically appropriate. The process involves discussion and consultation with the dental surgeons of the province, and is managed by the Executive Director of the Medical Services Branch.

Formal public consultations about de-insuring hospital, physician or surgical-dental services may be held if warranted. There were no services de-insured during 2019-2020.

3.0 Universality

3.1 Eligibility

The Saskatchewan Medical Care Insurance Act (sections 2 and 12) and the Medical Care Insurance Beneficiary and Administration Regulations define eligibility for insured health services in Saskatchewan. Section 11 of the Act requires that all residents register for provincial health coverage.

While the Regulations set out classes of beneficiaries exempt from insured services under the Act, it is possible for individual residents to request that the Health Registry not issue a provincial health card in certain cases (e.g., for religious reasons).

Eligibility is limited to residents. A “resident” means a person who is legally entitled to remain in Canada, who makes his or her home and is ordinarily present in Saskatchewan, or any other person declared by the Lieutenant Governor-in-Council to be a resident. Canadian citizens and permanent residents of Canada relocating from within Canada to Saskatchewan are generally eligible for coverage on the first day of the third month following establishment of residency in Saskatchewan. There were no changes to residency requirements in 2019-2020.

Returning Canadian citizens, the families of returning members of the Canadian Forces, international students, and international workers are eligible for coverage on establishing residency in Saskatchewan, provided that residency is established before the first day of the third month following their admittance to Canada.

The following persons are not covered under Saskatchewan’s Medical Services Plan:

Such people become eligible for coverage as follows:

Individuals who are not successful when applying for a provincial health card may appeal the decision by submitting to Health Registries - eHealth Saskatchewan, a Saskatchewan Health Services Card Application—Appeal Form.

The number of persons registered for health services in Saskatchewan on June 30, 2019, was 1,216,490.

3.2 Other Categories of Individuals

Other categories of individuals who are eligible for insured health service coverage include persons allowed to enter and remain in Canada under authority of a work permit, study permit or Minister’s permit issued by Immigration, Refugees and Citizenship Canada. Their accompanying family may also be eligible for insured health service coverage.

Refugees are eligible on confirmation of Convention status or with a study or work permit, Minister’s permit or permanent resident or landed immigrant record.

People moving to Saskatchewan from outside of Canada may be eligible for Saskatchewan health converge on, or before, the first day of the third month after arriving in Canada, if among one of the follow groups:

4.0 Portability

4.1 Minimum Waiting Period

In general, insured persons from another province or territory who move to Saskatchewan are eligible on the first day of the third month following establishment of residency. However, where one spouse arrives in advance of the other, the eligibility for the initial arriving spouse is established on either a) the first day of the third month following arrival of the second spouse; or b) the first day of the thirteenth month following the establishment of residency by the first spouse. The second spouse would be eligible on the first day of the third month following arrival.

4.2 Coverage during Temporary Absences in Canada

Section 3 of the Medical Care Insurance Beneficiary and Administration Regulations of the Saskatchewan Medical Care Insurance Act prescribes the portability of health insurance provided to Saskatchewan residents while temporarily absent within Canada.

Residents of Saskatchewan are able to maintain health coverage during a period of temporary absence, conditional upon the registrant's intent to return to Saskatchewan residency.

In 2015–2016, Saskatchewan amended the Medical Care Insurance Beneficiary and Administration Regulations to increase the amount of time residents are allowed to be out-of-province while still maintaining their health care benefits. Residents are now able to maintain health coverage after spending a maximum of seven months outside of Saskatchewan. Residents were only allowed to be absent for a maximum of six months over any 12 month period before their health benefits were discontinued. The new policy took effect January 1, 2016.

Section 6.6 of the Health Administration Act provides the authority for paying in-patient hospital services to Saskatchewan beneficiaries temporarily residing outside the province. Section 10 of the Saskatchewan Medical Care Insurance Payment Regulations (1994) provides payment for physician services to Saskatchewan beneficiaries temporarily residing outside the province but within Canada. No amendments were made to the Act or the Regulations in 2019-2020.

Saskatchewan has bilateral reciprocal billing agreements with all provinces for hospital services. Quebec does not participate in reciprocal billing of physician services.

4.3 Coverage during Temporary Absences outside Canada

Section 3 of the Medical Care Insurance Beneficiary and Administration Regulations of the Saskatchewan Medical Care Insurance Act prescribes the portability of health insurance provided to Saskatchewan residents who are temporarily absent from Canada.

Residents of Saskatchewan are able to maintain health coverage during a period of temporary absence, conditional upon the registrant's intent to return to Saskatchewan residency.

Section 3 of the Medical Care Insurance Beneficiary and Administration Regulations provides open-ended temporary absence coverage for persons whose principal place of residence is in Saskatchewan, but who are not able to satisfy the annual five months physical presence requirement because the nature of their employment requires travel from place to place outside Canada (e.g., cruise line workers).

Section 6.6 of the Health Administration Act provides the authority under which a resident is eligible for health coverage when temporarily outside Canada. In summary, a resident is eligible for medically necessary hospital services at the rate of $100 per in-patient and $50 per out-patient visit per day. No amendments were made to the Regulations in 2019-2020.

4.4 Prior Approval Requirement

Out-of-Province

The Saskatchewan Ministry of Health covers most hospital and medical out-of-province care received by its residents in Canada through reciprocal billing arrangements. These arrangements mean that residents do not need prior approval and may not be billed for most hospital and medical services received within the publicly funded health care system in other provinces or territories while travelling within Canada. The cost of travel, meals and accommodation are not covered. Prior approval is required for the following services provided out-of-province:

Prior approval from the Saskatchewan Ministry of Health must be obtained by the patient's specialist before the out-of-province services are received.

Out-of-Country

If a specialist physician refers a patient outside Canada for treatment not available in Saskatchewan or another province, the referring specialist must obtain prior approval for coverage from the Medical Services Plan of the Saskatchewan Ministry of Health. The Saskatchewan Cancer Agency is consulted for out-of-country cancer treatment requests. If approved, the Saskatchewan Ministry of Health will pay the full cost of treatment, excluding any items that would not be covered in Saskatchewan.

In Saskatchewan, the Health Services Review Committee (HSRC) is an arms-length panel that reviews government decisions made on requests for out-of-province and out-of-country medical coverage, ensuring legislation, policy, and guidelines are followed appropriately.

The Ministry of Health informs eligible applicants of their right to request a review by the HSRC upon denial of their out-of-province or out-of-country coverage request. A person can request a review by the HSRC only if the coverage request was for out-of-province insured medical health services, elective out-of-country insured medical services (physician and hospital care) or community care programs (mental health, alcohol and drug, problem gambling, and rehabilitative services).

If a case is ineligible for HSRC or if HSRC upholds the Saskatchewan Ministry of Health's coverage decision, a person may contact the Provincial Ombudsman for their review.

5.0 Accessibility

5.1 Access to Insured Health Services

To ensure that access to insured hospital, physician and surgical-dental services is not impeded or precluded by financial barriers, extra-billing by physicians or dental surgeons, and user charges by hospitals for insured health services are not allowed in Saskatchewan.

Pursuant to section 18 (1.1) of the Saskatchewan Medical Care Insurance Act, no physician or other person who provides an insured service to a beneficiary shall demand or accept payment for that service in an amount that he knows exceeds the payment to be made for that service prescribed in the Saskatchewan Medical Care Insurance Regulations.

With regard to extra-billing and user charges, compliance is monitored through consultations with the provincial health authority, physicians and dentists, as well as complaints from members of the public. The Saskatchewan Ministry of Health's General Inquiry contact information is as follows:

Saskatchewan Ministry of Health
1-800-667-7766
info@health.gov.sk.ca

When requests are made by a beneficiary to reimburse monies paid directly to a physician for insured physician services that are extra-billing charges, correspondence is sent to the beneficiary (copying the physician) advising them of Section 18 (1.1) of the Saskatchewan Medical Care Insurance Payment Act that a physician must accept the negotiated rate as payment in full for insured services provided to a beneficiary. Once they have received payment from Medical Services Plan for the eligible service(s), reimbursement for any difference in the amount charged by the practitioner and the amount paid by Medical Services should be collected directly from the practitioner. If further complaint is made, the beneficiary is directed to address complaints to the Saskatchewan College of Physicians and Surgeons.

In addition, a private third-party facility must obtain a health facility license to provide certain insured services (e.g., surgical services) on behalf of the publicly funded health system. The Health Facilities Licensing Act (HFLA) or the Patient Choice Medical Imaging Act (PCMIA) authorizes and prescribes the conditions under which a health facility license may be issued to a private facility. The HFLA or PCMIA stipulate that a licensee may not charge or permit any other person to charge any fee to any beneficiary for any insured health service as defined under the HFLA or PCMIA.

Legislation prescribes that the Saskatchewan Minister of Health may amend, suspend or cancel a license if, in the opinion of the Minister, the licensee has failed to comply with the above clause.

Persons who have a complaint of an extra-billing and user charge may also raise the concern with the College of Physicians and Surgeons of Saskatchewan. The College has in their bylaws 7.1 Code of Ethics that includes:

Contravention of, or failure to comply with, the Code of Ethics is unbecoming, improper, unprofessional or discreditable conduct for the purposes of the Medical Care Insurance Act.

The health system continues to strengthen coordination, communication, and referral guidelines to better coordinate services to ensure patients have timely access to the most appropriate specialist and diagnostic services. By reducing the wait time for a consult with a specialist or diagnostic services (such as MRI and CTs), patients will be able to access treatment sooner.

Other Programs and Initiatives to Improve Access

The Family Physician Comprehensive Care Program is intended to support recruitment and retention of family physicians by recognizing those physicians who provide a full range of services to their patients and the continuity of care that result from these comprehensive services.

Leveraging Immediate Non-Urgent Knowledge (LINK) is a provincial telephone consultation service that allows primary care providers to consult with a specialist about serious and/or complex non-urgent patient health concerns. LINK helps patients get answers to their health concerns sooner, prevents unnecessary referrals and supports better referrals to the right specialist when required.

Specialist's wait times can vary for a variety of reasons and can result in two patients with the same condition and acuity having very different wait times. Pooled referrals offer referring physicians and their patients more choices to reduce wait times and improve patient access. Pooled referral systems direct patients to the next available specialist able to treat the patient's condition yet still allow physicians to make direct referrals to a specific specialist using the same referral process.

Saskatchewan's online Specialist Directory makes it easier to find current surgical wait times and information about surgical specialists in Saskatchewan. It can help patients and their family doctors view their options for surgical services and help them to easily identify the most appropriate surgeon for them. One of the many benefits is it can enable patients who are willing to travel to have the surgery more quickly in a location other than their nearest surgical centre.

5.2 Physician Compensation

Section 6 of the Saskatchewan Medical Care Insurance Payment Regulations (1994) outlines the obligation of the Minister of Health to make payments for insured services in accordance with the Physician Payment Schedule and the Dentist Payment Schedule.

Fee-for-service is the most widely used method of compensating physicians for insured health services in Saskatchewan, although sessional payments, salary, and blended methods are also used. Fee-for-service is the only mechanism used to fund dentists for insured surgical-dental services. Total expenditures for in-province physician services and programs in 2019-2020 amounted to $1.051 billion: $556.4 million for fee-for-service billings; $32.9 million for Specialist Emergency Coverage Programs; and $395.3 million in non-fee-for-service expenditures. There was also an additional $65.8 million for the Clinical Services Fund and other Saskatchewan Medical Association and bursary programs.

The Saskatchewan Joint Medical Professional Review Committee (JMPRC) is a physician peer-review Committee that was established by section 49 of The Saskatchewan Medical Care Insurance Act (1988) to review the billing patterns of Saskatchewan physicians who are directly billing the publicly funded system for insured services. The JMPRC reviews billing patterns of physicians referred by the Director of Professional Review of the Ministry of Health and in cases where they determine that monies have been paid by the Minister inappropriately, they may order recovery from the physician.

Saskatchewan physicians do not charge block fees.

5.3 Payments to Hospitals

Funding to the Saskatchewan Health Authority (SHA) takes into account status quo funding levels and is adjusted for inflation, utilization increases, collective agreement increases, new programs and other adjustments as outlined in the current year provincial budget. The SHA is given a global budget and is responsible for allocating funds within that budget to address service needs and priorities identified through its needs assessment processes. The SHA may receive additional funds for providing specialized hospital programs and services (e.g., renal dialysis, medical imaging, respiratory, surgical and mental health and addictions services).

Payments to the SHA for delivering services are made pursuant to section 2-7 of the Provincial Health Authority Act. The legislation provides the authority for the Minister of Health to make grants to the SHA and health care organizations for the purposes of the Act, and to arrange for providing services in any area of Saskatchewan if it is in the public interest to do so.

The SHA provides an annual report on the aggregate financial results of its operations.

6.0 Recognition Given to Federal Transfers

Federal contributions provided through the Canada Health Transfer are publicly acknowledged by the Government of Saskatchewan in:

These documents were tabled in the Legislative Assembly and are publicly available to Saskatchewan residents. Federal contributions have also been acknowledged in news releases and issue papers, and in speeches and remarks made at various conferences, meetings and public policy forums.

Registered Persons
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
1. Number as of March 31st 1,154,257 1,176,932 1,199,429 1,196,842Saskatchewan table 1 Footnote 1 1,216,490Saskatchewan table 1 Footnote 1
Saskachewan table 1 Footnote 1

Saskatchewan's numbers as of June 30, 2019.

Saskatchewan table 1 Return to footnote 1 referrer
Insured Hospital Services Within Own Province or Territory
Public Facilities 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
2. Number 66 66 66 66 66
3. Payments for insured health services ($)
 1,943,748,000 1,976,162,750 1,968,702,500Saskatchewan table 2 Footnote 1 2,067,238,750Saskatchewan table 2 Footnote 1 2,141,445,000Saskatchewan table 2 Footnote 1
Private For-Profit Facilities 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
4. Number of private for-profit facilities providing insured health services 5 5 6 6 6
5. Payments to private for-profit facilities for insured health services ($)  Not available Not availableSaskatchewan table 2 Footnote 2 Not availableSaskatchewan table 2 Footnote 2 Not availableSaskatchewan table 2 Footnote 2 Not availableSaskatchewan table 2 Footnote 2
Saskatchewan table 2 Footnote 1

As reported by the Saskatchewan Health Authority in their annual audited financial statements.

  • Includes acute care services, specialized hospital services, and in-hospital specialist services.
  • Does not include in-patient mental health or addiction treatment services.
  • Does not include payments to Saskatchewan Cancer Agency for out-patient chemotherapy and radiation.
  • Physician compensation is included under the appropriate functional areas.

Saskatchewan table 2 Return to footnote 1 referrer

Saskatchewan table 2 Footnote 2

CT and MRI services are not considered insured services in Saskatchewan within the meaning of the Saskatchewan Medical Care Insurance Act. Private facilities providing surgical, MRI and CT services may receive payments for these services under contract with the provincial health authority. The Ministry of Health does not directly provide payments to these facilities.

Saskatchewan table 2 Return to footnote 2 referrer
Insured Hospital Services Provided to Residents in Another Province or TerritorySaskatchewan table 3 Footnote 1
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
6. Total number of cases, in-patient 4,923 4,376 4,277 4,174 3,991
7. Total payments, in-patient ($) 67,838,500 49,817,000 54,776,000 64,494,900 55,922,600
8. Total number of cases, out-patient 77,250 68,995 71,933 72,192 74,539
9. Total payments, out-patient ($) 28,739,900 27,218,000 28,957,000 29,364,100 30,332,600
Saskatchewan table 3 Footnote 1

Data for prior years has been re-stated to reflect total number of hospital cases rather than claims as a single hospitalization can result in numerous claims.

Saskatchewan table 3 Return to footnote 1 referrer
Insured Hospital Services Provided Outside CanadaSaskatchewan table 4 Footnote 1
Pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
10. Total number of cases, pre-approved in-patient 7 5 2 7 8
11. Total payments, pre-approved  in-patient ($) 1,096,600 933,300 37,900 3,078,800 1,855,300
12. Total number of cases, pre-approved out-patient 176 52 53 218 216
13. Total payments, pre-approved out-patient ($) 1,066,600 405,900 269,600 2,055,800 1,433,700
Non Pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
14. Total number of cases, non pre-approved in-patient 344 335 308 317 283
15. Total payments, non pre-approved    in-patient ($) 203,100 116,700 248,800 193,800 2,431,900
16. Total number of cases, non pre-approved out-patient 1,403 1,285 1,191 1,244 920
17. Total payments, non pre-approved out-patient ($) 69,700 62,200 58,700 69,400 45,200
Saskatchewan table 4 Footnote 1

Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report,but did not require provinces or territories to report on previous years.

Saskatchewan table 4 Return to footnote 1 referrer
Insured Physician Services Within Own Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
18. Number of participating physicians 2,375 2,491 2,560 2,600 2,622
19. Number of opted-out physicians 0 0 0 0 0
20. Number of non-participating physicians 0 0 0 0 0
21. Total payments for services provided by physicians paid through all payment methods ($) 941,409,025 982,568,484 997,950,125 1,009,110,700 1,050,449,400
22. Total payments for services provided by physicians paid through fee-for-service ($) 535,162,606 557,334,395 561,557,167Saskatchewan table 5 Footnote 1 556,831,300Saskatchewan table 5 Footnote 1 556,434,500Saskatchewan table 5 Footnote 1
Saskatchewan table 5 Footnote 1

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.

Saskatchewan table 5 Return to footnote 1 referrer
Insured Physician Services Provided to Residents in Another Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
23. Number of services 753,736 785,072 740,342 757,219 770,674
24. Total payments ($) 40,339,800 42,855,888 41,691,900 42,976,000 44,549,700
Insured Physician Services Provided Outside CanadaSaskatchewan table 7 Footnote 1
Pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
25. Number of pre-approved services Not  available Not  available Not  available 596 764
26. Total pre-approved payments ($) Not  available Not  available Not  available 500,368 747,889
Non Pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
27. Number of non pre-approved services Not  available Not  available Not  available 4,906 4,817
28. Total non pre-approved payments ($) Not  available Not  available Not  available 274,585 289,000
Saskatchewan table 7 Footnote 1

Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report, but did not require provinces or territories to report on previous years.

Saskatchewan table 7 Return to footnote 1 referrer
Insured Surgical-Dental Services Within Own Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
29. Number of participating dentists 79 78 78 88 76
30. Number of opted-out dentistsSaskatchewan table 8 Footnote 1 Not  available 0 0 0 0
31. Number of non-participating dentistsSaskatchewan table 8 Footnote 1 Not  available 0 0 0 1
32. Number of services provided 18,777 13,139 11,550 10,916 12,656
33. Total payments ($) 2,146,101 1,688,771 1,516,900 1,529,800 1,565,900
Saskatchewan table 8 Footnote 1

Health Canada requested this data as of the 2016-2017 report, but did not require provinces or territories to report 2015-16 data.

Saskatchewan table 8 Return to footnote 1 referrer

Alberta

The Minister of Health, the Department of Health (Alberta Health) and the Regional Health Authority (Alberta Health Services) play key roles in Alberta's health care system. All persons and entities work together to provide safe, high quality and universally accessible, publicly funded health care services for Albertans.

COVID-19 Measures   

As COVID-19 began to impact the entire health system in Alberta, many measures were initiated to adapt and respond to the pandemic. Early in the pandemic, Alberta Health Services established a leading testing program, procured personal protective equipment and set aside acute care capacity to respond to a range of COVID-19 scenarios. In March 2020, health service billing codes for practitioners delivering health care through means other than face-to-face interactions were activated and non-urgent surgical procedures undertaken in hospitals and chartered surgical facilities were paused. Up-to-date information about changes made to Alberta Health Care Insurance Plan (AHCIP) coverage as part of Alberta's pandemic response is available through the AHCIP website, including coverage for temporary residents.

With the benefit of expert advice from Alberta's Chief Medical Officer of Health, public health measures were put in place that minimized the spread of COVID-19, while balancing the economic impact. Alberta has one of the highest testing rates in the world; ongoing testing and contact tracing has enabled the province to:

1.0 Public Administration

1.1 Health Care Insurance Plan and Public Authority

Alberta Health administers and operates the Alberta Health Care Insurance Plan (AHCIP), in accordance with the Canada Health Act. Since 1969, the Alberta Health Care Insurance Act (AHCIA), which is available on the Alberta Queen's Printer website, has governed the operation of the AHCIP. Alberta Health sets policy and direction to achieve a sustainable and accountable health system to promote and protect the health of Albertans. Section 3 of the AHCIA enables the AHCIP and designates the Alberta Minister of Health, as the public authority responsible for the administration and operation of the AHCIP.

1.2 Reporting Relationship

The Alberta Minister of Health (the Minister) is accountable for the AHCIP. The Minister, as the public authority responsible for the administration and operation of the AHCIP, is required under the AHCIA to administer and operate the AHCIP on a non-profit basis, in accordance with the AHCIA and the regulations to provide benefits for basic health services to all residents of Alberta. The legislation includes a number of accountability measures relating to the administration and operation of the AHCIP including provisions that enable the Minister to audit and review claims for benefits and recover overpayments to practitioners.

The Fiscal Planning and Transparency Act (FPTA), which is available on the Alberta Queen's Printer website, provides a framework for government budgeting and fiscal planning. A ministry annual report is prepared under the direction of the Minister in accordance with the FPTA and the government's accounting policies. The 2019-2020 Annual Report of the Ministry of Health, covering the fiscal year April 1, 2019 to March 31, 2020, was released to the public on August 27, 2020.  

1.3 Audit of Accounts

The Auditor General of Alberta is an independent office responsible for conducting annual financial audits and other audits pertaining to the government's management of public resources. In accordance with Alberta's Auditor General Act, audit reports are tabled with the Legislative Assembly. The Auditor General's opinion on the audit of the province's consolidated financial statements, which includes the financial transactions and other information of the Ministry of Health, was published on August 27, 2020, in the Government of Alberta's 2019-2020 annual report. The report indicated that the consolidated financial statements present fairly, in all material respects, the financial position and results of operations for the year ended March 31, 2020.

2.0 Comprehensiveness

2.1 Insured Hospital Services

In Alberta, Alberta Health Services (AHS) is the entity responsible to the Minister for ensuring the provision of insured hospital services. The Hospitals Act, the Hospitalization Benefits Regulation (AR 244/1990), the Health Care Protection Act (HCPA) and the Health Care Protection Regulation (HCPR) govern the provision of insured services by hospitals or chartered surgical facilities. After the reporting period, in July 2020, the Health Facilities Act (HFA) and Health Facilities Regulation (AR 208/2000), which are available on the Alberta Queen's Printer website, replaced the HCPA and HCPR. The new title of the HFA better reflects the purpose and nature of the Act.

During 2019-2020, no amendments were made to the legislation regarding insured hospital services. A directory of approved hospitals in Alberta is available online.

The publicly funded services provided by approved hospitals in Alberta include all of the hospital services listed in the Canada Health Act. The insured hospital services range from advanced levels of diagnostic and treatment services for in-patients and out-patients, to routine care and management of patients with previously diagnosed chronic conditions. The benefits available to hospital patients in Alberta are established in the Hospitalization Benefits Regulation. The Regulation is available on the Alberta Queen's Printer website.

The list of insured services included in the Regulations is intended to be both comprehensive and generic, thereby limiting the need for routine review and updating. No new services were added during 2019-2020 to the insured hospital services covered by the Alberta Health Care Insurance Plan (AHCIP).

Computerized Tomography (CT) and Magnetic Resonance Imaging (MRI) diagnostic procedures are not considered insured services under the Schedule of Medical Benefits but are publicly funded and provided to eligible Albertans by AHS at an AHS or AHS contracted facility. AHS has a system that sets priorities and manages wait times. If a patient chooses to attend a private diagnostic clinic and self pay, AHS has a process for reimbursement if criteria are met.

2.2 Insured Physician Services

The Alberta Health Care Insurance Act (AHCIA) governs the payment to physicians for insured physician services under section 6. Only physicians who meet the requirements stated in the AHCIA are permitted to make a claim for payment of benefits for providing insured services under the AHCIP.

Alberta had 10,618 physicians participating under the AHCIP as of March 31, 2020. Within this, 8,721 physicians were paid exclusively under fee-for-service, 884 were compensated solely through an Alternative Relationship Plan, and the remaining 1,013 physicians received compensation from both fee-for-service and through an Alternative Relationship Plan. As of March 31, 2020, there were two non-participating physicians in the province.

Before being registered with the AHCIP, a physician must complete the appropriate registration forms and include a copy of the licence issued to them by the College of Physicians and Surgeons of Alberta.

Under section 8 of the AHCIA, all physicians are deemed to participate in the AHCIP. Under section 8(2), a physician may choose to not participate in the AHCIP by taking the following actions at least 180 days prior to the effective date of not participating: a) notifying the Minister of Health in writing indicating the effective date of not participating, b) publishing a notice of the proposed non-participation in a newspaper having general circulation in the area in which the physician practises, and c) posting a notice of the proposed non-participation in a part of the physician's office to which patients have access.

Legal requirements are set out in section 8(3) of the AHCIA for a physician who has not previously practised in Alberta. Under section 8(3) the physician may choose to not participate in the AHCIP prior to commencing practice by: (a) notifying the Minister in writing indicating the date on which the physician will commence non-participating practice, and (b) publishing a notice of the proposed non-participation in a newspaper having general circulation in the area in which the physician intends to practise.

By not participating in the AHCIP, a physician agrees that, commencing on the effective date, they will not participate in the publicly funded health system. This means that the physician cannot make a claim from the AHCIP for payment for providing what would otherwise be insured health services and the patient cannot seek reimbursement for any amounts paid by the patient for receiving health services from the non-participating physician.

Section 12 of the Alberta Health Care Insurance Regulation (AR 76/2006) lists services that are not considered basic or extended health services. The Medical Benefits Regulation (AR 84/2006) establishes the benefits payable for insured medical services provided to a resident of Alberta. Descriptions of those services are set out in the Schedule of Medical Benefits.

The Ministry of Health is committed to having a Schedule of Medical Benefits that supports continuous improvement and is responsive to health reform. The medical community is continuously consulted and health services codes are created to ensure the schedule reflects the current standard of practice within Alberta. There is no public consultation. All changes to the benefit schedule require the approval of the Minister of Health.

During 2019-2020, new virtual care health service codes were added to the Schedule of Medical Benefits to ensure continuation of essential medical services during the COVID-19 pandemic. Effective March 12, 2020, the Ministry of Health activated health service code 03.01AD (telephone advice to a patient or their agent, during a viral epidemic). This health service code was previously active during the H1N1 epidemic. On March 17, 2020, a further six health services codes were added to the Schedule to cover telephone and videoconference visits, consultations, and mental health services (psychotherapy) with a family physician or specialist. Prior to the introduction of these health service codes, the Schedule already contained codes for physician to patient telephone calls, videoconferences, and secure electronic communications. These pre-existing health service codes were intended for follow-up patient management such as the communication of test results. However, the new health service codes are designed to replicate an in-person assessment. 

2.3 Insured Surgical-Dental Services

In Alberta, a small number of medically necessary oral surgical and dental procedures are insured. These are listed in the Schedule of Oral and Maxillofacial Surgery Benefits. In 2019-2020, no updates were made to this schedule.

The majority of dental procedures that can be billed to the AHCIP can only be performed by a dentist certified as an oral and maxillofacial surgeon who meets the requirements stated in the AHCIA. Insured dental-surgical services must be performed in either a public hospital or a chartered surgical facility. Major surgical services, as described in section 2(2) (b) of the HFA, may only be provided in a public hospital. As of March 31, 2020, there were 219 dentists participating under the AHCIP for eligible dental procedures and no dentists were opted-out of the AHCIP. Routine dental care is not covered by the AHCIP.

Although there is no formal agreement with dentists, the Ministry of Health meets with members of the Alberta Dental Association and College to discuss changes to the Schedule of Oral and Maxillofacial Surgery Benefits. There is no public consultation. All changes to the benefit schedule require the approval of the Minister of Health.

Under section 7 of the AHCIA, all dentists are deemed to participate in the AHCIP. Under section 7(2), a dentist may choose to opt out of the AHCIP by taking the following actions at least 30 days prior to the effective date of opting out: (a) notifying the Minister in writing indicating the effective date of not participating; (b) publishing a notice of the proposed non-participation in a newspaper having general circulation in the area in which the dentist practises; and, (c) posting a notice of the proposed non-participation in a part of the dentist's office to which patients have access. Legal requirements are set out in section 7(3) of the AHCIA for a dentist who has not previously practised in Alberta. Under section 7(3), the dentist may choose to not participate in the AHCIP prior to commencing practice by (a) notifying the Minister in writing indicating the date on which the dentist will commence non-participating practice, and (b) publishing a notice of the proposed non-participation in a newspaper having general circulation in the area in which the dentist intends to practise.

By choosing to not participate in the AHCIP, a dentist agrees that, commencing on the effective date, they will not participate in the publicly funded health system. This means that the dentist cannot make a claim from the AHCIP for payment for providing what would otherwise be publicly funded surgical-dental services and the patient cannot seek reimbursement for any amounts paid by the patient for receiving surgical-dental services from the non-participating dentist.

2.4 Uninsured Hospital, Physician, and Surgical-Dental Services

Section 12 of the Alberta Health Care Insurance Regulation lists services that are not considered basic or extended health services unless otherwise approved by the Minister of Health. Section 4(2) and section 5(2) of the Oral and Maxillofacial Surgery Benefits Regulation (AR 86/2006) indicate no benefits are payable for oral and maxillofacial surgery services provided to an Alberta resident in another province or territory of Canada or outside of Canada if they are not insured services in Alberta. Section 4(2) of the Hospitalization Benefits Regulation provides a list of hospital services that are not considered to be insured.

Services not covered by the AHCIP include:

The Preferred Accommodation and Non-Standard Goods or Services Policy describes the Government of Alberta's expectations of AHS and guides the provision of preferred accommodation and enhanced or non-standard goods and services. This policy framework requires AHS to provide 30 days advance notice to the Minister of Health's designate regarding the categories of preferred accommodation offered and the charges associated with each category. AHS is also required to provide 30 days advance notice to the Minister of Health's designate regarding any goods or services that will be provided as non-standard goods or services. AHS must also provide information about the associated charge for these goods or services, and when applicable, the criteria or clinical indications that may qualify patients to receive it as a standard good or service. Alberta's policy for Preferred Accommodation and Non-Standard Goods or Services is available online.

Health services that are deleted from the Schedule of Medical Benefits are those services that the medical community has identified as obsolete. The process to engage the medical community is completed through consultation with the Alberta Medical Association and AHS. The Alberta Medical Association acts as the representative for each physician section. AHS is engaged in this decision process in order to understand how changes may impact current service delivery models or the health system at a macro level.

Effective March 31, 2020, Alberta de-insured the medical examination, including completion of a form, required to obtain or renew an operator's license, where the patient is 74.5 years of age or older. This service was never insured for patients under 74.5 years of age. Also effective March 31, 2020, one health service code was de-listed as the activity was included under another insured health service code.

3.0 Universality

3.1 Eligibility

Under the terms of the Alberta Health Care Insurance Act (AHCIA), Alberta residents are eligible to receive publicly funded health care services under the Alberta Health Care Insurance Plan (AHCIP). There were no changes made to eligibility requirements for the AHCIP in 2019-20.

A resident is defined as a person who is lawfully entitled to be or to remain in Canada, who makes the province their home and is ordinarily present in Alberta, and any other person deemed by the regulations to be a resident. The term "resident" does not include a tourist, transient or visitor to Alberta.

Persons moving permanently to Alberta from outside Canada are eligible for coverage if they have permanent resident status, are returning permanent residents , or are returning Canadian citizens. Persons residing in Alberta on an approved Canada entry document may also be eligible for coverage under the AHCIP, and their eligibility is reviewed on a case-by-case basis.

A resident is not entitled to AHCIP coverage if the resident is a member of the Canadian Armed Forces or a person serving a term in a federal penitentiary as defined in the Corrections and Conditional Release Act. These residents receive health care coverage from the federal government. Spouses or partners and dependants of these residents are provided with AHCIP coverage if they are Alberta residents.

The AHCIP will cover individuals released within Alberta from the Canadian Armed Forces or federal penitentiaries, effective the date of release, if notified within three months. If individuals are released in another part of Canada, they are eligible for coverage on the first day of the third month after becoming a resident of Alberta.

In order to access insured services under the AHCIP, Alberta residents are required to register themselves and their eligible dependants. Family members are registered on the same account. Persons moving to Alberta should apply for coverage within three months of arrival or effective dates may be affected. For persons moving to Alberta from within Canada, their registration is effective on the first day of the third month after they become an Alberta resident. For persons moving to Alberta from outside Canada, their registration is effective the day they become an Alberta resident. The process for registering Albertans requires registrants to provide documentation that proves their identity, legal entitlement to be in Canada, and Alberta residency.

When a cancellation or denial of AHCIP coverage is questioned, an individual may contact the AHCIP by phone, e-mail, or mail to discuss the issue. If it cannot be resolved by front-line staff, it is escalated to a supervisor, then a manager, if needed. The manager will conduct a thorough investigation and send a letter with reasons for the decision, as it relates to legislation.

Individuals can choose not to participate in the AHCIP by filing a “Declaration of Election to Opt Out” at any time for themselves and their dependants. Coverage is cancelled for 36 months or until the declaration is revoked by the individual. A new declaration is required every 36 months of non-participation.

As of March 31, 2020, there were 4,783,609 Alberta residents registered with the AHCIP and 214 Alberta residents who were non-participants.

3.2 Other Categories of Individuals

Under the Alberta Health Care Insurance Regulation, a person may be deemed a resident for the purpose of AHCIP coverage if they are residing in Alberta to work, study, or are the spouse or partner or dependant of someone who is here to work or study. A Canada Entry Document such as a Work Permit or Study Permit, is required as proof of their legal entitlement to be, and remain, in Canada. Dependants accompanying temporary residents on a Work or Study Permit must have a Visitor Record (that limits the length of stay) as proof of their legal entitlement to be, and remain, in Canada. Deemed residents must intend on residing in Alberta for 12 months or more. AHCIP coverage is provided to temporary residents and their accompanying dependants who meet all the eligibility requirements. There were 75,110 people covered by the AHCIP under these conditions as of March 31, 2020.

Individuals who hold a Study Permit that does not indicate a school in Alberta are required to provide proof of registration from the accredited school they are attending. Open or employer-specific work permits must be valid for six months or more. Employer-specific work permits must state the individual is employed by a company operating in Alberta. With the exception of clergy, athletes or members of the British army, individuals with a Visitor Record must be the spouse, partner or dependant of an eligible resident or deemed resident.

Individuals with a Canada Entry Document that has the remark 'does not confirm resident status', are not eligible for AHCIP coverage. Permanent Residents who have proof of Permanent Resident Status and Convention Refugees who have a positive Notice of Decision letter are eligible for AHCIP coverage. Refugee claimants are not eligible.

Children of non-entitled residents (e.g., residents on a Visitor Record, with expired permits, or refugee claimants) who are born in Canada and meet residency requirements are eligible for AHCIP coverage. Children born to Canadian citizens who are temporarily absent from Alberta (and have maintained their coverage) are also eligible; however, documentation may be required.

Seasonal workers from outside Canada are considered Temporary Foreign Workers. To obtain AHCIP coverage, they must meet the definition of deemed resident, have a Work Permit as proof of their legal entitlement to be, and remain, in Canada and intend on residing in Alberta for 12 months or more. Seasonal workers from other provinces retain health coverage from their home province.

Returning Canadians whose residency has expired must provide evidence of their legal entitlement to be, and remain, in Canada (typically a permanent resident card) and meet residency requirements to be eligible for AHCIP coverage. Individuals who have applied for Permanent Resident status must maintain legal entitlement to be, and remain in Canada, (for example, a valid Work Permit, Study Permit or Visitor Record) while they await a decision on the Permanent Resident application. During this period, AHCIP coverage may be granted if they meet the eligibility requirements for a deemed resident.

4.0 Portability

4.1 Minimum Waiting Period

Under the Alberta Health Care Insurance Plan (AHCIP), generally, persons moving permanently to Alberta from another part of Canada are eligible for coverage on the first day of the third month following the date they establish residency in Alberta.

4.2 Coverage during Temporary Absences in Canada

The AHCIP provides coverage under the Alberta Health Care Insurance Regulation for eligible Alberta residents who temporarily leave Alberta for other parts of Canada.

A person is considered temporarily absent from Alberta if the person stays in another province or territory for a period that will not exceed 12 consecutive months and where the person intends to return to and maintain permanent residence in Alberta on the conclusion of their stay outside Alberta. Albertan students who attend an accredited school in Canada, and who intend to return to Alberta after completing their studies, maintain their AHCIP coverage.

Temporary Foreign Workers who are deemed residents retain their AHCIP coverage if they travel to another Canadian province for vacation; however, they do not retain their coverage if they leave Alberta to work in another province or if they leave Canada.

Individuals who are routinely absent from Alberta every year normally must spend a cumulative total of 183 days in a 12-month period in Alberta to maintain continuous coverage. Individuals not present in Alberta for the required 183 days may be considered residents of Alberta if they satisfy the Ministry of Health of their permanent and principal place of residence within the province. Individuals may also remain eligible for coverage if, on a recurring basis, they are absent from Alberta for up to 212 days in a 12-month period for the purpose of vacation.

Alberta participates in interprovincial hospital and medical reciprocal billing agreements. All provinces and territories, except Quebec, participate in medical reciprocal agreements. These agreements were established to minimize complex billing processes and to help ensure timely payments to physicians and hospitals when they provide services to residents from other provinces or territories. Under the agreements, where an eligible Albertan receives an insured physician service or hospital service in another participating province or territory, Alberta will reimburse for the insured service provided at the host province's or territory's rates for medical services and the applicable rate for hospital services.

In 2019-2020, no amendments were made to the legislation regarding portability within Canada. More information on coverage during temporary absences outside Alberta is available online.

Section 16 of the Hospitalization Benefits Regulation addresses payment for hospital services obtained outside of Alberta but within Canada. Section 4 of the Medical Benefits Regulation addresses payment of physician services obtained outside of Alberta but within Canada. These sections were not amended in 2019-2020.

4.3 Coverage during Temporary Absences outside Canada

The AHCIP provides coverage under the Alberta Health Care Insurance Regulation to eligible Alberta residents who are temporarily absent from Canada.

A person is considered to be temporarily absent from Alberta if the person stays outside Canada for a period that will not exceed six consecutive months, and the person intends to return to and maintain permanent residence in Alberta on the conclusion of their stay outside Alberta.

Individuals who are routinely absent from Alberta every year normally must spend a cumulative total of 183 days in a 12-month period in Alberta to maintain continuous coverage. Exceptions may be considered by the Ministry of Health depending on the individual circumstance. Individuals may also remain eligible for coverage if, on a recurring basis, they are absent from Alberta for up to 212 days in a 12-month period for the purpose of vacation.

Individuals leaving the province temporarily on extended vacations, or for temporary employment, may be eligible for coverage for 24 to 48 consecutive months. Students attending an accredited educational institute outside Canada on a full-time basis are entitled to coverage for the duration of their studies providing they intend to reside in Alberta at the conclusion of their studies.

The maximum amount payable for out-of-country in-patient hospital services is $100 (CAD) per day (not including day of discharge). The maximum hospital out-patient visit rate is $50 (CAD), with a limit of one visit per day. The only exception is haemodialysis received as an out-patient, which is paid at a maximum of $496 (CAD) per visit, with a limit of one visit per day. Physician and dental specialist or oral surgeon services are paid according to Alberta rates as per the Schedule of Medical Benefits. Funding may also be available through the Out-of-Country Health Services Committee. The committee evaluates requests made by Alberta physicians or dentists for eligible Alberta residents to be considered for funding of insured services covered under the AHCIP that are not available in Canada.

More information on coverage during temporary absences outside Canada is available online.

Section 16 of the Hospitalization Benefits Regulation also addresses payment for goods and services provided by hospitals or approved facilities outside of Canada. Section 5 of the Medical Benefits Regulation addresses payment of physician services obtained outside Canada. These sections were not amended in 2019-2020.

4.4 Prior Approval Requirement

Prior approval is not required for elective (non-emergency) insured services in another Canadian province or territory. Prior application is required for elective services received out-of-country and approval may only be given through the Out-of-Country Health Services Committee for insured services that are medically required, are not experimental, and are not available in Alberta or elsewhere in Canada.

Decisions made by the committee can be appealed. Appeals may be submitted by an Alberta physician or dentist on behalf of the Alberta resident or by the Alberta resident. The Out-of-Country Health Services Appeal Panel, was established under the Alberta Health Care Insurance Act, and continues under the Out-of-Country Health Services Regulation (AR 78/2006). The Appeal Panel reviews the application, the committee decision, and determines whether to confirm, vary or substitute the committee’s decision under appeal.

5.0 Accessibility

5.1 Access to Insured Health Services

The Government of Alberta is committed to meeting the health care needs of all Albertans. To ensure Albertans have the best possible access to primary health care services, the Alberta Ministry of Health funds Primary Care Networks (PCNs). PCNs support inter-disciplinary teams made up of family physicians and other health care professionals who work with Alberta Health Services (AHS) to coordinate the delivery of primary health care services for their patients. Each PCN has the flexibility to develop programs and provide services to meet the specific needs of patients. Access to health care services can be limited by geography, hours of operation, and wait times. As of March 31, 2020, there were 41 PCNs operating in Alberta. More than 3.8 million Albertans were enrolled in a PCN. A total of 4,707 primary care providers (including family physicians, general practitioners, pediatricians, and nurse practitioners), and the full-time equivalent of 1,305 other health care providers were registered providers in PCNs.

Section 9 of the Alberta Health Care Insurance Act (AHCIA) prohibits extra-billing by opted-in physicians or dentists (i.e., physicians and dentist participating in the Alberta Health Care Insurance Plan (AHCIP)). No physician or dentist who participates in the AHCIP and who provides insured services to a resident with coverage under the AHCIP is allowed to charge or collect from any person an amount in addition to the benefits payable by the Minister of Health for those insured services.

Section 11 of the AHCIA prohibits any person from charging or collecting from any person the following payments, where the amount is in addition to the benefits payable by the Minister of Health for the insured service:

  1. an amount for any goods or services that are provided as a condition to receiving an insured service provided by a physician or dentist who is participating in the AHCIP; or
  2. an amount the payment of which is a condition to receiving an insured service provided by a physician or dentist who is participating in the AHCIP.

When an individual questions extra-billing or user charges, they may contact AHCIP staff by phone, e-mail, fax, or mail as follows:

Alberta Health
Attention: Alberta Health Care Insurance Plan
PO Box1360, Stn Main
Edmonton AB T5J 2N3
Phone: Edmonton: 780-427-1432; Toll free in Alberta: 310-0000 then 780-427-1432
Fax: 780-422-0102
E-mail: health.ahcipmail@gov.ab.ca
(This email address is for general information or non-personal questions regarding the AHCIP)

If the matter cannot be resolved with the health practitioner through communication or education, it may proceed to a compliance review.

The Ministry of Health monitors and enforces compliance with the AHCIA through a dedicated compliance unit. The unit reviews billing compliance, recovers inappropriately paid funds, and contributes to education on appropriate billing practices. These reviews are conducted under section 18 of the AHCIA. If a compliance review uncovers evidence of non-compliance with sections 9 or 11 of the AHCIA, then sections 9, 11, 12, 13 and 14 set out the fines and other steps that may be taken by the Minister of Health.

Sections 9(2), 9(2.1) and 9(3) set out the escalating disciplinary actions the Minister may take in response to extra billing, in addition to any actions taken under sections 13 and/or 14.

Section 11(3) and 11(4) establish that the Minister can recover from any person a prohibited fee that has been collected and must then reimburse the recovered amount to the person who was charged the amount.

Section 12(1) establishes that a physician or dentist who is opted into the AHCIP and provides insured services in circumstances where the physician or dentist knows, or reasonably ought to have known, that a person has been charged an amount in contravention of section 11 should not receive payment of benefits from the Minister for those insured services and that if benefits have been received in contravention of section 12(1), then the sanctions set out in section 9(2) of the AHCIA apply.

Section 13 of the AHCIA sets out the Minister’s right to recover amounts received in contravention of sections 9, 10 or 12 by one or more of the following means: (a) by withholding those amounts from any benefits payable to the physician, dentist or person referred to in section 20.1; (b) by civil action as though those amounts were a debt owing to the Crown in right of Alberta; or (c) pursuant to any agreement between the Minister and the physician, dentist or person referred to in section 20.1 that provides for the repayment of those amounts. Repayment of those amounts is set out in section 13 (3) as follows: The Minister shall reimburse a person in respect of whom benefits may be paid for any amounts recovered under this section that were paid by the person and have not been previously reimbursed.

Section 14 establishes that contravention of sections 9, 10, 11, or 12 is an offence and subject to the fines set out in section 14.

Health infrastructure is important in ensuring current and future health care needs are met. The Ministries of Health and Infrastructure share the responsibility for planning and management of the Health Capital Plan and projects. The Ministry of Health is responsible for setting strategic directions and implementing health policy, legislation, standards and providing global operating funding to AHS. AHS identifies and prioritizes health service needs requiring capital development. The Government of Alberta supports health infrastructure by funding capital development and the Infrastructure Maintenance Program. The Ministry of Infrastructure is responsible for the design, construction and delivery of major health capital projects throughout the province. Health legislation also stipulates the requirements for the purchase and disposition of assets and properties and the general provisions for health infrastructure.

Budget 2019 included $3.55 billion over four years for health facilities, equipment and IT infrastructure. In 2019-20, a detoxification and residential treatment facility in Red Deer was completed; seven projects representing 438 new designated supportive living and long-term care spaces were opened; nine new health facilities were in progress; and seven existing health facilities were in progress for major renovations, modernizations or expansions. 

5.2 Physician Compensation

The AHCIA governs the eligibility and payment to physicians for providing insured medical services to eligible Alberta residents. Physicians are compensated through the AHCIP on a volume-driven, fee-for-service basis or through the use of alternative compensation models such as Clinical Alternative Relationship Plans and the Academic Medicine and Health Services Program. Some primary care physicians are compensated through a Blended Capitation Model which blends fee-for-service and capitation payments.

Under the Oral and Maxillofacial Surgery Benefits Regulation (AR 86/2006), benefits are payable in accordance with the regulations under the AHCIA for oral and maxillofacial surgery services provided to a resident of Alberta by a dentist.

In Alberta, the College of Physicians and Surgeons of Alberta enforces standards of practice for charging for uninsured professional services (non-insured services under the AHCIA), which include rules related to block billing by physicians.

The Academic Medicine and Health Services Program has accountability and reporting expectations for physicians participating in the academic alternative compensation arrangements, as well as for the Faculties of Medicine at both the University of Alberta and Calgary and AHS. Key performance themes include clinical service delivery, administration and leadership, research productivity, and educational quality. These themes are used to measure performance on an annual basis.

Clinical Alternative Relationship Plans and the Academic Medicine and Health Services Program are used by specialists and family physicians and offer alternative compensation models to the traditional fee-for-service payment system. Their purpose is to enhance physician recruitment and retention, team-based approaches to service delivery, access to services, patient satisfaction, and value for money. They also support innovative health care delivery, which will result in better health outcomes. The predictable funding provided through Clinical Alternative Relationship Plans and the Academic Medicine and Health Services Program enables physician groups to recruit new physicians to their programs and retain their services while in some cases providing additional funding to support service delivery.

The Government of Alberta and the Alberta Medical Association (AMA) entered into the Alberta Medical Association Agreement in 2013, which was retroactive to April 1, 2011. In 2018, the Alberta Medical Association Agreement was amended and included no increases to physician rates and prices paid for insured medical services. Certain financial terms in the Alberta Medical Association Agreement were to expire March 31, 2020. After several months of negotiations and mediation, the Government of Alberta utilized the language in the agreement to terminate it on February 20, 2020. This decision was necessary with an estimated $2 billion budget cost pressure over three years expected if the status quo remained in place. In the absence of an agreement, the Government of Alberta implemented a new physician funding framework on March 31, 2020. The Government of Alberta continues to engage the AMA, in good faith, on physician compensation matters and other health matters that concern physicians.

To ensure accountability with the AHCIA, the Ministry of Health conducts regular reviews of claims filed by physicians to assess their compliance within the AHCIA. The Ministry of Health uses statistical and risk assessment methodologies to identify errors or issues in the claims that were paid under the AHCIP. Compliance reviews can be initiated for a practitioner or group of practitioners to determine compliance with specific legislative or contractual requirements. Further, a compliance review may be triggered as a result of a specific complaint about a physician from an external party.

5.3 Payments to Hospitals

Alberta's public hospitals are operated by AHS or by faith-based voluntary organizations under service agreements with AHS. In Alberta, public hospitals are operated in accordance with the Hospitals Act. The Health Facilities Act (HFA) prohibits the operation of private hospitals.

The Regional Health Authorities Act governs the funding of AHS, Alberta's single regional health authority. The Ministry of Health funds AHS through base operating funds provided twice each month. AHS determines funding for individual hospitals and for chartered surgical facilities that are under contract to provide insured surgical services. The HFA governs the provision of insured and uninsured surgical services performed in public hospitals and chartered surgical facilities. The HFA prohibits queue jumping. Specifically, no person shall give or accept any money or other valuable consideration, pay for or accept payment for enhanced medical goods or services or non-medical goods or services, or provide an uninsured surgical service for the purpose of giving any person priority for the receipt of an insured surgical service. Access to insured surgical services is based on the medical needs of patients and determined by physicians and dentists.

The Minister of Health is required to approve any service agreement between operators of a chartered surgical facility and AHS in order for the facility to provide insured surgical services. Ministerial designation of a chartered surgical facility and accreditation by the College of Physicians and Surgeons of Alberta is also required.

According to the HFA, ministerial approval for a proposed facility services agreement shall not be given unless:

A) the Minister of Health is satisfied:

B) the Minister has considered the assessment of the proposed agreement with respect to the factors referred to in section 8(1.1).

Pursuant to the terms of any agreement between AHS and the operator of a chartered surgical facility, AHS agrees to pay a contracted "facility fee". This fee covers certain services specified under the HFA that are medically necessary and are directly related to the provision of a surgical service at an approved surgical facility. Physicians who provide insured surgical services to patients within an accredited chartered surgical facility are paid on a fee-for-service basis through the AHCIP. These fees are the same regardless of whether the physician provides the insured service in a public hospital setting or in a chartered surgical facility.

6.0 Recognition Given To Federal Transfers

The Government of Alberta publicly acknowledged the federal contribution provided through the Canada Health Transfer in the 2019-2020 Government of Alberta Annual Report.

Registered Persons
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
1. Number as of March 31st 4,449,483 4,529,842 4,598,089 4,700,840 4,783,609
Insured Hospital Services Within Own Province or Territory
Public Facilities 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
2. Number 225 228 228 228 228
3. Payments for insured health services ($) Not available Not available Not available Not available Not available
Private For-Profit Facilities 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
4. Number of private for-profit facilities providing insured health services Not available Not available Not available Not available Not available
5. Payments to private for-profit facilities for insured health services ($)  Not available Not available Not available Not available Not available
Insured Hospital Services Provided to Residents in Another Province or TerritoryAlberta table 3 Footnote 1
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
6. Total number of claims, in-patient 6,787 7,059 6,668 6,484 5,872
7. Total payments, in-patient ($) 48,651,644 48,492,921 46,468,281 48,297,039 45,985,705
8. Total number of claims, out-patient 135,369 147,350 135,149 130,737 124,744
9. Total payments, out-patient ($) 43,000,306 50,582,365 47,508,204 48,132,671 46,258,409
Alberta table 3 Footnote 1

Data reported reflect claims processed up to three months after the close of the fiscal year. Any claims processed after this date are not reflected in the presented information.

Alberta table 3 Return to footnote 1 referrer
Insured Hospital Services Provided Outside CanadaAlberta table 4 Footnote 1Alberta table 4 Footnote 2Alberta table 4 Footnote 3
Pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
10. Total number of claims, pre-approved in-patientAlberta table 4 Footnote 4 4,216 3,855 4,014 3,672 3,225
11. Total payments, pre-approved in-patient   ($)Alberta table 4 Footnote 4 407,398 372,724 389,741 349,087 307,394
12. Total number of claims, pre-approved out-patientAlberta table 4 Footnote 4 5,008 4,945 4,709 4,402 3,287
13. Total payments, pre-approved out-patient ($)Alberta table 4 Footnote 4 479,625 458,265 459,683 394,654 345,422
Non Pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
14. Total number of claims, non pre-approved in-patientAlberta table 4 Footnote 4 Not available Not available Not available Not available Not available
15. Total payments, non pre-approved in-patient ($)Alberta table 4 Footnote 4 Not available Not available Not available Not available Not available
16. Total number of claims, non pre-approved out-patientAlberta table 4 Footnote 4 Not available Not available Not available Not available Not available
17. Total payments, non pre-approved out-patient ($)Alberta table 4 Footnote 4 Not available Not available Not available Not available Not available
Alberta table 4 Footnote 1

Data reported reflect claims processed up to three months after the close of the fiscal year. Any claims processed after this date are not reflected in the presented information.

Alberta table 4 Return to footnote 1 referrer

Alberta table 4 Footnote 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.

Alberta table 4 Return to footnote 2 referrer

Alberta table 4 Footnote 3

Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report,but did not require provinces or territories to report on previous years.

Alberta table 4 Return to footnote 3 referrer

Alberta table 4 Footnote 4

The claims in our data system cannot be separated into pre-approved or non pre-approved, therefore, the numbers reflect the total claims and payments as reported for previous years.

Alberta table 4 Return to footnote 4 referrer
Insured Physician Services Within Own Province or TerritoryAlberta table 5 Footnote 1
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
18. Number of participating physiciansAlberta table 5 Footnote 2 9,331 9,684 10,058 10,326Alberta table 5 Footnote 3 10,618Alberta table 5 Footnote 3
19. Number of opted-out physiciansAlberta table 5 Footnote 4 0 0 0 0 0
20. Number of non-participating physicians 1 1 2 2 2
21. Total payments for services provided by physicians paid through all payment methods ($) Not available Not available Not available Not available Not available
22. Total payments for services provided by physicians paid through fee-for-service ($) 3,336,009,256 3,531,947,298 3,602,354,459 3,779,015,740 3,947,765,122
Alberta table 5 Footnote 1

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.

Alberta table 5 Return to footnote 1 referrer

Alberta table 5 Footnote 2

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.

Alberta table 5 Return to footnote 2 referrer

Alberta table 5 Footnote 3

8,721 of these are paid under fee-for-service, 884 under an Alternative Relationship Plan and the remaining 1,013 received compensation from both fee-for-service and alternative relationship plans.

Alberta table 5 Return to footnote 3 referrer

Alberta table 5 Footnote 4

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.

Alberta table 5 Return to footnote 4 referrer
Insured Physician Services Provided to Residents in Another Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
23. Number of services 795,738 840,246 796,364 738,060 726,338
24. Total payments ($) 34,639,878 37,906,996 35,943,674 35,826,012 35,406,860
Insured Physician Services Provided Outside CanadaAlberta table 7 Footnote 1Alberta table 7 Footnote 2Alberta table 7 Footnote 3
Pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
25. Number of pre-approved services 32,980 31,224 30,653 27,434 Not available
26. Total pre-approved payments ($) 2,589,749 2,474,336 2,494,650 2,204,584 Not available
Non Pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
27. Number of non pre-approved services Not available Not available Not available Not available Not available
28. Total non pre-approvedAlberta table 7 Footnote 4 payments ($) Not available Not available Not available Not available Not available
Alberta table 7 Footnote 1

These data do not include Alberta residents who have received health services through the Out-of-Country Health Services Committee application process. Additionally, following a methodology change in 2015-2016, there is a one-year lag from fiscal year end to date of payment for out-of-country data. This means data for out-of-country physician services are still being processed for 2019-2020.

Alberta table 7 Return to footnote 1 referrer

Alberta table 7 Footnote 2

Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report, but did not require provinces or territories to report on previous years.

Alberta table 7 Return to footnote 2 referrer

Alberta table 7 Footnote 3

The claims in our data system cannot be separated into pre-approved or non pre-approved, therefore, the numbers reflect the total claims and payments as reported for previous years.

Alberta table 7 Return to footnote 3 referrer

Alberta table 7 Footnote 4

Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report,but did not require provinces or territories to report on previous years.

Alberta table 7 Return to footnote 4 referrer
Insured Surgical-Dental Services Within Own Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
29. Number of participating dentists 215 217 232 226 219
30. Number of opted-out dentistsAlberta table 8 Footnote 1Alberta table 8 Footnote 2 0 0 0 0 0
31. Number of non-participating dentistsAlberta table 8 Footnote 1Alberta table 8 Footnote 2 0 0 0 0 0
32. Number of services provided 31,309 34,603 39,647 42,766 46,593
33. Total payments ($) 9,185,042 9,756,738 11,402,793 12,616,145 13,967,172
Alberta table 8 Footnote 1

Alberta's legislation provides that all dentists are deemed to be participating in the Alberta Health Care Insurance Plan, unless they opt out in accordance with the procedure set out in section 7 of the Alberta Health Care Insurance Act.

Alberta table 8 Return to footnote 1 referrer

Alberta table 8 Footnote 2

Health Canada requested this data as of the 2016-2017 report, but did not require provinces or territories to report 2015-16 data.

Alberta table 8 Return to footnote 2 referrer

British Columbia

British Columbia (BC) has a progressive and integrated health care system, which includes a health care insurance plan that provides publicly funded health care services to residents of BC in accordance with the guiding principles of the Canada Health Act. The Ministry of Health (the Ministry) has overall responsibility for ensuring that quality, appropriate, and timely health care services are available to all British Columbian residents.

To read more about BC’s publicly funded health system, please refer to the Ministry of Health’s 2019-2020 to 2021–2022 Service Plan.

COVID-19 Measures

A number of measures specific to the COVID-19 public health emergency were put into place to support British Columbia’s health care system during the 2019-2020 reporting period.

In response to the COVID-19 pandemic, a public health emergency was declared in BC on March 17, 2020,Footnote 7 followed by a state of emergency declared on March 18, 2020,Footnote 8 both of which continue to be in effect (as of late November 2020). An additional measure was put in effect on April 8, 2020 that required all returning travellers to have an approved self-isolation plan upon arrival.Footnote 9 BC has been in Phase 3 of BC’s Restart Plan since June 24, 2020,Footnote 10 having previously moved from Phase 1 to Phase 2 on May 19, 2020.Footnote 11  On August 21, 2020, additional enforcement measures were introduced for owners or organizers contravening the Provincial Health Officer’s order on gatherings and events.Footnote 12

The Management of COVID-19: Health Sector Plan for Fall/Winter 2020/21Footnote 13 was released on September 9, 2020, which includes key health system management actions to be completed by the end of October. Key areas of ongoing focus include:

Health Professional Regulation:

A number of regulatory actions, including amendments to health profession regulations and regulatory college bylaws, have been taken to support the timely delivery of safe health services and the effective use of health human resources. These regulatory actions include the following:

1.0 Public Administration

1.1 Health Care Insurance Plan and Public Authority

The Ministry of Health (Ministry) sets goals and standards, and issues health authority mandate letters and performance expectations for provincial health service delivery. The Ministry works with the six health authorities (HA) throughout the province to provide quality, appropriate, and timely health services to British Columbians. There are five regional HAs that deliver health care services to meet the needs of the population within their respective geographic regions. A sixth health authority, the Provincial Health Services Authority (PHSA), is responsible for managing the quality, coordination, and accessibility of province-wide health programs and services across the full continuum of care.   The Ministry also works in partnership with the First Nations Health Authority to improve the health status of Indigenous Peoples in BC.

The BC Medical Services Plan (MSP), which is managed by the Medical Services Commission (MSC) on behalf of the Government of BC, provides health care coverage (including for diagnostic services) to beneficiaries and corresponding payments to medical and health care practitioners.

MSP is administered pursuant to the Medicare Protection Act (MPA). The purpose of the MPA is to preserve a publicly managed and fiscally sustainable health care system for British Columbia (BC), in which access to necessary medical care is based on need and not on an individual’s ability to pay. It expressly incorporates the principles of the Canada Health Act.

The MSC reports to the Minister of Health (the Minister), in accordance with the MPA. Under the MPA, the function and legislative mandate of the MSC is to facilitate reasonable access, throughout British Columbia (BC), to quality medical care, health care, and prescribed diagnostic services for British Columbians.

The MSC is a nine-member statutory body comprised of three representatives of the Government of BC, three representatives from the BC Medical Association (operating as the Doctors of BC), and three members from the public who have been jointly nominated by the Doctors of BC and the Government of BC to represent beneficiaries. General hospital services are publicly funded in BC under the Hospital Insurance Act, the Hospital Insurance Act Regulations under the Hospital Insurance Act, the Hospital Act, and Hospital District Act.

Medically required laboratory services are publicly funded under the Laboratory Services Act. The Minister is responsible for all matters related to laboratory services (including the facility approval process), governance, accountability and provision of benefits for all laboratory services in BC. Following the amalgamation of the BC Clinical Support Services Society with the PHSA on June 29, 2018, the Minister delegated the delivery of operational laboratory services activities to Provincial Laboratory Medicine Services (previously the BC Agency for Pathology and Laboratory Medicine), a program under PHSA. The PHSA’s mandate is to provide effective provincial oversight, which includes provincial planning, coordination, monitoring, evaluating, and reporting on province-wide results and health outcomes for publicly funded laboratory and pathology services.

1.2 Reporting Relationship

The Ministry provides information on the performance of BC’s publicly funded health care system in its Annual Service Plan Report. Tracking and reporting this information is consistent with the Ministry’s strategic approach to performance planning and reporting, and it is consistent with requirements contained in the provincial Budget Transparency and Accountability Act.

The MSC is accountable to the Government of BC through the Minister. The MSC Annual Report, which provides an annual accounting of the business of the MSC, its advisory committees and other delegated bodies, is published annually for the prior fiscal year.

Regional health authorities and the PHSA have independent boards; however, in practice the Board Chairs report to the Minister of Health.

1.3 Audit of Accounts

The Ministry’s accounts and financial transactions are subject to audit as follows:

The OAG’s annual audit of the Ministry’s accounts and financial transactions are reflected in the OAG’s overall review and opinion related to the BC Public Accounts, which can be found on the Government of BC website. The OAG’s special audits and reports can be located on the Office of the Auditor  General of BC website.

1.4 Designated Agency

Since 2005, the Ministry has contracted with MAXIMUS Canada to deliver many of the administrative operations of MSP and PharmaCare (the Province’s drug insurance plan), including responding to public inquiries, registering clients, and processing medical and pharmaceutical claims from health professionals. MAXIMUS Canada administers the Province’s medical and drug insurance plans under the Health Insurance BC (HIBC) program. Policy and decision-making functions remain within the responsibility of the Ministry.

HIBC submits monthly reports to the Ministry regarding performance on service levels to the public and health care providers. HIBC processes payments for health care services in accordance with payment schedules approved by the MSC.

As of January 1, 2020, MSP premiums have been eliminated. The MPA was amended pursuant to the Medicare Protection Amendment Act, 2019 to effect this change. Premiums for periods of enrollment after January 1, 2020, will no longer be paid by beneficiaries.

Prior to January 1, 2020, adult MSP beneficiaries who did not meet the (primarily income-based) exceptions were obligated to pay premiums. With respect to MSP premiums incurred prior to this time, Advanced Solutions (a DXC Technology Company) performed revenue management services associated with MSP premiums, including account management and collection, on behalf of the Government of BC (Ministry of Finance) under the Revenue Services of BC (RSBC) program. The Government of BC remains responsible for and retains control of all government administered collection actions.

HIBC and RSBC are required to comply with all applicable laws, including the:

2.0 Comprehensiveness

2.1 Insured Hospital Services

The Hospital Act and Hospital Act Regulation provide authority for the Minister to: designate facilities as hospitals and societies as hospital societies; license private long-term care hospitals (also referred to as long-term care homes); approve the bylaws of hospitals; inspect hospitals; and appoint a public administrator. This legislation also establishes broad parameters for the operation of hospitals.

The Hospital Insurance Act and the Hospital Insurance Act Regulation provide authority for the Minister to make payments to health authorities for the purpose of operating hospitals. They also outline who is entitled to receive publicly funded services and define the “general hospital services” that are to be provided as benefits.

Hospital services are publicly funded benefits when they are provided to a beneficiary in a public hospital, are medically required, and are recommended by the attending physician, midwife, nurse practitioner, or oral and maxillofacial surgeon. There is no scheduled or regular process to review publicly funded hospital services, as these services are intended to be inclusive.

All hospital services that were funded in 2018-2019 continued to be funded in 2019-2020.

When medically required, the following are provided to beneficiaries who are in-patients in a general hospital:

When medically required, the following are provided as benefits to out-patients who are beneficiaries:

When medically required, the following diagnostic services—which are specified in the Medical and Health Care Services Regulation under the MPA—are provided as benefits to out-patients who are beneficiaries. Depending on the service, they may be provided at hospitals or privately-owned facilities that the Medical Services Commission (MSC) has approved to provide the service, including:

Medically required in-patient and out-patient laboratory services are provided as benefits under the Laboratory Services Act (LSA).

Insured hospital services are provided to beneficiaries without charge, with a few exceptions, such as:

Some facilities providing long-term care services (the term “extended care” is also sometimes used) are regulated under Part 2 of the Hospital Act. Health authorities and hospital societies are required to follow Home and Community Care policies to determine benefits in such cases.

2.2 Insured Physician Services

Unless specifically excluded, the following medical services are publicly funded as benefits under the MPA or the LSA:

To practice in BC, physicians must be registered and in good standing with the College of Physicians and Surgeons of BC. To receive payment for publicly funded services, they must be enrolled with MSP. In the fiscal year 2019-2020, 11,849 physicians were enrolled with MSP and received payments through fee-for-service (FFS).

The types of practitioners (in addition to physicians and dentists) who may enrol and provide benefits under MSP include midwives, optometrists, osteopaths and supplementary benefit practitioners. For eligible beneficiaries, the Supplementary Benefits Program provides partial payment for acupuncture, massage therapy, physiotherapy, chiropractic, naturopathy, and non-surgical podiatry services. The program contributes $23 towards the cost of each patient visit to a maximum of ten visits per patient per annum summed across the six types of providers. Eligibility for the program is based on income. Income is verified by way of an automated Canada Revenue Agency income verification process that runs once per year.

Practitioners enrolled in MSP may choose to be “opted-in” or “opted-out”. Opted-in practitioners are those who are enrolled in MSP and who elect to bill MSP directly for MSP benefits provided to MSP beneficiaries. Except in certain very rare circumstances, an opted-in practitioner may not bill a patient directly for a benefit. Opted-out practitioners are enrolled in MSP but elect to bill patients directly for benefits. Enrolled practitioners wishing to opt out of MSP must give written notice to the MSC. In this case, beneficiaries may apply to MSP for reimbursement of the fee for benefits rendered. Under the MPA, an opted-out physician may not charge a patient more for a benefit than the prescribed MSP fee amount.

Under the Physician Master Agreement between the Government of BC, MSC and Doctors of BC, modifications to the MSC Payment Schedule such as additions, deletions or fee changes are made by the MSC upon advice from Doctors of BC or the Government of BC. To modify the MSC Payment Schedule, the parties must submit proposals to the Tariff Committee. On recommendation of the Doctors of BC and Government of BC, interim listings may be designated by the MSC for new procedures or other services for a limited period while definitive listings are established.

During fiscal year 2019-2020, 24 net new physician services were added to the MSC Payment Schedule to reflect current practice standards including, for example, the introduction of two new Obstetrics and Gynecology services for insertion of intra-peritoneal catheters for chemotherapy under general anaesthetic, the removal of intra-peritoneal catheters for chemotherapy, and two new General Surgery services for Oncoplastic breast-conserving surgery.

Additionally, 10 physician services were deleted from the MSC Payment Schedule in fiscal 2019-2020, including, for example, Therapeutic Radiology Consultation services.  These services were deleted as they had not been billed in the past five fiscal years. Also, as part of the response to, and planning for the COVID-19 pandemic, the MSC Payment Schedule was amended on a temporary basis to support access to physician services during the pandemic, including virtual care. Temporary changes to the Payment Schedule, including new fees, were implemented with the end dates of the temporary fees to be determined by the Provincial Health Officer.

Temporary fee changes include:

2.3 Insured Surgical-Dental Services

In certain circumstances, in-patient or out-patient hospitalization is medically required for the safe and proper completion of surgical-dental services. In such cases, the surgical-dental procedure component is publicly funded if the service falls within the meaning of covered dental or orthodontic services by the Medical and Health Care Services Regulation under the MPA. The hospitalization component is funded by the health authority.  Further, in 2015 it was clarified that dental services which are provided in privately owned/operated surgical facilities under contract with a health authority and are listed in the Dental Payment Schedule are insured benefits under MSP.

Publicly funded surgical-dental procedures include those related to remedying a disorder of the oral cavity or a functional component of mastication. Generally, this includes oral surgery related to trauma, orthognathic surgery, medically required extractions, and surgical treatment of temporomandibular joint dysfunction.

The dental procedures funded by MSP are established through the negotiation of a master agreement between the BC Dental Association (BCDA) and the Government of BC. Public consultation is not used. The master agreement outlines any changes to surgical-dental benefits during the term of the agreement, including any additional benefit procedures. Additions or changes to the list of benefits are managed by MSP on the advice of the Dental Liaison Committee, which consists of representatives from both the Ministry of Health (Ministry) and the BCDA. Additions and changes to the Dental Payment Schedule must be approved by the MSC. No new procedures were added as benefits during the 2019-2020 fiscal year.

Any general dentist in good standing with the BC College of Dental Surgeons of British Columbia (CDSBC) who is enrolled in MSP and has hospital privileges may provide surgical-dental benefits in a hospital or other approved facility. There were 201 dentists enrolled with MSP in 2019-2020 (including general dentists, pediatric dental specialists, oral surgeons, oral medicine dental specialists, and orthodontists billing through MSP).

Dentists must register with the CDSBC in order to practise, but they are not required to participate in MSP. If they do choose to participate, they must enroll in MSP in order to receive payment for MSP insured services. Dentists enrolling in MSP may choose to opt out of billing MSP for insured services, instead billing the patient directly. The patient may then submit a claim to MSP for reimbursement of the insured service.

2.4 Uninsured Hospital, Physician and Surgical-Dental Services

Medical necessity is the criterion for public funding of hospital and medical services. Coverage is excluded for out-patient take-home drugs, and any drugs not clinically approved by the hospital. Procedures not publicly funded under the Hospital Insurance Act and Hospital Insurance Act Regulations include:

Non-publicly funded hospital services also include:

Health authorities are required by Ministry policy to fund medically necessary transfers between acute care hospitals within BC, but beneficiaries are required to pay a fee to partially off-set costs when an ambulance or contracted alternative service provider is used for transport in other situations.

Services not covered under MSP include:

With respect to MSP, the MSC has authority to determine which services are benefits.

3.0 Universality

3.1 Eligibility

Section 7 of the Medicare Protection Act (MPA) sets out the Medical Services Plan (MSP) enrollment requirement for residents of BC (as defined in the MPA) to enroll in MSP. A person must be a resident of BC to qualify for provincial health care benefits.

Section 1 of the MPA defines a resident as a person who is either deemed to be a resident under regulation, or:

Deemed residents include individuals such as some holders of permits issued under the federal Immigration and Refugee Protection Act (see section 3.2 of this report) among others, but this does not include a tourist or visitor to BC.

Residents who do not want to participate in the BC’s public health care plan may choose to opt out of the publicly funded program. Individuals are required to file an Election to Opt Out statement and submit that statement to the MSC. A statement, once signed, is irrevocable and results in the resident being responsible for paying the entire cost of all hospital, medical and other health care services they may receive during the 12-month opted-out period. Residents cannot opt out retroactively and must reapply to opt out at the expiry of each 12-month period.

All residents are entitled to medically required hospital and medical care coverage. Those residents who are members of the Canadian Forces and those serving a term of imprisonment in a federal penitentiary, as defined in the Corrections and Conditional Release Act, are eligible for federally funded health insurance. MSP provides first-day coverage to discharged members of the Canadian Forces and to those returning from an overseas tour of duty, as well as to released inmates of federal penitentiaries located in BC.

It is possible for a beneficiary’s enrollment to be cancelled by order of the MSC, if MSC determines that the beneficiary was not eligible for enrollment or believes that the beneficiary has ceased to be a resident. Section 11 of the MPA requires that the beneficiary must be notified that they have a right to a hearing, prior to making an order cancelling a beneficiary’s enrollment. If the beneficiary requests a hearing, the hearing is conducted by a delegate of the MSC—either in person or in writing. Decisions of the MSC or its delegates may be judicially reviewed by the Supreme Court of BC.

The number of residents registered with MSP as of March 31, 2020, was 5,108,915.

3.2 Other Categories of Individuals

Holders of study permits, and work permits, as well as applicants for permanent resident status who are the spouse or child of an eligible resident, are eligible for enrollment and benefits when they are deemed to be residents under the MPA in accordance with section 2 of the Medical and Health Care Services Regulation.

3.3 Premiums

Until January 1, 2020, the MPA and the Medical and Health Care Services Regulation provided authority for the MSC to collect premiums from beneficiaries.  As announced by the Government of BC, and further to amendments enacted through the Medicare Protection Amendment Act, 2019, MSP premiums were eliminated for all beneficiaries effective January 1, 2020.

Enrollment in MSP is mandatory (subject to an adult’s right to formally opt out). Outstanding premium debt is not a barrier to receiving coverage.

The MSP monthly premium rates for 2019 were $37.50 for one adult and $75 for two adults in a family. Additionally, there were no MSP premiums for children under the age of 19, or for dependent post-secondary students enrolled in full-time studies (including trade, technical or high schools).

Prior to January 1, 2020, MSP had two programs that offered assistance with the payment of premiums based on financial need. Firstly, regular premium assistance had several levels of assistance and was based on a person’s net income for the preceding tax year, combined with that of the person’s spouse, if applicable, less MSP deductions. Premium assistance rates were no longer calculated to include children. The maximum income for premium assistance eligibility 2018–2019 was $42,000 adjusted net income per year. The sum net income for premium assistance eligibility of a beneficiary and spouse when one spouse is in long-term care was $54,000. The monthly premium rates that were paid by beneficiaries receiving premium assistance ranged from $11.50 to $32.50 for a single adult, and $23 to $65 for a family of two adults.

There were groups of specified beneficiaries, including those in receipt of assistance under the Employment and Assistance Act or the Employment and Assistance for Persons with Disabilities Act, where no premium was payable in accordance with section 10 of the Medical and Health Care Services Regulation.

Additionally, for short-term periods, up to 100 per cent subsidy was offered under the temporary premium assistance program based on current, unexpected financial hardship. Premium assistance was available only to beneficiaries who, for the last 12 consecutive months, had resided in Canada and were either a Canadian citizen or a holder of permanent resident (landed immigrant) status under the federal Immigration and Refugee Protection Act.

Given that MSP premiums were eliminated effective January 1, 2020, the premium assistance and temporary premium assistance programs ceased being effective as of that date. The MPA was amended pursuant to the Medicare Protection Amendment Act, 2019 to reflect this change.

Retroactive premium assistance for premiums incurred prior to January 1, 2020 will remain available.

3.4 International Student Health Fee

As the Province has eliminated MSP premiums for British Columbians, an updated payment method will ensure international students continue to contribute to, and benefit from, BC health care coverage. Under the updated system, effective September 1, 2019, all international K-12 and post-secondary students began paying a monthly health care coverage fee of $37.50.

For post-secondary students who were paying $37.50 per month in MSP premiums, the health fee restored their contributions to the $75 per month that was charged prior to 2018. Effective January 1, 2020, the health fee for international students is $75 per month.

International students with a study permit valid for a period of six or more months are required to apply for the MSP as soon as they arrive in BC. Through this application process, they will be enrolled and then invoiced for the new health fee.

4.0  Portability

4.1 Minimum Waiting Period

New residents or persons re-establishing residence in British Columbia (BC) are eligible for coverage after completing a waiting period that normally consists of the balance of the month in which residence is established, plus two additional months. For example, if an eligible person applies during the month of July, coverage is available October 1. If absences from Canada exceed a total of 30 days during the waiting period, eligibility for coverage may be affected. New residents from other parts of Canada are advised to maintain coverage with their former provincial or territorial health insurance plan during the waiting period.

4.2 Coverage during Temporary Absences in Canada

Sections 3, 3.1, 4, and 5 of the Medical and Health Care Services Regulation set out the portability provisions for persons temporarily absent from BC regarding publicly funded services.

In general terms, residents who spend part of every year outside BC must be physically present in BC at least six months in a calendar year, and continue to maintain their home in BC, in order to retain coverage. As of January 1, 2013, longer term vacationers who are deemed residents may qualify for a total absence of up to seven months per calendar year for vacation purposes only, provided they give prior notice to the Medical Services Commission (MSC) and continue to meet the other requirements, such as maintaining their home in BC.

Individuals leaving BC temporarily on extended vacations, or for temporary employment, may be eligible to retain their medical coverage for up to 24 consecutive months provided they receive prior approval of the MSC and meet other requirements of section 4 of the Medical and Health Care Services Regulation. Approval is limited to once in five years for absences exceeding six months in a calendar year. When a beneficiary stays outside BC longer than the approved period, there is a requirement to fulfill a waiting period upon re-establishing residence in the province before coverage can be renewed. Students and extended family of students attending a recognized school in another province or territory on a full-time basis are entitled to coverage for the duration of their studies.

According to inter-provincial/territorial reciprocal billing arrangements, physicians, except in Quebec, bill their own medical plans directly for services rendered to BC residents who are eligible for MSP coverage, upon presentation of a valid Personal Health Number or BC Services Card. BC then reimburses the province or territory at the rate of the fee schedule in the province or territory in which services were rendered. For in-patient hospital care, services are paid at the ward rate approved for each hospital by the Assistant Deputy Ministers Policy Advisory Committee. For out-patient services, the payment is at the inter-provincial/ territorial reciprocal billing rate. Payment for these services, except for excluded services that are billed to the patient, is handled through inter-provincial/territorial reciprocal billing procedures.

Quebec does not participate in reciprocal billing agreements for physician services. As a result, claims for services provided to BC beneficiaries by Quebec physicians must be handled individually. When travelling in Quebec (or outside of Canada), the beneficiary is usually required to pay for medical services and seek reimbursement later from the Government of BC.

BC pays host provinces/territories the approved hospital billing rates and out-patient rates. These rates are recommended by the Interprovincial Health Insurance Agreements Coordinating Committee and approved by provincial-territorial Deputy Ministers of Health.

4.3 Coverage during Temporary Absences outside Canada

The provisions that define portability of health insurance during temporary absences outside Canada are as follows: section 24 of the Hospital Insurance Act; Division 6 of the Hospital Insurance Act Regulation; sections 5.5 and 29 of the Medicare Protection Act; and sections 3–5 and 35 of the Medical and Health Care Services Regulation.

Residents who leave BC temporarily to attend school or university are eligible for MSP coverage for the duration of their studies, provided they were physically present in Canada for six of the 12 months immediately preceding departure and are in full-time attendance at a recognized educational facility. Beneficiaries who have been studying outside BC must return to the province by the end of the month following the month in which studies are completed. Any student who will not return to BC within that timeframe is encouraged to contact MSP.

In some circumstances, while temporarily outside the province for work or vacation, an individual may be deemed an eligible resident during an 'extended absence' of up to 24 consecutive months, once in a five-year period. To qualify, an individual must obtain prior approval for status as a resident during the absence, continue to maintain their home in BC, be physically present in Canada for six of the 12 months immediately preceding departure, and have not been granted an extended absence in the previous five calendar years. In addition, they must not have taken advantage of the additional one-month absence available to vacationers during the year the extended absence begins, or during the calendar year prior to the start of the extended absence. In certain situations, if a person's employment requires them to routinely travel outside of BC for more than six months per calendar year, they can apply to the MSC for approval to maintain their eligibility.

BC residents who are temporarily absent from BC and cannot return due to extenuating health circumstances may be deemed residents for up to an additional 12 months, if they are visiting in Canada or abroad. This also applies to the person's spouse and children provided they are with the person, and they are also residents or deemed residents.

BC residents who are eligible for coverage while temporarily absent from BC may receive reimbursement from MSP for out-of-country medical expenses. MSP provides coverage for out-of-country emergency physician services up to the BC physician fee rates. Reimbursement for out-of-country emergency hospital services is limited to a maximum benefit of $75 per day.  Any excess cost is the responsibility of the beneficiary.

Reimbursements are made in Canadian dollars.

4.4 Prior Approval Requirement

No prior approval is required for medically required procedures that are covered under interprovincial reciprocal agreements with other provinces and territories. Prior approval from the MSC is required for procedures that are excluded under the reciprocal agreements.

The physician services excluded under the Interprovincial Agreements for the Reciprocal Processing of Out-of-Province Medical Claims are:

All non-emergency procedures performed outside Canada require approval from the MSC before the procedure is performed, in order to be eligible for reimbursement under the publicly funded program. All such applications for reimbursement are to be submitted to the Ministry of Health (Ministry) or its designate, Health Insurance BC. The beneficiary is notified of the decision in writing.

If a decision is made to deny the application for funding, the beneficiary may request an administrative review of the denial.

If, after the administrative review is concluded, the application for funding under MSP is denied again, the beneficiary may request a review of the decision.  For out-of-country applications, the review is conducted by an MSC Review Panel. The panel consists of three members—one delegate representing the Ministry, one delegate representing the Doctors of BC, and one delegate representing the general public. This tripartite structure ensures that decisions affecting administration of the provincial health care system reflect the best interest of all concerned.

For out-of-province but inside Canada applications, the review is conducted by an advisory committee of the MSC.

5.0 Accessibility

5.1 Access to Insured Health Services

The MSC has a legislative mandate to protect the integrity and sustainability of the health care system and uphold the MPA. Section 36 of the MPA gives the MSC the authority to audit private clinics for extra billing. Extra billing is the practice of charging beneficiaries for MSP benefits, or for matters relating to the rendering of benefits.

On October 1, 2018, the Government of BC brought sections of the MPA that had previously been passed by the Legislative Assembly in 2003 (Bill 92) into force. In general terms, these provisions enhance enforcement powers in relation to extra-billing to better ensure that eligible BC residents (beneficiaries) receive quality public health care based on need, not on ability to pay. These changes uphold the fundamental principles of the MPA, as well as the Canada Health Act.

A number of the new MPA provisions were subject to a series of injunctions of varying scope, as part of the Cambie Surgeries Corp. v. British Columbia (Attorney General) litigation in which the plaintiffs challenged the extra-billing provisions contained in the MPA.  In September 2020, the injunction expired when the British Columbia Supreme Court issued its decision in that litigation (dismissing the plaintiffs’ claims challenging the MPA).  As of November 2020, the plaintiffs had filed a notice of appeal of the decision and applied for an injunction to prevent use of the new MPA extra-billing enforcement provisions in relation to private surgical clinics pending the outcome of their appeal. 

The MPA (section 45) prohibits the sale or issuance of health insurance by private insurers to patients for services that would be a publicly funded benefit. Section 17 prevents extra-billing by prohibiting persons from being charged for, or in relation to, a benefit or for “materials, consultations, procedures, use of an office, clinic or other place or for any other matters that relate to the rendering of a benefit” provided by a practitioner who is enrolled in MSP.

In 2018–2019, the MPA was amended to strengthen requirements for beneficiaries to be notified of intended charges for services that would be benefits if rendered by a practitioner who is enrolled in MSP. If notice is not provided as required, a person is not liable to pay for the service unless the service was rendered in an emergency, making it impracticable to comply with the notice requirement.

The Ministry and the MSC respond to complaints of extra-billing made by patients and take appropriate actions to correct identified situations. Information regarding the extra-billing review process is available on the Government of BC site.

Beneficiaries in BC, as defined in section 1 of the Medicare Protection Act (MPA), are eligible for publicly funded health care services as medically necessary. To ensure equal access to all regardless of income, sections 17 and 18 of the MPA limit charges by medical practitioners in most contexts. Similarly, section 15 of the Laboratory Services Act prohibits extra-billing to beneficiaries for medically required laboratory services provided at an approved laboratory facility, and sections 12 and 13 of the Hospital Insurance Act prohibit extra-billing for hospital services.

If a benefit is provided by an enrolled medical practitioner who has opted out of MSP, any amount charged exceeding the amount allowed under the MPA is considered extra-billing and must be refunded. The Medical Services Commission (MSC) may apply for an injunction restraining a person from contravening the extra-billing provisions of the MPA.

The Audit and Inspection Committee (AIC) is a four-member panel of the MSC comprised of three physicians together with one member who represents the public. The MSC has delegated its powers and duties under section 36 of the MPA (i.e., to audit and inspect medical practitioners) to the AIC. On December 1, 2006, section 10 of the Medicare Protection Amendment Act 2003 was brought into force. This section expanded the audit and inspection powers of the Commission to include the power to audit clinics as corporate entities, rather than just physicians.

The AIC has responsibility for two types of audits. Patterns of practice audits are done to ensure that services billed to MSP have been delivered and billed accurately. Extra-billing audits focus on whether beneficiaries are being charged for services in contravention of the MPA. The AIC decides whether on-site audits are appropriate, and it outlines the nature and extent of the audits. It also reviews the audit results and makes recommendations to the Chair of the MSC for further appropriate action.

The Billing Integrity Program develops and analyses practitioner’s profiles, monitors trends, conducts audits, and, where appropriate, seeks recovery of inappropriately paid monies in accordance with the MPA.

A hearing is held before a panel of three or more persons who are appointed by the MSC to represent the Doctors of BC, beneficiaries and government. A panel has authority to make an order for recovery of money and other remedies. The hearing affords the practitioner a fair process that adheres to the rules of natural justice.

If a beneficiary believes they have been charged inappropriately for an insured medical benefit, they can request an inquiry by completing an extra-billing investigation form. This form is available publicly on the MSP website.

The MSC’s audit powers over health care practitioners have been delegated to various special committees. A special committee for each body of health care practitioners has been established. The special committees are: the Chiropractic Special Committee; the Dentistry Special Committee; the Massage Therapy Special Committee; the Naturopathy Special Committee; the Optometry Special Committee; the Physical Therapy Special Committee; the Podiatry Special Committee, the Acupuncture Special Committee; and the Midwifery Special Committee.

Each audit results in the submission of a detailed report to the individual Special Committee. Subsequently, the individual Special Committee makes recommendation to the Health Care Practitioners Special Committee for Audit Hearings to assist in determining if recovery should be pursued. Practitioners have a right to be heard before the Health Care Practitioners Special Committee for Audit Hearings makes a determination.

Further, access to publicly funded services continues to be enhanced. The Ministry of Heath (Ministry) is moving towards an integrated system of patient care with interdisciplinary teams of health care providers to meet the health needs of communities and populations and increase access and attachment of patients. To support team-based care, the Ministry has implemented or expanded alternate compensation options:

Infrastructure and Capital Planning

BC continues to make strategic investments in health sector capital infrastructure. The Ministry invests annually to renew and extend the asset life of existing health facilities, medical and diagnostic equipment, and information management technology at numerous health facilities across BC. The Ministry maintains a long-term capital plan to ensure health infrastructure is maintained and renewed within expected asset lifecycle timelines.

5.2 Physician Compensation

The PMA is a formal agreement signed by the Government of BC, the Doctors of BC, and the MSC. The three-year agreement (April 1, 2019 to March 31, 2022) supports ongoing efforts to recruit and retain physicians, while also improving access to FPs, specialists and health care in rural and remote communities.

The Doctors of BC represent the interests of all physicians who receive payment for the medical services they provide to beneficiaries in relation to the PMA. The PMA establishes mechanisms that promote enhanced collaboration and accountabilities between the Government of BC and Doctors of BC through various joint committees. It also provides a formal conflict management process at both the local and provincial levels, and language limiting physician service withdrawals. The role of health authorities in the planning and delivery of health care services is reinforced in the PMA.

The PMA establishes the compensation and benefit structure for physicians who provide publicly funded medical services whether via FFS, contract or blended capitation funding models. Through the PMA, the Government of BC also provides targeted financial support for areas such as: rural programs; specialist services; full-service family practice; and shared care models involving FPs, specialists and other health care professionals.

Physicians are registered by the College of Physicians and Surgeons of BC, a body established under the Health Professions Act. The PMA provides processes for monitoring and managing the funding established by the MSC under section 25 of the MPA for publicly funded medical services provided by physicians on a FFS basis. Mechanisms for revisions to the MSC Payment Schedule and for the payment of physicians are detailed in the PMA.

Dentists are registered by the College of Dental Surgeons of BC, which is also a body established under the Health Professions Act. The Province and the BC Dental Association (BCDA) are in the process of negotiating a new Dentistry Master Agreement for the period from April 1, 2019 to March 31, 2021 that covers the following services: dental surgery; oral surgery; orthodontic services; oral medicine; pediatric dental services; and dental technical procedures. The provisions of the prior Master Agreement, which was put into effect April 1, 2014 and expired on March 31, 2019, remain in place until a new agreement has been negotiated.Footnote 14 The Province and the BCDA collaborate through a Dentistry Liaison Committee.

Payment for medical services delivered in the province is made through MSP to the following: individual practitioners who submit claims under FFS; health authorities who contract and employ physicians for providing services to patients; and health authorities and/or physician groups who provide patient services under blended capitation funding models.

The MSC is authorized to monitor the billing and payment of claims in order to manage expenditures for medical and health care benefits on behalf of MSP beneficiaries. The Ministry's Billing Integrity Program monitors, audits and investigates billing patterns and practices of medical and health care practitioners to detect and deter inappropriate and incorrect billing of MSP claims to MSC. The Billing Integrity Program develops and analyzes practitioner's profiles, monitors trends, conducts audits, and, where appropriate, seeks recovery of inappropriately paid monies in accordance with the MPA.

5.3 Payments to Hospitals

Funding for publicly funded hospital services is included within annual funding allocations to health authorities, as well as specifically targeted funding from time to time. This funding allocation is used to fund the full range of necessary health services for the population of the region (or for specific provincial services, for the population of BC), including the provision of hospital services. Annual funding allocations to health authorities are determined as part of the Ministry's annual budget process in consultation with the Ministry of Finance and Treasury Board. The current year funding allocations and notional out-year allocations are conveyed to health authorities by means of annual funding letters.

The Hospital Insurance Act (including the Hospital Insurance Act Regulation) and the Health Authorities Act govern payments made by the Government of BC to health authorities. These statutes establish the authority of the Minister to make payments to regional health authorities and the Provincial Health Services Authority and specify in broad terms what services are publicly funded when provided within a hospital and in delivering regional and other health care services.

The BC Tripartite Framework Agreement on First Nation Health Governance and other negotiated agreements provide the basis for the Ministry to provide funding to the First Nations Health Authority. Funding to support the Nisga'a Nation health care services and programs is provided to the Nisga'a Valley Health Authority under the terms of the 1999 Nisga's Valley Health Board Transitional Funding Agreement.

The Ministry does not specifically fund hospitals directly; instead, health authorities are funded and provide operating budgets to hospitals within their regions to deliver specified services. The exception to this is when funding provided to health authorities (again not directly to hospitals) is targeted for specific priority projects (e.g., to fund wages or to provide operating funding to support large hospital construction projects coming on stream). Since it is specifically targeted, the funding must be reported on separately.

Annual incremental funding is allocated to health authorities using the Ministry's Population Needs-Based Funding model and other funding allocation methodologies (targeted funding allocations directed to specific health authorities, e.g., for wage costs related to collective bargaining). The annual funding allocation to health authorities does not include funding for programs directly operated by the Ministry, such as payments to physicians that occur through MSP and payments for prescription drugs that are covered under PharmaCare.

The accountability mechanisms associated with government funding for hospitals are part of several comprehensive documents that set expectations for health authorities. These include the annual funding letters, annual service plans, mandate letters, and annual bilateral agreements. Taken together, these documents convey the Ministry's broad expectations for health authorities and explain how performance will be monitored in relation to these expectations.

6.0 Recognition Given To Federal Transfers

Funding provided by the federal government through the Canada Health Transfer is recognized and reported by the Government of BC through various government websites and provincial government documents. In 2019–2020, these documents included:

Registered Persons
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
1. Number as of March 31st 4,746,685 4,827,696 4,925,188 4,997,617 5,108,915
Insured Hospital Services Within Own Province or Territory
Public Facilities 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
2. NumberBC table 2 Footnote 1 120 120 120 120 121
3. Payments for insured health services ($)BC table 2 Footnote 2 Not available Not available Not available Not available Not available
Private For-Profit Facilities 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
4. Number of private for-profit facilities providing insured health services Not available Not available Not available Not available Not available
5. Payments to private for-profit facilities for insured health services ($)  Not available Not available Not available Not available Not available
BC table 2 Footnote 1

As per the guidelines, the number of public facilities in this table excludes psychiatric hospitals and extended care facilities.

Return to footnote 1 referrer

Footnote 2

BC Ministry of Health Funding to Health Authorities for the provision of the full range of regionally delivered services are as follows: $11.5 billion in 2016-2017, $12.1 billion in 2017-2018, $12.7 billion in 2018-2019 and $13.7 billion in 2019-2020.

Return to footnote 2 referrer
Insured Hospital Services Provided to Residents in Another Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
6. Total number of claims, in-patient 7,159 5,270 5,898 5,417 5,622
7. Total payments, in-patient ($) 67,261,694 56,882,669 61,093,890 57,540,788 59,949,069
8. Total number of claims, out-patient 71,313 76,662 85,285 85,637 83,059
9. Total payments, out-patient ($) 29,450,951 28,619,689 31,232,700 31,331,256 31,703,771
Insured Hospital Services Provided Outside CanadaBC table 4 Footnote 1
Pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
10. Total number of claims, in-patient 38 18 47 28 44
11. Total payments, in-patient ($) 4,396,030 6,486,370 4,451,966 3,635,035 13,722,925
12. Total number of claims, out-patient Not Applicable Not Applicable Not Applicable Not Applicable 10
13. Total payments, pre-approved out-patient ($) Not Applicable Not Applicable Not Applicable Not Applicable 564,745
Non pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
14. Total number of claims, in-patient 2,380 1,982 1,743 2,092 1,817
15. Total payments, in-patient ($) 720,890 606,431 570,951 586,897 740,655
16. Total number of claims, out-patient 3,189 2,601 1,904 2,867 2,667
17. Total payments, out-patient ($) 2,375,378 2,782,841 2,987,362 2,652,836 6,749,987
BC table 4 Footnote 1

Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report, but did not require provinces or territories to report on previous years.

BC table 4 Return to footnote 1 referrer
Insured Physician Services Within Own Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
18. Number of participating physiciansBC table 5 Footnote 1 10,705 11,001 11,254 11,588 11,849
19. Number of opted-out physicians 2 2 2 2 2
20. Number of non-participating physicians Not available Not available Not available Not available Not available
21. Total payments for services provided by physicians paid through all payment methods ($) Not available Not available Not available Not available Not available
22. Total payments for services provided by physicians paid through fee-for-service ($) 2,907,582,518 3,023,409,095 3,097,014,160 3,234,028,029 3,342,862,100
BC table 5 Footnote 1

The number of participating physicians in item 18 is for physicians who received payments through fee-for-service.

BC table 5 Return to footnote 1 referrer
Insured Physician Services Provided to Residents in Another Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
23. Number of services 675,046 668,136 685,270 685,621 678,818
24. Total payments ($) 36,090,357 35,532,618 35,788,808 36,896,106 35,479,965
Insured Physician Services Provided Outside CanadaBC table 7 Footnote 1
Pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
25. Number of pre-approved services 1,891 2,178 1,931 2,260 3,783
26. Total pre-approved payments ($) 3,711,796 4,989,144 5,268,867 6,915,394 6,512,749
Non pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
27. Number of non pre-approved services 67,025 64,938 64,336 48,488 33,681
28. Total non pre-approved payments ($) 3,522,394 3,388,615 4,268,886 3,099,450 1,714,922
BC table 7 Footnote 1

Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report, but did not require provinces or territories to report on previous years.

Return to footnote 1 referrer
Insured Surgical-Dental Services Within Own Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
29. Number of participating dentists 207 192 200 208 201
30. Number of opted-out dentistsBC table 8 Footnote 1 Not available Not available Not available Not available Not available
31. Number of non-participating dentistsBC table 8 Footnote 1 Not available Not available Not available Not available Not available
32. Number of services provided 52,770 55,069 55,912 61,540 64,388
33. Total payments ($) 8,232,622 8,308,740 8,471,681 9,604,988 10,047,804
BC table 8 Footnote 1

Health Canada requested this data as of the 2019-2020 report, but did not require provinces or territories to report data for 2015-2016.

BC table 8 Return to footnote 1 referrer

Yukon

The Government of Yukon is committed to ensuring that Yukoners acquire the skills to live responsible, healthy and independent lives. The Minister of Health and 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).

The Health Services Division of DHSS is responsible for a variety of health care, disease prevention, and treatment services which assist eligible Yukon residents in attaining maximum independence within their community. The Health Services Division oversees Insured Health Services, Community Health Services, Community Nursing, Communicable Disease Control, Health Promotion, Dental Health, and Environmental Health.

In 2019–2020, DHSS focused on developing more comprehensive and coordinated programs and services that met people’s health needs, when and where services are required.

COVID-19

In March of 2020 the Yukon physician fee schedule was temporarily expanded to allow for the provision of additional telemedicine and virtual care services to make it safer for patients to connect with doctors during the COVID-19 pandemic.

1.0 Public Administration

1.1 Health Care Insurance Plan and Public Authority

The Insured Health and Hearing Services Branch (IHHS) is responsible for the delivery of health care benefits as set out in the Health Care Insurance Plan Act and Hospital Insurance Services Act. The overall objective of IHHS is to ensure access to, and portability of, insured physician and hospital services according to the provisions of these acts.

The Government of Yukon delivers insured health benefits according to the Yukon Health Care Insurance Plan (YHCIP) and the Yukon Hospital Insurance Services Plan (YHISP). Both the YHCIP and YHISP are administered by the Director, Insured Health and Hearing Services. This position is a joint appointment by the Minister of Health and Social Services (the Minister) and the Commissioner of the Yukon Territory.

The Health Care Insurance Plan Act, section 3(2) and section 4, establishes the public authority to operate the health care plan.

The Hospital Insurance Services Act, section 3(1) and section 5, establishes the public authority to operate the hospital care plan.

Subject to the Health Care Insurance Plan Act (section 5), the Hospital Insurance Services Act (section 6) and the Regulations, it is the responsibility of the Director, Insured Health and Hearing Services to:

Specific to the Hospital Insurance Services Act, the Director, Insured Health and Hearing Services has the responsibility to:

There were no amendments to either act in 2019–2020.

1.2 Reporting Relationship

The Department of Health and Social Services is accountable to the Legislative Assembly and the Government of Yukon through the Minister.

Section 6 of the Health Care Insurance Plan Act and section 7 of the Hospital Insurance Services Act require that the Director, Insured Health and Hearing Services make an annual report to the Minister of Health and Social Services respecting the administration of the two health insurance plans. A Statement of Revenue and Expenditures is tabled in the legislature and is subject to discussion at that level. The Statement of Revenue and Expenditures was tabled in the 2019 fall sitting of the Yukon legislature.

1.3 Audit of Accounts

The Health Care Insurance Plan and the Hospital Insurance Services Plan are subject to audit by the Office of the Auditor General of Canada. The Auditor General of Canada is the Auditor of the Government of Yukon in accordance with section 34 of the Yukon Act (Canada). The Auditor General is required to conduct an annual audit of the transactions and consolidated financial statements of the Government of Yukon. Further, the Auditor General of Canada is to report to the Yukon Legislative Assembly any matter falling within the scope of the audit that, in his or her opinion, should be reported to the Assembly.

Further, section 13(2) of the Hospital Act requires the Yukon Hospital Corporation to submit a report of their operations for that fiscal year to the Minister within six months after the end of each fiscal year. The report is to include the financial statements of the Corporation and the Auditor’s report.

2.0 Comprehensiveness

2.1 Insured Hospital Services

The Hospital Insurance Services Act, sections 3, 4, 5, 6 and 9, establish authority to provide insured hospital services to insured residents. The Yukon Hospital Insurance Services Ordinance was first passed in 1960 and came into effect April 9, 1960. No amendments were made to the Act in 2019-2020.

Adopted on December 7, 1989, the Hospital Act establishes the responsibility of the legislature and the government to ensure “compliance with appropriate methods of operation and standards of facilities and care.” Adopted on November 11, 1994, the annexed Hospital Standards Regulation sets out the conditions under which all hospitals in the territory are to operate. Section 4(1) provides for the Ministerial appointment of one or more investigators to report on the management and administration of a hospital. Section 4(2) requires that the hospital’s Board of Trustees establish and maintain a quality assurance program.

In April 1997, the Yukon Government assumed responsibility for operating health units in rural Yukon communities from the federal government. These health centres are staffed by one or more nurses and auxiliary staff. Primary Health Care Nurses in the absence of a physician, provide daily clinics for medical treatment, community health programs and 24-hour emergency services in 11 communities throughout Yukon along with the Whitehorse Health Centre which offers immunization clinics and prenatal and postnatal care.

In 2019–2020, insured in-patient and out-patient hospital services were delivered in 14 facilities throughout the territory. These facilities include Whitehorse General Hospital, Watson Lake Community Hospital, Dawson City Community Hospital and 11 Community Health Centres. In addition, in March 2020 a respiratory assessment centre was opened in Whitehorse, Yukon to assess patients with respiratory illnesses and test for COVID-19.

Pursuant to the Hospital Insurance Services Regulations, section 2(e) and (f), services provided in an approved hospital are insured. Section 2(e) defines in-patient insured services as all of the following services to in-patients, namely:

Section 2(f) of the Regulations defines “out-patient insured services” as all of the following services to out-patients, when used for emergency diagnosis or treatment within 24 hours of an accident (period may be extended by the Administrator, provided the service could not be obtained within 24 hours of the accident):

Pursuant to the Hospital Insurance Services Regulations, all in-patient and out-patient services provided in an approved hospital, by hospital employees, are insured services. Standard nursing care, pharmaceuticals, supplies, diagnostic and operating services are provided. Any new programs or enhancements with significant funding implications or reductions to services or programs require the prior approval of the Minister, Health and Social Services. This process is managed by the Director, Insured Health and Hearing Services. Public representation regarding changes in service levels is made through membership on the hospital board.

2.2 Insured Physician Services

Insured physician services in Yukon are defined as medically required services rendered by a medical practitioner. Sections 1 to 8 of the Health Care Insurance Plan Act and sections 2, 3, 7, 10 and 13 of the Health Care Insurance Plan Regulations provide for insured physician services. No amendments were made to the Act in 2019-2020.

The Yukon Health Care Insurance Plan covers physicians providing medically required services. In order to participate in the Yukon Health Care Insurance Plan, physicians must:

There were 80 physicians participating in the Yukon Health Care Insurance Plan in 2019–2020. These physicians were supplemented by visiting locum physicians who provide care throughout Yukon. In 2019-2020 there were no physicians practicing in the territory who were providing services outside of the Yukon Health Care Insurance Plan.

Section 7 of the Yukon Health Care Insurance Plan Regulations covers payment for medical services. Subsection 4 allows physicians to make arrangements for payment for insured services on a basis other than fee-for-service. Notice in writing of this election must be submitted to the Director, Insured Health and Hearing Services. In 2019–2020, physicians were remunerated by both fee-for-service and through alternative payment arrangements.

The process used to add a new fee to the Payment Schedule for Yukon is administered through a committee structure. This process requires physicians to submit requests in writing to the Yukon Health Care Insurance Plan, Yukon Medical Association Fee Liaison Committee. Following review by this committee, a decision is made to include or exclude the service. The relevant fees are normally set in accordance with similar fees in other jurisdictions. Once a fee-for-service value has been determined, notification of the service and the applicable fee is provided to all Yukon physicians. Public consultation is not required.

Alternatively, new fees can be implemented as a result of the fee negotiation process between the Yukon Medical Association and the Department of Health and Social Services.

The current Memorandum of Understanding (MOU) with the Yukon Medical Association maintains a focus on collaborative care and ensures greater access for patients, and targets the creation of multi-disciplinary teams that include further integration of nurse practitioners into the care system. The current five-year MOU with the Yukon Medical Association will end on March 31, 2022.

2.3 Insured Surgical-Dental Services

Dentists providing insured surgical-dental services under the Health Care Insurance Plan of Yukon must be licensed pursuant to the Dental Professions Act and are given billing numbers to bill the Yukon Health Care Insurance Plan for providing insured dental services. The Plan is also billed directly for services provided outside the territory.

Insured dental services are limited to those surgical-dental procedures listed in Schedule B of the Health Care Insurance Plan Regulations. The procedures must be performed in a hospital. In 2019-2020 no dentists provided insured surgical-dental services under the Yukon Health Care Insurance Plan.

The addition or deletion of new surgical-dental services to the list of insured services requires amendment by Order-in-Council to Schedule B of the Health Care Insurance Plan Regulations. Coverage decisions are made on the basis of whether or not the service must be provided in hospital under general anaesthesia. The Director, Insured Health and Hearing Services administers this process.

There were no new insured surgical-dental services added in 2019-2020.

2.4 Uninsured Hospital, Physician and Surgical-Dental Services

Only services prescribed by and rendered in accordance with the Health Care Insurance

Plan Act and Regulations and the Hospital Insurance Services Act and Regulations are insured. All other services are uninsured.

Uninsured hospital services include:

Section 3 of the Yukon Health Care Insurance Plan Regulations contains a list of services that are prescribed as non-insured. Uninsured physician services include:

Physicians in Yukon may bill patients directly for non-insured services. Block fees are not used at this time; however, some do bill by service item. Billable services include but are not limited to:

Payment does not affect patient access to services because not all physicians or clinics bill for these services and other agencies or employers may cover the cost.

Uninsured dental services include procedures considered restorative and procedures that are not performed in a hospital under general anaesthesia.

All Yukon residents have equal access to services. Third parties, such as private insurers or the Worker’s Compensation Health and Safety Board, do not receive priority access to services through additional payment. The purchase of non-insured services, such as fiberglass casts, does not delay or prevent access to insured services at any time. Insured persons are given treatment options at the time of service.

Yukon has no formal process to monitor compliance; however, feedback from physicians, hospital administrators, medical professionals and staff allows the Director, Insured Health and Hearing Services to monitor usage and service concerns.

The process used to de-insure services covered by the Yukon Health Insurance Plan is as follows:

Physician services—the joint Yukon Health Care Insurance Plan and Yukon Medical Association Fee Liaison Committee is responsible for reviewing changes to the Payment Schedule for Yukon including decisions to de-insure certain services. In consultation with the Yukon Medical Advisor, decisions to de-insure services are based on medical evidence that indicates the service is not medically necessary, is ineffective or a potential risk to the patient’s health. Once a decision has been made to de-insure a service, all physicians are notified in writing.

Hospital services—an amendment by Order-in-Council to sections 2(e) and 2(f) of the Yukon Hospital Insurance Services Regulations would be required. As of March 31, 2020, no insured in-patient or out-patient hospital services, as provided for in the Regulations, have been de-insured.

Surgical-dental services—an amendment by Order-in-Council to Schedule B of the Health Care Insurance Plan Regulations is required. A service could be de-insured if determined not medically necessary or is no longer required to be carried out in a hospital under general anaesthesia. The Director, Insured Health and Hearing Services manages this process. No surgical-dental services were de-insured in 2019–2020.

3.0 Universality

3.1 Eligibility

Eligibility requirements for insured health services are set out in the Health Care Insurance Plan Act and Regulations, sections 2 and 4, and the Hospital Insurance Services Act and Regulations, sections 2 and 4. There were no changes to the legislation in 2019-2020.

Subject to the provisions of these acts and regulations, every Yukon resident is eligible for and entitled to insured health services on uniform terms and conditions. The term “resident” is defined using the wording of the Canada Health Act and means a person lawfully entitled to be or to remain in Canada, who makes his or her home and is ordinarily present in Yukon, but does not include a tourist, transient, foreign student or visitor. Pursuant to section 4(1) of the Yukon Health Care Insurance Plan Regulations and the Yukon Hospital Insurance Services Regulations, an insured person is eligible for and entitled to insured services after midnight on the last day of the second month following the month of arrival to the Territory. All persons returning to or establishing residency in Yukon are required to complete this waiting period. The only exception is for children adopted by insured persons, and for newborns.

The following persons are not eligible for coverage in Yukon:

The above persons may become eligible for coverage if they meet one or more of the following conditions:

As of March 31, 2020, there were 42,382 registrants in the Yukon Health Care Insurance Plan.

3.2 Other Categories of Individuals

The Yukon Health Care Insurance Plan provides health care coverage for other categories of individuals, as follows:

International students, temporary workers, tourists, transients or visitors to Yukon do not qualify as residents of the territory and are not eligible for Yukon Health Care Insurance Plan coverage.

4.0 Portability

4.1 Minimum Waiting Period

Where applicable, the eligibility of all persons is administered in accordance with the Interprovincial Agreement on Eligibility and Portability. Under section 4(1) of both the Health Care Insurance Plan Act and the Hospital Insurance Services Act Regulations, “an insured person is eligible for and entitled to insured services after midnight on the last day of the second month following the month of arrival to the Territory.” All persons entitled to coverage are required to complete the minimum waiting period with the exception of children adopted by insured persons (see section 3.1), and newborns.

4.2 Coverage during Temporary Absences in Canada

The provisions relating to portability of health care insurance during temporary absences outside Yukon, but within Canada, are defined in sections 5, 6, 7 and 10 of the Yukon Health Care Insurance Plan Regulations and sections 6, 7(1), 7(2) and 9 of the Yukon Hospital Insurance Services Regulations. There were no changes to these regulations in 2019-2020.

The Regulations state that, “where an insured person is absent from the Territory and intends to return, he/she is entitled to insured services during a period of 12 months of continuous absence.” Persons leaving Yukon for a period exceeding six months must contact Yukon Insured Health Services and complete a Temporary Absence form. Failure to do so may result in cancellation of coverage.

Students attending educational institutions full-time outside Yukon remain eligible for the duration of their academic studies. 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. Requests for extensions must be renewed yearly and are subject to approval by the Director.

For temporary workers and missionaries, the Director may approve absences in excess of 12 consecutive months upon receiving a written request from the insured person. Requests for extensions must be renewed yearly and are subject to approval by the Director.

The provisions regarding coverage during temporary absences in Canada fully comply with the terms and conditions of the Interprovincial Agreement on Eligibility and Portability effective February 1, 2001. Definitions are consistent in regulations, policies and procedures.

Yukon participates fully with the Interprovincial Medical Reciprocal Billing Agreements and Hospital Reciprocal Billing Agreements in place with all other provinces and territories with the exception of Quebec, which does not participate in the medical reciprocal billing arrangement. Persons receiving medical (physician) services in Quebec may be required to pay directly and submit claims to the Yukon Health Care Insurance Plan for reimbursement.

The Hospital Reciprocal Billing Agreements provide for payment of insured in-patient and out-patient hospital services to eligible residents receiving insured services outside Yukon, but within Canada.

The Medical Reciprocal Billing Agreements provide for payment of insured physician services on behalf of eligible residents receiving insured services outside Yukon, but within Canada.

Insured services provided to Yukon residents while temporarily absent from the territory are paid at the rates established by the host province.

4.3 Coverage during Temporary Absences outside Canada

The provisions that define portability of health care insurance to insured persons during temporary absences outside Canada are defined in sections 5, 6, 7, 9, 10 and 11 of the Yukon Health Care Insurance Plan Regulations and sections 6, 7(1), 7(2) and 9 of the Yukon Hospital Insurance Services Regulations. There were no changes to these regulations in 2019-2020.

Sections 5 and 6 state that, where an insured person is absent from Yukon and intends to return, the person is entitled to insured services during a period of 12 months of continuous absence.

Persons leaving Yukon for a period exceeding six months must contact Yukon Health Care Insurance Plan and complete a Temporary Absence form. Failure to do so may result in cancellation of the coverage.

The provisions for portability of health insurance during out-of-country absences for students, temporary workers and missionaries are the same as for absences within Canada (see section 4.2 of this report).

Insured physician services provided to eligible Yukon residents temporarily outside the country are paid at rates equivalent to those paid had the service been provided in Yukon. Reimbursement is made to the insured person by the Yukon Health Care Insurance Plan or directly to the provider of the insured service.

Insured in-patient hospital services provided to eligible Yukon residents outside Canada are paid at the rate established in the Standard Ward Rates Regulation for the Whitehorse General Hospital. For 2019–2020 the in-patient rate was set at $2,010 per day at Whitehorse General Hospital, $1,788 per day at Watson Lake Community Hospital and $1,724 per day at Dawson City Community Hospital. These rates are set annually by the Interprovincial Health Insurance Agreements Coordinating Committee (IHIACC).

Insured out-patient hospital services provided to eligible Yukon residents outside Canada are paid at the rate established by the IHIACC.

4.4 Prior Approval Requirement

There is no legislated requirement that eligible residents must seek prior approval before seeking elective or emergency hospital or physician services outside Yukon or outside Canada.

When treatment is provided outside Yukon or outside Canada plan members will only be reimbursed the amounts as described in Sections 4.2 and 4.3.

Prior approval by the Director of Insured Health Services is required for full reimbursement of services sought outside of Canada.

5.0 Accessibility

5.1 Access to Insured Health Services

There are no user fees or user charges under the Yukon Health Care Insurance Plan. All services are provided on a uniform basis and are not impeded by financial or other barriers. There is no extra-billing in Yukon for any services covered by the Plan.

In 2019-2020 Yukon did not have any private for-profit health care facilities delivering insured health services.

If a patient has a complaint related to physician services including extra-billing or user charges they can contact the Yukon Medical Council (YMC).

Information on complaints can be found on the YMC’s website.

The YMC can be reached by phone at 867-667-3774 or by email to ymc@gov.yk.ca.

Access to hospital or physician services not available locally are provided through the Visiting Specialist Program, Telehealth Program, or the Travel for Medical Treatment Program. These programs ensure that there is minimal or no delay in receiving medically necessary services.

To improve access to insured health services, the number of resident specialists working in Yukon continues to increase to better serve Yukoners.

Additionally, Insured Health and Hearing Services provides extended health benefits to eligible Yukon residents which include the Travel for Medical Treatment Program, the Children’s Drug and Optical Program, the Chronic Disease and Disability Benefits Program, Pharmacare Program, Extended Benefits Program, and Hearing Services Program.

The Yukon Hospital Corporation operates the three hospitals in the territory: Whitehorse General Hospital, Watson Lake Community Hospital, and Dawson City Community Hospital.

5.2 Physician Compensation

The Department of Health and Social Services seeks its negotiating mandate from the Government of Yukon before entering into negotiations with the Yukon Medical Association (YMA). The YMA and the government each appoint members to the negotiating team. Meetings are held as required until an agreement has been reached. The YMA’s negotiating team then seeks approval of the tentative agreement from the YMA membership. The Department seeks ratification of the agreement from the Government of Yukon. The final agreement is signed with the concurrence of both parties.

The legislation governing payments to physicians and dentists for insured services are the Health Care Insurance Plan Act and the Health Care Insurance Plan Regulations.

The fee-for-service system is used to reimburse the majority of physicians providing insured services to residents. Other systems of reimbursement include alternative payment arrangements which are primarily used for specialist services in Whitehorse as well as physician services in rural communities.

5.3 Payments to Hospitals

The Government of Yukon funds the Yukon Hospital Corporation (Whitehorse General Hospital, Watson Lake Community Hospital, and Dawson City Community Hospital) through contribution agreements with the Department of Health and Social Services. Global operations and maintenance (O&M) and capital funding levels are negotiated and adjusted based on operational requirements. In addition to the established O&M and capital funding set out in the agreement, provision is made for the hospital to submit requests for additional funding assistance for implementing new or enhanced programs.

The legislation governing payments made by the health care plan to facilities that provide insured hospital services is the Hospital Insurance Services Plan Act and Regulations. The legislation and regulations set out the legislative framework for payment to hospitals for insured services provided by that hospital to insured persons.

6.0 Recognition Given to Federal Transfers

The Government of Yukon has acknowledged the federal contributions provided through the Canada Health Transfer (CHT) in its 2019–2020 annual Main Estimates and Public Accounts publications, which are available publicly. Section 3(1) (d) and (e) of the Health Care Insurance Plan Act and section 3 of the Hospital Insurance Services Act acknowledge the contribution of the Government of Canada.

Registered Persons
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
1. Number as of March 31st 38,736 39,960 40,726 41,412 42,382
Insured Hospital Services Within Own Province or Territory
Public FacilitiesYukon table 2 Footnote 1 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
2. Number 14 14 14 14 14
3. Payments for insured health services ($)
96,850,809 98,671,448 95,464,882 79,548,179 88,761,576
Private For-Profit Facilities 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
4. Number of private for-profit facilities providing insured health services 0 0 0 0 0
5. Payments to private for-profit facilities for insured health services ($)  0 0 0 0 0
Yukon table 2 Footnote 1

Public facilities are the 11 health centres (Beaver Creek, Carcross, Carmacks, Destruction Bay, Faro, Haines Junction, Mayo, Old Crow, Pelly Crossing, Ross River, and Teslin) and 3 hospitals (Whitehorse, Dawson City and Watson Lake). As Whitehorse, Dawson City and Watson Lake all have hospitals, the health centres in these communities are classified as a Public Health Offices.

Yukon table 2 Return to footnote 1 referrer
Insured Hospital Services Provided to Residents in Another Province or TerritoryYukon table 3 Footnote 1
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
6. Total number of claims, in-patient 1,235 1,218 1,220 1,236 1,491
7. Total payments, in-patient ($) 17,865,677 18,981,947 18,611,146 18,687,516 24,844,188
8. Total number of claims, out-patient 14,513 14,785 15,554 15,856 15,583
9. Total payments, out-patient ($) 4,851,075 5,429,919 5,615,333 5,786,856 5,809,521
Yukon table 3 Footnote 1

Hospitals have up to a year from date of service to bill jurisdictions (information is based upon date of service; therefore, 2019-20 billing period is open until March 31, 2021).

Yukon table 3 Return to footnote 1 referrer
Insured Hospital Services Provided Outside CanadaYukon table 4 Footnote 1Yukon table 4 Footnote 2
Pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
10. Total number of claims, in-patient Not available Not available Not available Not available Not available
11. Total payments, in-patient ($) Not available Not available Not available Not available Not available
12. Total number of claims, out-patient Not available Not available Not available Not available Not available
13. Total payments, out-patient ($) Not available Not available Not available Not available Not available
Non pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
14. Total number of claims, in-patient 23 18 10 19 7
15. Total payments, in-patient ($) 62,040 164,673 82,088 136,430 35,883
16. Total number of claims, out-patient 48 42 58 56 46
17. Total payments, out-patient ($) 12,646 13,482 16,590 18,166 29,558
Yukon table 4 Footnote 1

Yukon does not have an electronic method of capturing pre-approved claims versus non pre-approved claims. Totals are reported as non pre-approved claims.

Yukon table 4 Return to footnote 1 referrer

Yukon table 4 Footnote 2

Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report,but did not require provinces or territories to report on previous years.

Yukon table 4 Return to footnote 2 referrer
Insured Physician Services Within Own Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
18. Number of participating physicians 72 78 77 80 80
19. Number of opted-out physicians 0 0 0 0 0
20. Number of non-participating physicians 0 0 0 0 0
21. Total payments for services provided by physicians paid through all payment methods ($) 27,753,925 29,654,509 30,764,362 32,836,649 35,876,192
22. Total payments for services provided by physicians paid through fee-for-service ($) 19,851,219 20,625,637 21,013,041 22,675,907 25,066,841
Insured Physician Services Provided to Residents in Another Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
23. Number of services 62,027 52,766 55,902 56,302 71,257
24. Total payments ($) 3,954,752 4,018,173 4,422,905 4,333,394 5,376,424
Insured Physician Services Provided Outside CanadaYukon table 7 Footnote 1
Pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
25. Number of services Not available Not available Not available Not available Not available
26. Total payments ($) Not available Not available Not available Not available Not available
Non pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
27. Number of services Not available Not available Not available Not available Not available
28. Total payments ($) Not available Not available Not available Not available Not available
Yukon table 7 Footnote 1

Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report,but did not require provinces or territories to report on previous years.

Yukon table 7 Return to footnote 1 referrer
Insured Surgical-Dental Services Within Own Province or TerritoryYukon table 8 Footnote 1
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
29. Number of participating dentists 0 0 0 0 0
30. Number of opted-out dentistsYukon table 8 Footnote 2 0 0 0 0 0
31. Number of non-participating dentists Yukon table 8 Footnote 2 0 0 0 0 0
32. Number of services provided 0 0 0 0 0
33. Total payments ($) 0 0 0 0 0
Yukon table 8 Footnote 1

No insured surgical-dental services performed in Yukon.

Yukon table 8 Return to footnote 1 referrer

Yukon table 8 Footnote 2

Health Canada requested this data as of the 2016-2017 report, but did not require provinces or territories to report data for 2015-16.

Yukon table 8 Return to footnote 2 referrer

Northwest Territories

The Department of Health and Social Services (the Department) is responsible for setting the strategic direction for the health and social services system through the development of legislation, policy and standards; establishing approved programs and services; establishing and monitoring system budgets and expenditures; and evaluating and reporting on system outcomes and performance. The Department is responsible for ensuring that all statutory functions and requirements are fulfilled, ensuring professionals are appropriately licensed and managing access to health insurance.

The Health and Social Services Authorities are governed by the Leadership Council. Regional Wellness Councils provide advice to the Leadership Council and valuable input on the needs and priorities of the residents in their regions. The Leadership Council is responsible to the Minister of Health and Social Services for governing, managing and providing health and social services in accordance with the plan set out by the Minister.

The Department recognizes that the identification of priorities and the development and delivery of responsive programs and services is best managed in partnership with Indigenous people and communities through an integrated system.  

In response to the COVID-19 pandemic, the Northwest Territories Health and Social Services Authority expanded Virtual Care options to support care in remote communities, to reduce the need to travel for care, and to replace in-person appointments – where appropriate - with phone, telemedicine, or video conferencing applications.

To support the reduction of in-person appointments amendments were made to the Pharmacy Act Continuing Care Prescription Regulations to provide for additional refills. The amendments only have effect with the direction of the Chief Public Health Officer, during a Public Health Emergency declared by the Minister pursuant to the Public Health Act.

1.0 Public Administration

1.1 Health Care Insurance Plan and Public Authority

The Northwest Territories (NWT) Health Care Plan consists of the NWT Medical Care Plan and the NWT Hospital Insurance Plan.

The public authority responsible for the administration of the NWT Medical Care Plan is the Director of Medical Insurance, appointed by the Minister of Health and Social Services (the Minister), under s.23(1) of the Medical Care Act. The Minister establishes the Northwest Territories Health and Social Services Authority and the Health and Social Service Authorities' Boards of Management pursuant to s.5(1), s.10(1), and s.10(2) of the Hospital Insurance and Health and Social Services Administration Act. The Hospital Insurance and Health and Social Services Administration Act recognizes, at s.10.3(1), that the Tłı̨chǫ Community Services Agency established by the Tłı̨chǫ Community Services Agency Act is deemed to be a Board of Management. The territorial authority and the boards administer the Hospital Insurance Plan; their legislated mandate is to:

There were no amendments made in 2019-2020 to the Medical Care Act or the Hospital Insurance and Health and Social Services Administration Act.

1.2 Reporting Relationship

During the reporting period there were three Health and Social Service Authorities: Northwest Territories Health and Social Services Authority (Territorial Authority), Hay River Health and Social Services Authority, and Tłı̨chǫ Community Services Agency.

Territorial Authority affairs are directed by a Territorial Board of Management.

Six Regional Wellness Councils provide advice to the Territorial Board of Management, which is composed of the Regional Wellness Council chairpersons and the chairpersons of the Tłı̨chǫ Community Services Agency and Hay River Health and Social Services Authority. The Territorial Board of Management and the remaining Boards of Management are accountable to the Minister.

The Territorial Board of Management and the remaining Boards of Management are responsible for the delivery of health and social services and for the management, control, and operation of facilities and services throughout the Northwest Territories. The Territorial Board of Management and the Boards of Management are required under legislation to comply with the territorial plan, which is set by the Minister.

The Minister appoints the Director of Medical Insurance who is responsible for administering the Medical Care Act and its Regulations. The Director prepares an annual report for the Minister on the operation of the NWT Medical Care Plan. This report can be found within the NWT Health and Social Services Annual Report 2019-2020.Footnote 15

The Minister appoints the Chair of the Territorial Board of Management as well as the chairperson and members of each Regional Wellness Council. The Minister also appoints the Chair and Members of the Hay River Health and Social Services Authority. The chairpersons and members of the Regional Wellness Councils may serve for three years and may be re-appointed to serve another term.

The Minister may appoint a Public Administrator to assume the role of a Board of Management in certain circumstances if the Minister feels it is necessary. During 2019-2020, a Public Administrator was in place for the Hay River Health and Social Services Authority. The Public Administration acts in the place of a Board of Management.

The Tłı̨chǫ Community Services Agency was established under the Tłı̨chǫ Community Services Agency Act as part of the Tłı̨chǫ Land Claims and Self Government Agreement.  The Act, which is administered by the Minister of Executive and Indigenous Affairs, stipulates that the Tłı̨chǫ Community Services Agency has all the powers, duties and functions of a Board of Management under the Hospital Insurance and Health and Social Services Administration Act. Under the Act, each Tłı̨chǫ community government is responsible for appointing one board member and the Minister of Executive and Indigenous Affairs is responsible for appointing the Chairperson following a consultation with the board members.  The Act also sets the term for members to a maximum of four years with the Chairperson’s term being fixed by the Minister.

The Director of Medical Insurance and the Boards of Management are responsible to the Minister, as per section 8(1)(b) of the Canada Health Act.

In accordance with the Financial Administration Act and the Hospital Insurance and Health and Social Services Administration Act, there is an obligation to report to the Legislative Assembly on the preceding year’s operations and financial position of the Department of Health and Social Services (the Department).  Each year the NWT Health and Social Services System Annual Report meets these obligations, as well as meets the obligation to annually table a report on the operations of the Medical Care Plan.

1.3 Audit of Accounts

The Office of the Auditor General of Canada (OAG) audits payments made under the NWT Hospital Insurance Plan and the NWT Medical Care Plan through their annual audit of the Government of the NWT’s Public Accounts.

The Hospital Insurance Plan and the Medical Care Plan are administered by the Department of Health and Social Services. The latest OAG audit was on the 2018-2019 Public Accounts and was completed as of November 27, 2019. The GNWT, Public Accounts 2018-2019 was published on December 10, 2019.

2.0 Comprehensiveness

2.1 Insured Hospital Services

Insured hospital services in the Northwest Territories (NWT) are provided under the Hospital Insurance and Health and Social Services Administration Act.  No amendments were made to the Act.  In February 2020, the Critical Incident Regulations came into effect. The Critical Incident Regulations address mandatory notification of critical incidents or alleged critical incidents. A critical incident is an unintended event that occurs when health services are provided to an individual and results in a consequence to him or her that is serious and undesired, such as death, disability, injury or harm, unplanned admission to hospital or unusual extension of a hospital stay, and does not result from the individual's underlying health condition or from a risk inherent in providing health services.

During the reporting period, insured hospital services were provided to in-patients and out-patients by 23 facilities throughout the NWT. Consistent with Section 9 of the Canada Health Act, the NWT offers a comprehensive range of insured services to its residents.

Insured in-patient hospital services include:

Insured out-patient hospital services include:

The Minister of Health and Social Services (the Minister) may approve additions or deletions to insured services provided in the NWT.  While there were no changes to insured services in 2019-2020, assessment of additions is accomplished on a case by case basis. The Director of Medical Insurance makes such determinations based on the advice of the Medical Advisor. This process is a ‘right size’ approach, scaling the complexity of decision making to be appropriate to the size of the NWT health and social services system.  Public consultation is readily available through Regional Wellness Councils.

As outlined in the Government of the NWT Medical Travel Policy, travel assistance is provided to residents with a valid NWT Health Care Card who require medically necessary insured services that are not available in their home community or elsewhere in the NWT.Footnote 16 This ensures that residents of the NWT have reasonable access to insured hospital and physician services.

The NWT does not have any private diagnostic clinics charging patients for services that would be considered insured if provided in a hospital.

2.2 Insured Physician Services

The NWT Medical Care Act and the NWT Medical Care Regulations provide for insured physician services. Medically necessary services provided in approved facilities by physicians, nurses, nurse practitioners, and midwives are considered insured services under the NWT Health Care Plan. These professionals are required by legislation to be licensed to practice in the NWT under the Medical Profession Act (physicians), Nursing Profession Act (nurses and nurse practitioners) and Midwifery Profession Act. Amendments to the Midwifery Profession General Regulations to update the Continuing Competency Program and the Code of Conduct for registered midwives in the NWT were made in October 2019.

For the period 2019–2020, there were 411 licensed physicians (resident, locum and visiting) active in the NWT.

Physicians may opt out and collect fees other than under the NWT Medical Care Plan by providing written notice to the Director of Medical Insurance. There were no opted-out physicians in the NWT during the reporting period.

The NWT Medical Care Plan insures all medically necessary physician services such as:

Services not insured include:

The Director of Medical Insurance is responsible for recommending an insured services tariff for services payable by the NWT Medical Care Plan for the Minister's approval. The Minister ultimately determines if services will be added, altered, or removed from the tariff by:

While there were no changes to insured services in 2019-2020, assessment of additions is accomplished on a case by case basis. The Director of Medical Insurance makes such determinations based on the advice of the Medical Advisor. This process is a ‘right size’ approach, scaling the complexity of decision making to be appropriate to the size of the NWT health and social services system.  Public consultation is readily available through Regional Wellness Councils.

2.3 Insured Surgical-Dental Services

Licensed oral surgeons may submit claims for insured surgical-dental work in the NWT. The Province of Alberta's Schedule of Oral and Maxillofacial Surgery Benefits is used as a guide.Footnote 17

Dentists are unable to participate in the NWT Medical Care Plan except where medically necessary and performed in a hospital. Dentists, when delivering services in a hospital, bill third-party insurance providers for dental surgery, and the anaesthetic services are covered under the NWT Medical Care Plan.

The only surgical-dental related procedures, covered under insured services, are for procedures focusing on reconstructive surgery of the face, primarily of the mouth and jaw as a result of trauma or birth defect. Such procedures are not identified as dental surgery but are identified as medically necessary surgery and are subject to physician referral.  No procedures were added in 2019-2020 to list of insured surgical services covered by the NWT Medical Care Plan.

2.4 Uninsured Hospital, Physician and Surgical-Dental Services

Not all services provided by hospitals, medical practitioners and dentists are covered under the NWT Health Care Plan. Some uninsured services include:

Prior approval is required for NWT residents to receive items, services, or both, that are generally considered uninsured under the NWT Health Care Plan. A Medical Advisor makes recommendations to the Director of Medical Insurance regarding the appropriateness of the request.

The Workers' Safety and Compensation Commission (WSCC) covers the costs of the services to treat a worker who is injured on the job according to WSCC policy. The policy that covers requirements for entitlement can be found in NWT and Nunavut WSCC, Policy Manual, (Policy 03.02) available on the Workers' Safety and Compensation Commission site.

Changes to the list of uninsured hospital, physician, and surgical-dental services may be made by the Minister. While there were no changes to uninsured services in 2019-2020, assessment of additions is accomplished on a case by case basis. The Director of Medical Insurance makes such determinations based on the advice of the Medical Advisor. This process is a ‘right size’ approach, scaling the complexity of decision making to be appropriate to the size of the NWT health and social services system.  Public consultation is readily available through Regional Wellness Councils.

3.0 Universality

3.1 Eligibility

The Medical Care Act and the Hospital Insurance and Health and Social Services Administration Act define eligibility for the Northwest Territories (NWT) Health Care Plan. The NWT uses guidelines that are consistent with the legislation and Interprovincial Agreement on Eligibility and Portability to determine eligibility in order to fulfill obligations of section 10 in the Canada Health Act.

Every resident is, on the first day of the third month after becoming a resident, eligible for and entitled to payment of benefits in respect of insured services rendered to the resident in accordance with the Medical Care Act and Medical Care Regulations.

According to the Medical Care Act, a resident is a person lawfully entitled to be or to remain in Canada, who makes their home and is ordinarily present in the NWT, but does not include a tourist, transient, or visitor to the NWT. There were no amendments to the Medical Care Act regarding eligibility made in 2019-2020.

In order to register for the NWT Health Care Plan, residents fill out an application form and provide relevant supporting documentation (e.g., visa, immigration papers, and proof of residency). Residents may register prior to the date they become eligible. Registration is directly linked to eligibility for coverage and claims are only paid if the client has registered.

Coverage begins when a signed application has been approved.

Residents can opt out of the NWT Health Care Plan if they choose not to register. There is nothing in the Medical Care Act that requires a resident to register for the NWT Health Care Plan. At any time, a resident may advise the NWT Health Care Plan administrator of a wish to opt out of the Plan.

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 period. For persons moving back to Canada, eligibility is restored when permanent residency is established.

In accordance with the Interprovincial Agreement on Eligibility and Portability of Hospital and Medical Care Insurance, residents who have been federal inmates become eligible upon release to the NWT; permanent residents become eligible upon establishment of permanent residency. Returning Canadians are eligible on the first day of arrival in NWT and permanent residents are also eligible on the first day, provided that the NWT is the first jurisdiction they are residing in upon arriving in or returning to Canada.

If an application for an NWT Health Care Card is denied, coverage is denied for a procedure, or if a person is appealing the decision to cancel their NWT Health Care Card, individuals may appeal to the Director of Medical Insurance. Second level and final appeals may be directed to the Deputy Minister of Health and Social Services.

As of March 31, 2020, there were 42,501 individuals registered with the NWT Health Care Plan.

3.2 Other Categories of Individuals

Holders of employment visas, student visas and, in some cases, visitor visas are covered if they meet the provisions of the Eligibility and Portability Agreement and guidelines for NWT Health Care Plan coverage.

Babies born to NWT residents outside of Canada are automatically covered effective on the date of birth, if:

Foreign students and workers are eligible for coverage if they hold study or work permits valid for a period of 12 months or longer. Those holding permits of less than 12 months are not eligible for coverage.

Permanent residents (landed immigrants) and returning permanent residents, including those with expired residency, are covered on the first day of arrival in the NWT provided the NWT is their first place of residence in Canada, and they intend to reside in the NWT.

Convention refugees are covered, provided they provide appropriate documentation.

The following are not eligible for an NWT Health Care Card as they are not considered residents:

4.0 Portability

4.1 Minimum Waiting Period

Waiting periods for persons moving to the Northwest Territories (NWT) are consistent with the Interprovincial Agreement on Eligibility and Portability. The waiting period ends the first day of the third month of residency for those moving permanently to the NWT.

4.2 Coverage during Temporary Absences in Canada

Section 4(2) of the Medical Care Act provides NWT residents with access to insured health coverage while temporarily out of the NWT but still in Canada, consistent with section 11(1) (b)(i) of the Canada Health Act. The Department of Health and Social Services (the Department) adheres to the Interprovincial Agreement on Eligibility and Portability. No amendments were made in 2019-2020 to the Medical Care Act.

NWT residents may be covered for up to one year of temporary absence for work, travel or holidays. Full-time students attending post-secondary school are covered as well. The full cost of insured services is paid for all services received in other Canadian jurisdictions. The criterion for Temporary Absence is that the individual must be physically present in the NWT for a period of 153 days in a calendar year to maintain residency.

When a valid NWT Health Care Card is produced, most doctor visits and hospital services are billed directly to the Department. During the reporting period, approximately 28.6 million dollars were paid out for hospital in-patient and out-patient services in other provinces and territories. Reimbursement guidelines exist for patients having to pay up front for medically necessary services.

The NWT participates in both the Hospital Reciprocal Billing Agreement and the Medical Reciprocal Billing Agreement with other jurisdictions (except Quebec).

4.3 Coverage during Temporary Absences Outside Canada

As per section 4(3) of the Medical Care Act and section 11(1)(b) (ii) of the Canada Health Act, the NWT provides reimbursement for NWT residents who require medically necessary services while temporarily outside Canada. No amendments were made in 2019-2020 to the Medical Care Act.

Individuals are required to pay up front and seek reimbursement upon their return to the NWT. Costs for eligible services, including in-patient services, out-patient services, and haemodialysis rendered outside Canada, will be reimbursed up to the amounts payable in the NWT. Residents temporarily out of Canada may receive coverage for up to one year; however, prior approval as well as documentation proving the NWT will be the individual's permanent residence upon return is required. Returning Canadians are covered on the first day of arrival in the NWT. Documentation is required to validate the first day of arrival. Permanent residents (Landed immigrants) are covered on the first day of arrival in the NWT, with appropriate documentation from Immigration Canada, provided the NWT is their first place of residence in Canada and they intend to reside here. Foreign workers holding a valid closed work permit are eligible for coverage on the first day they are present in the NWT. Live-in care givers with a work permit that lists NWT as the location of employment are eligible for first day coverage.

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.
First level appeals of decisions may be sent to the Director of Medical Insurance. Second level appeals are considered by the Deputy Minister of Health and Social Services. The decision of the Deputy Minister is final.

5.0 Accessibility

5.1 Access to Insured Health Services

The Government of the Northwest Territories (NWT) Medical Travel Policy provides NWT residents with assistance to access medically necessary insured services not available in their home community or in the NWT, consistent with section 12(1)(a) of the Canada Health Act.Footnote 18

Extra-billing is not permitted in the NWT, in adherence to section 18 of the Canada Health Act and section 14(1) of the Medical Care Act. The only exception is if a medical practitioner opts out of the NWT Medical Care Plan and collects his or her own fees. Extra-billing did not occur in 2019-2020.

User charges are also not permitted under section 14(2) of the Medical Care Act unless the medical practitioner has opted-out of the NWT Medical Care Plan, collects his or her own fees, and gives reasonable notice of the intention to collect fees.

The Medical Care Act includes a provision to allow the Minister of Health and Social Services (the Minister) to establish a Benefits Appeal Committee that could address any matter referred to it by the Minister, including complaints where a physician engaged in extra-billing and charged user fees. At present, there has been no need to establish this committee, because almost all physicians are compensated through contractual agreements with the Government of the NWT.

Complaints of extra-billing or user charges can be made to:

The Health Services Administration Office, Health and Social Services
Bag#9, Inuvik
NT, X0E OTO
by phone at: 1-800-661-0830 or 1-867-777-7400
or by Fax at: 1-867-777-3197

In 2019-2020, the Northwest Territories Health and Social Services Authority (Territorial Authority) launched the Primary Health Care Reform initiative aimed at improving primary care models, support relationship-building between clients and our system, and contribute to the best health, best care, and a better future for NWT residents. As part of this reform initiative, a demonstration project was initiated called Expanded Same Day Access. This project implemented expanded hours at the medical clinics in Yellowknife and a walk-in appointment option for clients.

5.2 Physician Compensation

The Department of Health and Social Services (the Department), in close consultation with the NWT Medical Association, sets physician compensation. Generally, family and specialist practitioners are compensated through contractual agreements with the Government of NWT, while the remaining practitioners are compensated on a fee-for-service basis. Fee-for-service rates in the NWT are itemized in the Insured Services Tariff approved by the Minister in accordance with the Medical Care Act.

Under the Medical Care Act, the Minister may appoint medical and financial inspectors who shall, under the direction of the Director, inspect, examine, and audit books, accounts, reports, and medical records maintained in hospitals, health facilities, offices of medical practitioners, and other health care facilities respecting patients who are receiving or who have received insured services. The Director may reassess an account for insured services submitted by a medical practitioner and make any appropriate adjustment in the amount paid to the medical practitioner in respect of the insured services.

Although physicians may charge for uninsured services in accordance with the Service Fee Policy, there is no ability to charge block fees.

5.3 Payments to Hospitals

Contribution agreements between the Department and the Boards of Management dictate payments made to hospitals. Government budgets, resources, and levels of services offered determine the allocated amounts.

Payments for the provision of insured hospital services are governed under the Hospital Insurance and Health and Social Services Administration Act and the Financial Administration Act. A comprehensive budget is used to fund hospitals in the NWT.

6.0 Recognition Given to Federal Transfers

Federal funding from the Canada Health Transfer has been recognized and reported by the Government of the Northwest Territories (GNWT) through the follow documents: GNWT, Public Accounts 2018-2019 (published December 10, 2019); and the GNWT, Main Estimates, 2020-2021 (published February 25, 2020).

The Public Accounts contain the consolidated financial statements of the GNWT, audited by the Auditor General of Canada, and are presented annually to the Legislative Assembly. The Main Estimates are also presented annually to the Legislative Assembly.

Registered Persons
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
1. Number as of March 31st (#) 43,430 42,780 43,632 43,324 42,501
Insured Hospital Services Within Own Province or Territory
Public Facilities 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
2. Number (#)  23 23 23 23 23
3. Payments for insured health services ($)Northwest Territories table 2 Footnote 1 72,824,873 74,482,130 75,767,548 81,773,467 97,113,884
Private For-Profit Facilities 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
4. Number of private for-profit facilities providing insured health services (#) 0 0 0 0 0
5. Payments to private for-profit facilities for insured health services($) Not applicable Not applicable Not applicable Not applicable Not applicable
Northwest Territories table 2 Footnote 1

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

Northwest Territories table 2 Return to footnote 1 referrer
Insured Hospital Services Provided to Residents in Another Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
6. Total number of claims, in-patient (#) 1,316 1,278 1,291 1,393 1,423
7. Total payments, in-patient ($) 21,899,702 22,181,729 19,458,993 25,785,734 21,495,046
8. Total number of claims, out-patient (#) 12,641 13,444 13,894 15,565 14,387
9. Total payments, out-patient ($) 4,804,337 5,684,108 6,269,596 7,602,454 7,055,604
Insured Hospital Services Provided Outside CanadaNorthwest Territories table 4 Footnote 1
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
10. Total number of claims, pre-approved in-patient Not available Not available Not available 0 0
11. Total payments, pre-approved in-patient ($) Not available Not available Not available 0 0
12. Total number of claims, pre-approved out-patient Not available Not available Not available 1 2
13. Total payments, pre-approved out-patient ($) Not available Not available Not available 320 5,253
14. Total number of claims, non pre-approved in-patient 14 9 13 11 7
15. Total payments, non pre-approved in-patient ($) 216,539 97,456 316,373 32,727 17,522
16. Total number of claims, non pre-approved out-patient 45 44 31 50 24
17. Total payments, non pre-approved out-patient ($) 39,388 52,643 19,719 26,157 9,029
Northwest Territories table 4 Footnote 1

2018-19 is the first year Health Canada required reporting preapproved versus non pre-approved claims and expenditures. Prior to 2018-19 all out of Canada claims are included in the non pre-approved category.

Northwest Territories table 4 Return to footnote 1 referrer
Insured Physician Services Within Own Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
18. Number of participating physicians (#)Northwest Territories table 5 Footnote 1 326 350 360 372 411
19. Number of opted-out physicians (#) 0 0 0 0 0
20. Number of not participating physicians (#) 0 0 0 0 0
21. Total payments for services provided by physicians paid through all payment methods ($)Northwest Territories table 5 Footnote 2 53,732,241 55,291,846 56,505,139 57,405,424 59,311,914
22. Total payments for services provided by physicians paid through fee-for-service ($) 1,635,526 1,259,330 1,201,976 1,183,680 1,325,187
Northwest Territories table 5 Footnote 1

Estimate based on total active physicians for each fiscal year.

Northwest Territories table 5 Return to footnote 1 referrer

Northwest Territories table 5 Footnote 2

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

Northwest Territories table 5 Return to footnote 2 referrer
Insured Physician Services Provided to Residents in Another Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
23. Number of services (#) 55,149 63,012 62,833 65,030 63,575
24. Total payments ($) 6,434,942 6,944,788 6,947,348 7,339,664 7,075,008
Insured Physician Services Provided Outside CanadaNorthwest Territories table 7 Footnote 1
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
25. Number of pre-approved services Not available Not available Not available 1 0
26. Total pre-approved payments ($) Not available Not available Not available 2,603 0
27. Number of non pre-approved services 200 101 115 73 47
28. Total non pre-approved payments ($) 171,104 7,471 18,383 6,532 14,038
Northwest Territories table 7 Footnote 1

2018-19 is the first year Health Canada required reporting preapproved versus non pre-approved claims and expenditures. Prior to 2018-19 all out of Canada claims are included in the non pre-approved category.

Northwest Territories table 7 Return to footnote 1 referrer
Insured Surgical-Dental Services Within Own Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
29. Number of participating dentists (#) Not available Not available Not available Not available Not available
30. Number of opted-out dentists (#)Northwest Territories table 8 Footnote 1 Not applicable Not applicable Not applicable Not applicable Not applicable
31. Number of non-participating dentists (#)Northwest Territories table 8 Footnote 1 Not applicable Not applicable Not applicable Not applicable Not applicable
32. Number of services provided (#) Not available Not available Not available Not available Not available
33. Total payments ($) Not available Not available Not available Not available Not available
Northwest Territories table 8 Footnote 1

Health Canada requested this data as of the 2016-2017 report, but did not require provinces or territories to report on previous years.

Northwest Territories table 8 Return to footnote 1 referrer

Nunavut

The Department of Health (the Department) faces many unique challenges when providing for the health and well-being of Nunavummiut. Of a total population of 38,780Footnote 19 approximately one third of the population is under the age of 15 years (12,348 people). The territory is made up of 25 communities located across three time zones and divided into three regions: the Qikiqtani (or Baffin), the Kivalliq and the Kitikmeot.

The Government of Nunavut incorporates Inuit Societal Values into program and policy development, as well as into service design and delivery. The delivery of health services in Nunavut is based on a primary health care model. Nunavut's primary health care providers are family physicians, nurse practitioners, midwives, community health nurses, and other allied health professionals.

In 2019–2020, the territorial operations and maintenance budget for the Department was $480,999,000 including supplementary appropriationsFootnote 20. One third of the Department's total operational budget was spent on costs associated with medical travel and treatment provided in out-of-territory facilities. Nunavut is a vast territory with a low population density and limited health infrastructure, therefore, access to a range of hospital and specialist services often requires that residents be sent out-of-territory for care.

In 2019–2020, a total of $35,650,000 was allocated to the Department for capital projectsFootnote 21. The Department's 2019–2020 capital projects include the construction of the new community health centres in Sanikiluaq and Kinngait.

COVID-19 Measures

Upon recommendation from the Chief Public Health Officer, a public health emergency was declared in Nunavut by the Minister of Health on March 18, 2020. During the 2019-2020 reporting period (March 18 – March 31, 2020) several public health measures were initiated as part of the Department's COVID-19 response plan to ensure the health and safety of Nunavummiut during the pandemic. During the reporting period, there were no confirmed or probable cases of COVID-19 in the territory.

Ongoing Health Services:

Adjusted Services:

1.0 Public Administration

1.1 Health Care Insurance Plan and Public Authority

The Health Care Insurance Plans of Nunavut, including physician and hospital services, are administered by the Department of Health (the Department) on a non-profit basis.

The Medical Care Act (NWT, 1988 and as duplicated for Nunavut by section 29 of the Nunavut Act, 1999) governs the entitlement to and payment of benefits for insured medical services.

The Hospital Insurance and Health and Social Services Administration Act (NWT, 1988 and as duplicated for Nunavut by section 29 of the Nunavut Act, 1999) enables the establishment of hospital and other health services.

The Department is responsible for delivering health care services to Nunavummiut, including the operation of community health centres, regional health centres, and a hospital. There are three regional offices that manage the delivery of health services at a regional level. Iqaluit operations are administered separately. The Government of Nunavut opted for decentralization to regional offices to support front-line workers and community-based delivery of a wide range of health programs and services.

1.2 Reporting Relationship

Legislation governing the administration of health services in Nunavut was carried over from the Northwest Territories (as Nunavut statutes) pursuant to the Nunavut Act. The Medical Care Act governs who is covered by the Nunavut Health Care Plan and the payment of benefits for insured medical services. Section 23(1) of the Medical Care Act requires the Minister responsible for the Act to appoint a Director of Medical Insurance.

The Director is responsible for the administration of the Act and its Regulations. Section 24 requires the Director to submit an annual report on the operation of the Nunavut Health Care Plan to the Minister for tabling in the Legislative Assembly. The 2018-2019 Annual Report on the Operation of the Medical Care Plan from the Director of Medical Insurance was submitted and is available on the Department's website.

1.3 Audit of Accounts

The Auditor General of Canada is the auditor of the Government of Nunavut in accordance with section 30.1 of the Financial Administration Act (Nunavut, 1999). The Auditor General is required to conduct an annual audit of the consolidated financial statements of the Government of Nunavut. The most recent audit of the Government of Nunavut's public accounts was completed on October 24, 2019, for the fiscal year 2018–2019Footnote 22. The Independent Auditor's Report to Nunavut's Legislative Assembly can be found on page 37 of the Government of Nunavut's Report of Public Accounts.

2.0 Comprehensiveness

2.1 Insured Hospital Services

Insured hospital services are provided in Nunavut under the authority of the Hospital Insurance and Health and Social Services Administration Act and Regulations, sections 2 to 4. No amendments were made to the Act or Regulations in 2019–2020.

In 2019–2020, insured hospital services were delivered in 28 facilities across Nunavut including:

The QGH is currently the only acute care facility in Nunavut, accredited by Accreditation Canada, providing a range of in-and out-patient hospital services as defined by the Canada Health Act. QGH offers 24-hour emergency services, in-patient care (including obstetrics, pediatrics and palliative care), surgical services, laboratory services, diagnostic imaging, respiratory therapy, rehabilitation services, and health information management services.

Currently, Rankin Inlet is providing 24-hour care for in-patients; out-patients receive care by on-call staff. Cambridge Bay is providing daily clinic hours, and emergency care is available, on-call, 24-hours a day. There are also a limited number of birthing beds at both facilities.

Other community health centres provide public health services, out-patient services and urgent treatment services.

Public health services are provided at public health clinics located in Rankin Inlet and Iqaluit. Public health programing is provided in the remaining communities through the local health centre. The Department of Health (the Department) also operates a Family Practice Clinic in Iqaluit. This clinic operates as part of the primary care program at QGH.

The Department is responsible for authorizing, licensing, inspecting and supervising all health facilities in the territory.

Insured in-patient hospital services include:

Out-patient services include:

The Department makes the determination to add insured hospital services based on the availability of appropriate resources, equipment and overall feasibility in accordance with financial guidelines set by the Department and with the approval of the Financial Management Board. No new services were added in 2019–2020 to the list of insured hospital services.

2.2 Insured Physician Services

The Medical Care Act, section 3(1), and Medical Care Regulations, section 3, provide for insured physician services in Nunavut. No amendments were made to the Act or Regulation in 2019–2020. The Nursing Act allows for licensure of nurse practitioners in Nunavut; this permits nurses to deliver insured services in Nunavut.

Upon initial registration physicians must be in good standing with a College of Physicians and Surgeons from a Canadian jurisdiction, and be licensed to practice in Nunavut. The Government of Nunavut's Medical Registration Committee currently manages this process for Nunavut physicians. Nunavut recruits and contracts its own family physicians, and accesses specialist services primarily from its main referral centres in Ottawa, Edmonton, Winnipeg, and Yellowknife. Recruitment of full-time family physicians has improved significantly; there are 39 family physician positions, covered by a combination of locums and full-time physicians, funded through the Department. In 2019-2020, physicians provided over 8,439 days of service across the territory.

Of the 39 full-time family physician positions in Nunavut, 24 are in the Qikiqtaaluk region; 10 in the Kivalliq region; and five in the Kitikmeot region. There are also two and a half general surgeon positions, two anaesthetist positions, and four pediatrician positions at the QGH. Visiting specialists, general practitioners, and locums also provide insured physician services; these arrangements are made by each of the Department's three regions.

Physicians can elect to collect fees other than those under the Medical Care Plan in accordance with section 12(2) (a) or (b) of the Medical Care Act by notifying the Director of Medical Insurance (the Director) in writing. An election can be revoked the first day of the following month after a letter to that effect is delivered to the Director. In 2019–2020, no physicians provided written notice of this election. All physicians practicing in Nunavut are under contract with the Department. In 2019–2020, 170 physicians provided service in Nunavut.

Insured physician services refer to all services rendered by medical practitioners that are medically required. Where insured services are unavailable in some places in Nunavut, the patient is referred to another jurisdiction to obtain the insured service. Nunavut has health service agreements with medical and treatment centres in Ottawa, Winnipeg, Churchill, Yellowknife and Edmonton. These are the out-of-territory sites to which Nunavut mainly refers its patients to access medical services not available within the territory.

The following is a list of common insured categories as per Nunavut's Medical Care Regulations. Services provided under these categories are considered insured if the medically required diagnosis and/or treatment is provided in-territory or out-of-territory.

The addition or deletion of insured physician services requires government approval. For this, the Director of Medical Insurance would become involved in negotiations with a collective group of physicians to discuss the service. Then the decision of the group would be presented to Cabinet for approval. No insured physician services were added or removed in 2019–2020.

2.3 Insured Surgical-Dental Services

Dentists providing insured surgical-dental services under the Nunavut Health Care Plan must be licensed pursuant to the Dental Professions Act (NWT, 1988 and as duplicated for Nunavut by section 29 of the Nunavut Act, 1999). Billing numbers are provided for billing the Plan regarding the provision of insured dental services.

Insured dental services are limited to those dental-surgical procedures scheduled in the Regulations, requiring the unique capabilities of a hospital for their performance; for example, orthognathic surgery. The Department insures all dental-surgical services outlined in provincial/territorial reciprocal billing agreements. Oral surgeons are brought to Nunavut on a regular basis, but on rare occasions, for medically complicated situations, patients are flown out of the territory. Dentists travelling to Nunavut to deliver services are under contract with the Government of Nunavut and do not have the option to opt-out.

The addition of new surgical-dental services to the list of insured services requires government approval. No new services were added to the list in 2019–2020.

2.4 Uninsured Hospital, Physician and Surgical-Dental Services

Services provided under the Workers' Compensation Act (NWT, 1988 and as duplicated for Nunavut by section 29 of the Nunavut Act, 1999) or other acts of Canada, except the Canada Health Act, are excluded.

Services provided by physicians that are not insured include:

Services not covered in a hospital include:

In 2019–2020, the Qikiqtani General Hospital charged a $2,638 per diem rate for services provided for non-Canadian resident stays. The in-patient rate charged in Rankin Inlet and Cambridge Bay was $1,482 per day.

When residents are sent out-of-territory for services, the Department relies on the policies and procedures guiding that particular jurisdiction when they provide services to Nunavut residents that could result in additional costs, only to the extent that these costs are covered by Nunavut's Medical Insurance Plan (see section 4.2 below). Any query or complaint is handled on an individual basis with the jurisdiction involved.

The Department also administers the Non-Insured Health Benefits (NIHB) Program, on behalf of Indigenous Services Canada, for Inuit and First Nations residents in Nunavut. NIHB covers a co-payment for medical travel, accommodations and meals at boarding homes (in Ottawa, Winnipeg, Churchill, Edmonton, Yellowknife and Iqaluit), prescription drugs, dental treatment, vision care, medical supplies and prostheses, and a number of other incidental services.

3.0 Universality

3.1 Eligibility

Eligibility for the Nunavut Health Care Plan is briefly defined under sections 3(1), (2), and (3) of the Medical Care Act. The Department of Health (the Department) also adheres to the Interprovincial Agreement on Eligibility and Portability, as well as internal guidelines. No amendments were made to the Act or Regulations in 2019–2020.

Subject to these provisions, every Nunavut resident is eligible for and entitled to insured health services on uniform terms and conditions. A resident means a person lawfully entitled to be in or to remain in Canada, who makes their home and is ordinarily present in Nunavut, but does not include a tourist, transient or visitor to Nunavut. Eligible residents receive a health card with a unique health care number.

Registration requirements include a completed application form and supporting documentation. A health care card is issued to each resident. To streamline document processing, a staggered renewal process is used. No premiums exist. Coverage under the Nunavut Medical Insurance Plan is linked to verification of registration, although every effort is made to ensure registration occurs when a coverage issue arises for an eligible resident. For non-residents, a valid health care card from their home province or territory is required.

Coverage generally begins the first day of the third month after arrival in Nunavut, but first-day coverage is provided under a number of circumstances, for example, newborns whose mothers or fathers are eligible for coverage. Permanent residents (landed immigrants), returning Canadians, repatriated Canadians, returning permanent residents, and non-Canadians who have been issued an employment visa for a period of 12 months or more, are also granted first-day coverage.

Members of the Canadian Armed Forces and inmates of a federal penitentiary are not eligible for registration. These groups are granted first-day coverage under the Nunavut Health Care Plan upon discharge.

Pursuant to section 7 of the Interprovincial Agreement on Eligibility and Portability, individuals in Nunavut who are temporarily absent from their home province or territory and who are not establishing residency in Nunavut remain covered by their home provincial or territorial health insurance plans for up to one year.

On March 31, 2020, 38,997 individuals were registered with the Nunavut Health Care Plan, an increase of 173 from the previous year. There are no formal provisions for Nunavut residents to opt-out of the Nunavut Health Care Plan, and no legislated appeals process or policy related to appeals of residency or coverage decisions.

3.2 Other Categories of Individuals

Categories of individuals not eligible for coverage include:

Children born out-of-country to Canadian citizens are covered only when they return to Nunavut. Returning residents (whose residency has expired) would be covered if proof of residency is provided.

When unique circumstances occur, assessments are done on an individual basis. This is consistent with section 15 of the Northwest Territories' Guidelines for Health Care Plan Registration, which was adopted by Nunavut in 1999.

4.0 Portability

4.1 Minimum Waiting Period

Consistent with section 3 of the Interprovincial Agreement on Eligibility and Portability, the waiting period before coverage begins for individuals moving within Canada is three months, or the first day of the third month following the establishment of residency in a new province or territory, or the first day of the third month when an individual, who has been temporarily absent from his or her home province, decides to take up permanent residency in Nunavut.

4.2 Coverage during Temporary Absences in Canada

The Medical Care Act, section 4(2), prescribes the benefits payable where insured medical services are provided outside Nunavut, but within Canada. The Hospital Insurance and Health and Social Services Administration Act, sections 5(d) and 28(1)(j)(o), provide the authority for the Minister of Health to enter into agreements with other jurisdictions to provide health services to Nunavut residents, and the terms and conditions of payment. No legislative or regulatory changes were made in 2019–2020 with respect to coverage outside Nunavut.

Students studying outside Nunavut must notify the Department of Health (the Department) and provide proof of enrollment to ensure continuing coverage. Requests for extensions must be renewed yearly and are subject to approval by the Director of Medical Insurance (the Director). Temporary absences for work, vacation or other reasons for up to one year are approved by the Director upon receipt of a written request from the insured person. The Director may approve absences in excess of 12 continuous months upon receiving a written request from the insured individual.

The provisions regarding coverage during temporary absences in Canada fully comply with the terms and conditions of the Interprovincial Agreement on Eligibility and Portability. Nunavut participates in physician and hospital reciprocal billing. As well, special bilateral agreements are in place with Ontario, Manitoba, Alberta, and the Northwest Territories. The Hospital Reciprocal Billing Agreements provide payment of in-patient and out-patient hospital services to eligible Nunavut residents receiving insured services out-of-territory. High-cost procedure rates, newborn rates, and out-patient rates are based on those established by the Interprovincial Health Insurance Agreements Coordinating Committee. The Physician Reciprocal Billing Agreements provide payment of insured physician services on behalf of eligible Nunavut residents receiving insured services out-of-territory. Payment is made to the host province or territory at the rates established by that province or territory.

4.3 Coverage during Temporary Absences outside Canada

The Medical Care Act, section 4(3), prescribes the benefits payable where insured medical services are provided outside Canada. The Hospital Insurance and Health and Social Services Administration Act, section 28(1)(j)(o), provides the authority for the Minister to set the terms and conditions of payment for services provided to Nunavut residents outside Canada. No amendments were made in 2019-2020 to either Act respectively. Nunavut residents are granted coverage for up to one year if they are temporarily out of the country for any reason, although they must give prior notice in writing. No exceptions are made to this process for specific categories of individuals as all cases are addressed individually. For services provided to residents who have been referred out-of-country for highly specialized procedures unavailable in Nunavut and Canada, Nunavut will pay the full cost. For non-referred or emergency services, the payment for hospital services is $2,638 per day and for out-patient care it is $359 per day.

Insured physician services provided to eligible residents temporarily outside the country are paid at rates equivalent to those paid had that service been provided in the territory. Reimbursement is made to the insured individual or directly to the provider of the insured service.

4.4 Prior Approval Requirement

Prior approval is required to receive reimbursement for elective services provided in private facilities in Canada or in any facility outside the country. There are no processes related to pre-approval appeals for out-of-jurisdiction coverage.

5.0 Accessibility

5.1 Access to Insured Health Services

The Medical Care Act, section 14, prohibits extra-billing by physicians unless the medical practitioner has made an election that is still in effect. Access to insured services is provided on uniform terms and conditions. To break down the barrier posed by distance and cost of travel, the Government of Nunavut provides medical travel assistance. Interpretation services in Inuktut are also provided to patients. The Department of Health (the Department) does not have a specific complaints office solely for extra-billing. However, the Department has other mechanisms for Nunavummiut to register concerns regarding their health care service and can be reached at:

NHIP@gov.nu.ca
Nunavut Health Insurance Programs Office Department of Health
Box 889
Rankin Inlet, NU X0C 0G0 Toll Free: 1 (800) 661-0833

Concerns raised regarding extra-billing that have occurred within Nunavut are fully investigated and addressed with disciplinary action if warranted. If extra-billing has occurred out-of-territory, it is up to the jurisdiction where it has occurred to investigate and address.

The Qikiqtani General Hospital, a site of Iqaluit Health Services is currently the only acute care hospital facility in Nunavut. The hospital has a total of 20 beds available for acute, medical, surgical, pediatric, rehabilitative, palliative and chronic care services. There are also four birthing rooms and four day surgery beds. The facility provides in-patient, out-patient and 24-hour emergency services. On-site physicians provide emergency services on rotation. Medical services provided include: an ambulatory care/out-patient clinic emergency stabilization services, pediatric services, and general medical, maternity and palliative care. Surgical services provided include ophthalmology, urology, orthopedics, gynaecology, pediatrics, general surgery, emergency trauma, otolaryngology and dental surgery under general anaesthesia and conscious sedation. Patients requiring specialized surgeries are sent to other jurisdictions. Diagnostic services include: radiology, laboratory, electrocardiogram and CT scans.

Outside of Iqaluit, out-patient and 24-hour emergency nursing services are provided by local health centres in Nunavut’s 24 other communities.

Nunavut has three continuing care centres located in Gjoa Haven, Igloolik and Cambridge Bay. These facilities provide full-time nursing and personal care to adults. The Gjoa Haven and Igloolik facilities have 10 beds each, and the Cambridge Bay facility has 8 beds.

Nunavut has agreements in place with a number of out-of-territory regional health authorities and specific facilities to provide medical specialists and other visiting health practitioner services. The following specialist services were provided in Nunavut during 2019–2020 under the visiting specialists program: ophthalmology, orthopedics, internal medicine, otolaryngology, neurology, rheumatology, dermatology, pediatrics, obstetrics/gynecology, urology, respirology, cardiology, total joint assessment clinic (TJAC), sleep study, oral surgery, and allergist. Visiting specialist clinics are scheduled in advance, and are offered on specific weeks throughout the year.

Nunavut’s Telehealth network, linking all 25 communities, allows for the delivery of a broad range of services over distances including specialist consultation services such as dermatology, psychiatry and internal medicine; rehabilitation services; regularly scheduled counseling sessions; family visitation; and continuing medical education. The long-term goal is to integrate Telehealth into the primary care delivery system, enabling residents of Nunavut greater access to a broader range of service options, and allowing service providers and communities to use existing resources more effectively.

For services and equipment unavailable in Nunavut, patients are referred to other jurisdictions.

 5.2 Physician Compensation

All full-time physicians in Nunavut work under contract with the Department. The Medical Care Act S.5.1(1) states “the Director, In accordance with this Act and the regulations, may enter into agreements, as the Director considers necessary, for services, including insured services, provided on an other than fee-for-service basis. The terms of the contracts are set by the Department. Visiting consultants are paid a daily contract rate for their professional services. Rates vary based on services rendered. The Department complies with the Financial Administration Act and Financial Administration Manual in monitoring or auditing remuneration.

5.3 Payments to Hospitals

Funding for the Qikiqtani General Hospital, regional health facilities and community health centres is provided through the Government of Nunavut’s budget process.

6.0 Recognition Given to Federal Transfers

Nunavummiut are aware of ongoing federal contributions through press releases and media coverage. The Government of Nunavut has also recognized the federal contribution provided through the Canada Health Transfer in various published documents. For fiscal year 2019–2020, they included the 2019–2020 Fiscal and Economic Indicators and the 2019–2022 Government of Nunavut and Territorial Corporations Business Plan.

Registered Persons
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
1. Number as of March 31stNunavut table 1 Footnote 1 37,764 38,662 39,293 38,824 38,997
Nunavut table 1 Footnote 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.

Return to footnote 1 referrer
Insured Hospital Services Within Own Province or Territory
Public Facilities 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
2. Number 28 28 28 28 28
3. Payments for insured health services ($)
 Not available Not available Not available Not available Not available
Private For-Profit Facilities 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
4. Number of private for-profit facilities providing insured health services 0 0 0 0 0
5. Payments to private for-profit facilities for insured health services ($)  0 0 0 0 0
Insured Hospital Services Provided to Residents in Another Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
6. Total number of claims, in-patient 3,324 3,616 3,791 3,976 4,139
7. Total payments, in-patient ($) 38,830,531 40,804,893 44,156,008 44,160,583 48,802,196
8. Total number of claims, out-patient 24,853 26,790 27,480 26,493 28,096
9. Total payments, out-patient ($) 9,638,408 11,369,138 12,178,482 12,337,509 12,961,710
Insured Hospital Services Provided Outside CanadaNunavut table 4 Footnote 1
Pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
10. Total number of claims, in-patient Not available Not available Not available Not available Not available
11. Total payments, pre-approved  ($) Not available Not available Not available Not available Not available
12. Total number of claims, out-patient Not available Not available Not available Not available Not available
13. Total payments, out-patient ($) Not available Not available Not available Not available Not available
Non pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
14. Total number of claims, in-patient Not available Not available Not available Not available Not available
15. Total payments, in-patient ($) Not available Not available Not available Not available Not available
16. Total number of claims, out-patient Not available Not available Not available Not available Not available
17. Total payments, out-patient ($) Not available Not available Not available Not available Not available
Nunavut table 4 Footnote 1

Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report, but did not require provinces or territories to report on previous years.

Nunavut table 4 Return to footnote 1 referrer
Insured Physician Services Within Own Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
18. Number of participating physicians 278 155 139 137 177Nunavut table 5 Footnote 1
19. Number of opted-out physicians 0 0 0 0 0
20. Number of non-participating physicians 0 0 0 0 0
21. Total payments for services provided by physicians paid through all payment methods ($) Not available Not available Not available Not available Not available
22. Total payments for services provided by physicians paid through fee-for-service ($)Nunavut table 5 Footnote 2 152,815 502,572 565,111 574,179 870,135
Nunavut table 5 Footnote 1

This figure captures the number of general practitioners providing services in Nunavut. The total does not include specialist services.

Nunavut table 5 Return to footnote 1 referrer

Nunavut table 5 Footnote 2

Typically, Nunavut does not pay its physicians through fee-for-service. Instead, the majority of physicians are compensated through contracted salaries.

Nunavut table 5 Return to footnote 2 referrer
Insured Physician Services Provided to Residents in Another Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
23. Number of services 93,365 99,539 107,416 121,456 128,069
24. Total payments ($) 8,088,273 8,694,011 9,162,104 9,899,822Nunavut table 6 Footnote 1 10,208,947
Nunavut table 6 Footnote 1

This figure captures the number of general practitioners providing services in Nunavut. The total does not include specialist services.

Nunavut table 6 Return to footnote 1 referrer
Insured Physician Services Provided Outside CanadaNunavut table 7 Footnote 1
Pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
25. Number of services Not applicable Not applicable Not applicable Not applicable Not applicable
26. Total payments ($) Not applicable Not applicable Not applicable Not applicable Not applicable
Non pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
27. Number of services Not applicable Not applicable Not applicable 7 9
28. Total payments ($) Not applicable Not applicable Not applicable 530 496
Nunavut table 7 Footnote 1

Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report, but did not require provinces or territories to report on previous years.

Nunavut table 7 Return to footnote 1 referrer
Insured Surgical-Dental Services Within Own Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
29. Number of participating dentists Not available Not available Not available Not available Not available
30. Number of opted-out dentistsNunavut table 8 Footnote 1 Not available Not available Not available Not available Not available
31. Number of non-participating dentistsNunavut table 8 Footnote 1 Not available Not available Not available Not available Not available
32. Number of services provided Not available Not available Not available Not available Not available
33. Total payments ($) Not available Not available Not available Not available Not available
Nunavut table 8 Footnote 1

Health Canada requested this data as of the 2016-2017 report, but did not require provinces or territories to report data for 2015-16.

Nunavut table 8 Return to footnote 1 referrer

Annex A - Canada Health Act and Extra-Billing and User Charges Information Regulations

This annex provides the reader with an office consolidation of the Canada Health Act and the Extra-billing and User Charges Information Regulations. An office consolidation is a rendering of the original Act, which includes any amendments that have been made since the Act's passage. The only regulations in force under the Act are the Extra-billing and User Charges Information Regulations. These Regulations require the provinces and territories to provide estimates of extra-billing and user charges prior to the beginning of each fiscal year so that appropriate penalties can be levied, as well as financial statements showing the amounts actually charged so that reconciliations with any estimated charges can be made. These Regulations are also presented in an office consolidation format. This unofficial consolidation is not necessarily current and is provided for the convenience of the reader only. For the official text of the Canada Health Act, please contact Justice Canada.

Links to Canada Health Act and Regulations:

Annex B - Policy Interpretation Letters

There are three key policy statements that clarify the federal position on the Canada Health Act. These statements were made in the form of ministerial letters from former federal Health Ministers to their provincial and territorial counterparts.

[Following is the text of the letter sent on June 18, 1985, to all provincial and territorial Ministers of Health by the Honourable Jake Epp, federal Minister of Health and Welfare. (Note: Minister Epp sent the French equivalent of this letter to Quebec on July 15, 1985.) ]

June 18, 1985

OTTAWA, K1A 0K9

Dear Minister:

Having consulted with all provincial and territorial Ministers of Health over the past several months, both individually and at the meeting in Winnipeg on May 16 and 17, I would like to confirm for you my intentions regarding the interpretation and implementation of the Canada Health Act. I would particularly appreciate if you could provide me with a written indication of your views on the attached proposals for regulations in order that I may act to have these officially put in place as soon as conveniently possible. Also, I will write to you further with regard to the material I will need to prepare the required annual report to Parliament.

As indicated at our meeting in Winnipeg, I intend to honour and respect provincial jurisdiction and authority in matters pertaining to health and the provision of health care services. I am persuaded, by conviction and experience, that more can be achieved through harmony and collaboration than through discord and confrontation.

With regard to the Canada Health Act, I can only conclude from our discussions that we together share a public trust and are mutually and equally committed to the maintenance and improvement of a universal, comprehensive, accessible and portable health insurance system, operated under public auspices for the benefit of all residents of Canada.

Our discussions have reinforced my belief that you require sufficient flexibility and administrative versatility to operate and administer your health care insurance plans. You know far better than I ever can, the needs and priorities of your residents, in light of geographic and economic considerations. Moreover, it is essential that provinces have the freedom to exercise their primary responsibility for the provision of personal health care services.

At the same time, I have come away from our discussions sensing a desire to sustain a positive federal involvement and role—both financial and otherwise—to support and assist provinces in their efforts dedicated to the fundamental objectives of the health care system: protecting, promoting and restoring the physical and mental well-being of Canadians. As a group, provincial/territorial Health Ministers accept a co-operative partnership with the federal government based primarily on the contributions it authorizes for purposes of providing insured and extended health care services.

I might also say that the Canada Health Act does not respond to challenges facing the health care system. I look forward to working collaboratively with you as we address challenges such as rapidly advancing medical technology and an aging population and strive to develop health promotion strategies and health care delivery alternatives.

Returning to the immediate challenge of implementing the Canada Health Act, I want to set forth some reasonably comprehensive statements of federal policy intent, beginning with each of the criteria contained in the Act.

Public Administration

This criterion is generally accepted. The intent is that the provincial health care insurance plans be administered by a public authority, accountable to the provincial government for decision-making on benefit levels and services, and whose records and accounts are publicly audited.

Comprehensiveness

The intent of the Canada Health Act is neither to expand nor contract the range of insured services covered under previous federal legislation. The range of insured services encompasses medically necessary hospital care, physician services and surgical-dental services which require a hospital for their proper performance. Hospital plans are expected to cover in-patient and out-patient hospital services associated with the provision of acute, rehabilitative and chronic care. As regards physician services, the range of insured services generally encompasses medically required services rendered by licensed medical practitioners as well as surgical-dental procedures that require a hospital for proper performance. Services rendered by other health care practitioners, except those required to provide necessary hospital services, are not subject to the Act's criteria.

Within these broad parameters, provinces, along with medical professionals, have the prerogative and responsibility for interpreting what physician services are medically necessary. As well, provinces determine which hospitals and hospital services are required to provide acute, rehabilitative or chronic care.

Universality

The intent of the Canada Health Act is to ensure that all bonafide residents of all provinces be entitled to coverage and to the benefits under one of the twelve provincial/territorial health care insurance plans. However, eligible residents do have the option not to participate under a provincial plan should they elect to do so.

The Agreement on Eligibility and Portability provides some helpful guidelines with respect to the determination of residency status and arrangements for obtaining and maintaining coverage. Its provisions are compatible with the Canada Health Act.

I want to say a few words about premiums. Unquestionably, provinces have the right to levy taxes and the Canada Health Act does not infringe upon that right. A premium scheme per se is not precluded by the Act, provided that the provincial health care insurance plan is operated and administered in a manner that does not deny coverage or preclude access to necessary hospital and physician services to bonafide residents of a province. Administrative arrangements should be such that residents are not precluded from or do not forego coverage by reason of an inability to pay premiums.

I am acutely aware of problems faced by some provinces in regard to tourists and visitors who may require health services while travelling in Canada. I will be undertaking a review of the current practices and procedures with my Cabinet colleagues, the Minister of External Affairs, and the Minister of Employment and Immigration, to ensure all reasonable means are taken to inform prospective visitors to Canada of the need to protect themselves with adequate health insurance coverage before entering the country.

In summary, I believe all of us as Ministers of Health are committed to the objective of ensuring that all duly qualified residents of a province obtain and retain entitlement to insured health services on uniform terms and conditions.

Portability

The intent of the portability provisions of the Canada Health Act is to provide insured persons continuing protection under their provincial health care insurance plan when they are temporarily absent from their province of residence or when moving from province to province. While temporarily in another province of Canada, bonafide residents should not be subject to out-of-pocket costs or charges for necessary hospital and physician services. Providers should be assured of reasonable levels of payment in respect of the cost of those services.

Insofar as insured services received while outside of Canada are concerned, the intent is to assure reasonable indemnification in respect of the cost of necessary emergency hospital or physician services or for referred services not available in a province or in neighbouring provinces. Generally speaking, payment formulae tied to what would have been paid for similar services in a province would be acceptable for purposes of the Canada Health Act.

In my discussions with provincial/territorial Ministers, I detected a desire to achieve these portability objectives and to minimize the difficulties that Canadians may encounter when moving or travelling about in Canada. In order that Canadians may maintain their health insurance coverage and obtain benefits or services without undue impediment, I believe that all provincial/territorial Health Ministers are interested in seeing these services provided more efficiently and economically.

Significant progress has been made over the past few years by way of reciprocal arrangements which contribute to the achievement of the in-Canada portability objectives of the Canada Health Act. These arrangements do not interfere with the rights and prerogatives of provinces to determine and provide the coverage for services rendered in another province. Likewise, they do not deter provinces from exercising reasonable controls through prior approval mechanisms for elective procedures. I recognize that work remains to be done respecting interprovincial payment arrangements to achieve this objective, especially as it pertains to physician services.

I appreciate that all difficulties cannot be resolved overnight and that provincial plans will require sufficient time to meet the objective of ensuring no direct charges to patients for necessary hospital and physician services provided in other provinces.

For necessary services provided out-of-Canada, I am confident that we can establish acceptable standards of indemnification for essential physician and hospital services. The legislation does not define a particular formula and I would be pleased to have your views.

In order that our efforts can progress in a coordinated manner, I would propose that the Federal-Provincial Advisory Committee on Institutional and Medical Services be charged with examining various options and recommending arrangements to achieve the objectives within one year.

Reasonable Accessibility

The Act is fairly clear with respect to certain aspects of accessibility. The Act seeks to discourage all point-of-service charges for insured services provided to insured persons and to prevent adverse discrimination against any population group with respect to charges for, or necessary use of, insured services. At the same time, the Act accents a partnership between the providers of insured services and provincial plans, requiring that provincial plans have in place reasonable systems of payment or compensation for their medical practitioners in order to ensure reasonable access to users. I want to emphasize my intention to respect provincial prerogatives regarding the organization, licensing, supply, distribution of health manpower, as well as the resource allocation and priorities for health services. I want to assure you that the reasonable access provision will not be used to intervene or interfere directly in matters such as the physical and geographic availability of services or provincial governance of the institutions and professions that provide insured services. Inevitably, major issues or concerns regarding access to health care services will come to my attention. I want to assure you that my Ministry will work through and with provincial/territorial Ministers in addressing such matters.

My aim in communicating my intentions with respect to the criteria in the Canada Health Act is to allow us to work together in developing our national health insurance scheme. Through continuing dialogue, open and willing exchange of information and mutually understood rules of the road, I believe that we can implement the Canada Health Act without acrimony and conflict. It is my preference that provincial/territorial Ministers themselves be given an opportunity to interpret and apply the criteria of the Canada Health Act to their respective health care insurance plans. At the same time, I believe that all provincial/territorial Health Ministers understand and respect my accountability to the Parliament of Canada, including an annual report on the operation of provincial health care insurance plans with regard to these fundamental criteria.

Conditions

This leads me to the conditions related to the recognition of federal contributions and to the provision of information, both of which may be specified in regulations. In these matters, I will be guided by the following principles:

  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, comprehensiveness, universality, portability and accessibility) continue to enjoy the support of all provincial and territorial governments. This support is shared by the vast majority of Canadians. At a time when there is concern about the potential erosion of the publicly funded and publicly administered health care system, it is vital to safeguard these principles.

As was evident and a concern to many of us at the recent Halifax meeting, a trend toward divergent interpretations of the Act is developing. While I will deal with other issues at the end of this letter, my primary concern is with private clinics and facility fees. The issue of private clinics is not new to us as Ministers of Health; it formed an important part of our discussions in Halifax last year. For reasons I will set out below, I am convinced that the growth of a second tier of health care facilities providing medically necessary services that operate, totally or in large part, outside the publicly funded and publicly administered system, presents a serious threat to Canada's health care system.

Specifically, and most immediately, I believe the facility fees charged by private clinics for medically necessary services are a major problem which must be dealt with firmly. It is my position that such fees constitute user charges and, as such, contravene the principle of accessibility set out in the Canada Health Act.

While there is no definition of facility fees in federal or most provincial legislation, the term, generally speaking, refers to amounts charged for non-physician (or "hospital") services provided at clinics and not reimbursed by the province. Where these fees are charged for medically necessary services in clinics which receive funding for these services under a provincial health insurance plan, they constitute a financial barrier to access. As a result, they violate the user charge provision of the Act (section 19).

Facility fees are objectionable because they impede access to medically necessary services. Moreover, when clinics which receive public funds for medically necessary services also charge facility fees, people who can afford the fees are being directly subsidized by all other Canadians. This subsidization of two-tier health care is unacceptable.

The formal basis for my position on facility fees is twofold. The first is a matter of policy. In the context of contemporary health care delivery, an interpretation which permits facility fees for medically necessary services so long as the provincial health insurance plan covers physician fees runs counter to the spirit and intent of the Act. While the appropriate pro-vision of many physician services at one time required an overnight stay in a hospital, advances in medical technology and the trend toward providing medical services in more accessible settings has made it possible to offer a wide range of medical procedures on an out-patient basis or outside of full-service hospitals. The accessibility criterion in the Act, of which the user charge provision is just a specific example, was clearly intended to ensure that Canadian residents receive all medically necessary care without financial or other barriers and regardless of venue. It must continue to mean that as the nature of medical practice evolves.

Second, as a matter of legal interpretation, the definition of "hospital" set out in the Act includes any facility which provides acute, rehabilitative or chronic care. This definition covers those health care facilities known as "clinics". As a matter of both policy and legal interpretation, therefore, where a provincial plan pays the physician fee for a medically necessary service delivered at a clinic, it must also pay for the related hospital services provided or face deductions for user charges.

I recognize that this interpretation will necessitate some changes in provinces where clinics currently charge facility fees for medically necessary services. As I do not wish to cause undue hardship to those provinces, I will commence enforcement of this interpretation as of October 15, 1995. This will allow the provinces the time to put into place the necessary legislative or regulatory framework. As of October 15, 1995, I will proceed to deduct from transfer payments any amounts charged for facility fees in respect of medically necessary services, as mandated by section 20 of the Canada Health Act. I believe this provides a reasonable transition period, given that all provinces have been aware of my concerns with respect to private clinics for some time, and given the promising headway already made by the Federal/Provincial/Territorial Advisory Committee on Health Services, which has been working for some time now on the issue of private clinics.

I want to make it clear that my intent is not to preclude the use of clinics to provide medically necessary services. I realize that in many situations they are a cost-effective way to deliver services, often in a technologically advanced manner. However, it is my intention to ensure that medically necessary services are provided on uniform terms and conditions, wherever they are offered. The principles of the Canada Health Act are supple enough to accommodate the evolution of medical science and of health care delivery. This evolution must not lead, however, to a two-tier system of health care.

I indicated earlier in this letter that, while user charges for medically necessary services are my most immediate concern, I am also concerned about the more general issues raised by the proliferation of private clinics. In particular, I am concerned about their potential to restrict access by Canadian residents to medically necessary services by eroding our publicly funded system. These concerns were reflected in the policy statement which resulted from the Halifax meeting. Ministers of Health present, with the exception of the Alberta Minister, agreed to:

take whatever steps are required to regulate the development of private clinics in Canada, and to maintain a high quality, publicly funded medicare system.

Private clinics raise several concerns for the federal government, concerns which provinces share. These relate to:

The only way to deal effectively with these concerns is to regulate the operation of private clinics.

I now call on Ministers in provinces which have not already done so to introduce regulatory frameworks to govern the operation of private clinics. I would emphasize that, while my immediate concern is the elimination of user charges, it is equally important that these regulatory frameworks be put in place to ensure reasonable access to medically necessary services and to support the viability of the publicly funded and administered system in the future. I do not feel the implementation of such frameworks should be long delayed.

I welcome any questions you may have with respect to my position on private clinics and facility fees. My officials are willing to meet with yours at any time to discuss these matters. I believe that our officials need to focus their attention, in the coming weeks, on the broader concerns about private clinics referred to above.

As I mentioned at the beginning of this letter, divergent interpretations of the Canada Health Act apply to a number of other practices. It is always my preference that matters of interpretation of the Act be resolved by finding a Federal/Provincial/Territorial consensus consistent with its fundamental principles. I have therefore encouraged F/P/T consultations in all cases where there are disagreements. In situations such as out-of-province or out-of-country coverage, I remain committed to following through on these consultative processes as long as they continue to promise a satisfactory conclusion in a reasonable time.

In closing, I would like to quote Mr. Justice Emmett M. Hall. In 1980, he reminded us:

"we, as a society, are aware that the trauma of illness, the pain of surgery, the slow decline to death, are burdens enough for the human being to bear without the added burden of medical or hospital bills penalizing the patient at the moment of vulnerability."

I trust that, mindful of these words, we will continue to work together to ensure the survival, and renewal, of what is perhaps our finest social project.

As the issues addressed in this letter are of great concern to Canadians, I intend to make this letter publicly available once all provincial Health Ministers have received it.

Yours sincerely,

Diane Marleau
Minister of Health

[Following is the text of the letter sent on August 8, 2018, to all provincial and territorial Ministers of Health by the federal Minister of Health, the Honourable Ginette Petitpas Taylor.]

Dear Minister,

It was a pleasure to see you recently at our Federal/Provincial/Territorial Health Ministers' Meeting in Winnipeg.  As I have explained, when I was appointed as federal Health Minister, the Prime Minister tasked me with promoting and defending the Canada Health Act and quite specifically with eliminating patient charges for services that should be publicly insured.  As you are aware, I have taken this responsibility seriously. 

Following our conversations earlier this year, I was pleased to hear that all provinces and territories participated in officials' level discussions convened by Health Canada this Spring.  We fine-tuned our approach based on the feedback provided in a series of multi- and bilateral meetings. 

The purpose of this letter is to formally advise that I am proceeding with the three Canada Health Act initiatives I discussed with you.  Taken together, the Diagnostic Services Policy, the Reimbursement Policy, and strengthened reporting, will provide me with tools to effectively administer the Act in the interest of all Canadians.

Diagnostic Services Policy

One of the overarching objectives of the Canada Health Act is to ensure that Canadians have access to medically necessary care based on their health needs and not their ability or willingness to pay.  However, in many jurisdictions patients are charged for medically necessary diagnostic services provided at private clinics.  Since the inception of the Canada Health Act, the federal position has always been that all medically necessary physician and hospital services – including diagnostic services – must be covered by provincial and territorial health insurance plans.

If an authorized provider has referred a patient for a medically necessary diagnostic test, the status of the procedure as a publicly insured service should not change simply because the service is delivered in a private clinic rather than in a hospital.  I do not accept the premise that since some patients are willing to pay for expedited access to medically necessary services, they should be provided with a venue to do so.  This practice results in patients jumping the queue twice – first, for the diagnostic service itself and then for any follow-up care that may be required.  Simply put, this is not fair and goes against the fundamental principle of Canadian health care – that is, that access should be based on health need, not on the ability or willingness, to pay.

The Canada Health Act does not preclude the private delivery of insured services.  Many insured health services are provided to Canadians in private clinics and are paid for by the provincial or territorial health insurance plan.  As long as there are no patient charges, provinces and territories can provide insured services as they best see fit.  However, my clarification of the status of medically necessary diagnostic services through this letter means, in effect, that any charges to patients for these services will be considered to be in contravention of the Canada Health Act.

I fully appreciate that it may take time in some jurisdictions to align provincial and territorial systems with the Diagnostic Services Policy.  As I indicated in Winnipeg, the policy will not take effect until April 1, 2020 and reporting on any patient charges for diagnostic services will begin in December 2022 (for the fiscal year 2020-21).  That would mean, in accordance with the Canada Health Act, that any Canada Health Transfer deductions would only be made in March 2023.  If, in the interim, a jurisdiction has eliminated patient charges for diagnostic services, that jurisdiction would be eligible for reimbursement of deducted funds through the new Reimbursement Policy.

Reimbursement Policy

The Canada Health Act was enacted to eliminate the unfair practice of patient charges. The Act is clear – when a province allows patient charges, mandatory deductions to federal transfer payments must be made.  During the first three years of the Canada Health Act, a provision in the Act allowed deductions to be refunded if the jurisdiction took the necessary steps to eliminate patient charges for services which should be publicly insured.  This proved effective, and by 1987, patient charges were eliminated for most hospital and physician services across Canada. However, when this refund provision expired, the incentive structure under the Act went from a positive one, to a purely negative one.  I believe this needs to change.

With the aim of emulating the success of the original refund provision, I am introducing a new Reimbursement Policy. Going forward, provinces and territories would be eligible to be reimbursed for deductions taken in respect of patient charges, should they demonstrate they have taken action to remove these barriers to access.  The attached document provides details on the scope and application of the Policy.  Any deductions made starting from March 2018 will be eligible for reimbursement under this Policy.

Strengthened Reporting

Finally, in order to ensure that I have the information needed to administer the Act in an even-handed manner and in order to report to Canadians on the state of their publicly funded health care insurance system, reporting from provinces and territories to Health Canada and from Health Canada to Canadians will be strengthened and standardized.  Details, which were discussed with your officials this past Spring, will be communicated by my Deputy in the coming weeks.  Again, respecting that a new approach cannot be instituted overnight, we will phase in the new reporting measures.

Canadians are rightfully proud of their health care system and have high expectations that their governments will work together to protect their access to it.  I am confident these initiatives will help us meet that challenge and will safeguard our universal health care system for future generations.

I have appreciated our discussions to date and look forward to ongoing collaboration.

Yours sincerely,The Honourable Ginette Petitpas Taylor, P.C., M.P.

Reimbursement Policy for Provinces and Territories- Subject to Deductions under the Canada Health Act (the Reimbursement Policy)

Background

A fundamental premise of the Canadian health care system is that Canadians should have access to medically necessary physician and hospital services unimpeded by financial or other barriers. The Canada Health Act (CHA) was enacted in response to a growing concern that access to publicly insured health care services was increasingly undermined by point of service charges to patients.

The CHA established the conditions and criteria provinces must meet in order to qualify for their full cash contribution under the Canada Health Transfer (CHT). The Act also established discretionary and mandatory deductions for violations of the CHA principles and the extra-billing and user chargesFootnote 5 (EBUC) provisions of the Act, respectively. The Minister is required to make dollar-for-dollar deductions to a province's or territory's (PT's) CHT payments when EBUC are permitted. The intent of the CHA with respect to deductions is to encourage compliance with the Act and its objective of ensuring Canadians' access to health care services on uniform terms and conditions and without financial barriers.

At the time the CHA came into force, many jurisdictions had legal frameworks for public health insurance which either explicitly allowed EBUC to be levied on patients, or, by convention, had permitted such fees to become entrenched in their health care systems. In view of these factors, it was acknowledged that it would take time for PTs to align their systems with the values and requirements of the CHA. The Act, therefore, included a provision for the first three years (1984-1987) which, in effect, provided refunds of amounts deducted from federal transfers for EBUC violations once the PT succeeded in eliminating EBUC.

PTs adopted legislation governing their public health insurance systems which mirrored, and in most cases went well beyond, the requirements of the CHA. As a result, over $244 million was refunded to seven PTs in respect of patient charges levied in the 1984-1987 period. The advent of the CHA, including the refund provision, helped eliminate EBUC for a considerable period of time in most parts of the country and in most care settings.

Time for a New Reimbursement Policy

Despite provisions discouraging or prohibiting EBUC in both federal and PT legislation, there are still instances of patients paying for access to insured health care services in some jurisdictions. As was the case in 1984, these charges put at risk the fundamental value of universal access to health care.

Some jurisdictions have been active in investigating allegations of patient charges, adopting legislative and regulatory measures to deter EBUC, ensuring that patients are reimbursed and that providers or institutions who contravene PT law (and the CHA) are disciplined. These governments are to be commended for their vigilance on behalf of patients.

Given the success of the original refund provision of the CHA in eliminating EBUC, the federal government is implementing a new Reimbursement Policy for Provinces and Territories Subject to Deductions under the Canada Health Act (the Reimbursement Policy). Under this new policy, if a province or territory is subject to a deduction, the federal Minister of Health has the discretion to provide a reimbursement if the PT comes into compliance with the Act by the end of the calendar year.

Current Process

Under the CHA's Extra-billing and User Charges Information Regulations (the Regulations), PTs are obligated to report to Health Canada on EBUC occurring within their jurisdiction. This takes the form of a financial statement submitted each year, by December 16, which describes any EBUC activity occurring in the fiscal year two years previous. If the Minister does not receive a statement, or believes the information was not provided in accordance with the Regulations, the Act obligates the Minister to estimate an amount after consultation with the PT. The CHT payments to the jurisdiction are then reduced by a corresponding amount in March of the following year.

Working Together to Eliminate Patient Charges

The objective of the Reimbursement Policy is to work collaboratively with PTs subject to a CHT deduction to ultimately eliminate these patient charges. When a PT is informed it will be subject to a CHT deduction for EBUC (typically in January/February), the conditions for reimbursement will also be outlined. In instances where the PT has already eliminated patient charges and a sufficient period of time has elapsed to assure Health Canada that the circumstances that led to these charges have been addressed, reimbursement may be made immediately. Where such charges are ongoing, Health Canada will work with PT officials on the elements of an action plan to meet the conditions for reimbursement. Action plans, and PT progress on meeting them, will be published in the Canada Health Act Annual Report.

To be considered for reimbursement, the jurisdiction would need to demonstrate it has followed through on the agreed upon action plan within the specified time period – typically 12 months but no more than two years following the initial deduction. Because the circumstances leading to deductions will vary from province to province, so will the action plans. Nonetheless, it is expected that all action plans will require the PT to submit the following documents to Health Canada in the January following the deduction:

Upon review of the jurisdiction's report, if the Minister is satisfied that the elements of the action plan have been fulfilled, the PT would receive a reimbursement. However, if the Minister is not satisfied that the conditions were fulfilled, no reimbursement would occur and the deduction amount would be forfeited. Following an initial deduction and reimbursement cycle, if the Minister remains satisfied that appropriate action has been taken, the Reimbursement Policy would allow for the immediate reimbursement of subsequent CHT deductions.

In order to qualify for continued consideration under the Reimbursement Policy, a PT must also comply with the regular reporting requirements set out in the Regulations and submit an accurate EBUC financial statement to Health Canada in the December following the CHT deduction and commit to doing so on an annual basis going forward.

Annex C- Dispute Avoidance and Resolution Process under the Canada Health Act

In April 2002, the Honourable A. Anne McLellan outlined in a letter to her provincial and territorial counterparts a Canada Health Act Dispute Avoidance and Resolution process, which was agreed to by provinces and territories, except Quebec. The process meets federal and provincial/territorial interests of avoiding disputes related to the interpretation of the criteria of the Canada Health Act, and when this is not possible, resolving disputes in a fair, transparent and timely manner.

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

Where dispute avoidance activities prove unsuccessful, dispute resolution activities may be initiated, beginning with government- to-government fact-finding and negotiations. If these are unsuccessful, either Minister of Health involved may refer the issues to a third party panel to undertake fact-finding and provide advice and recommendations.

The federal Minister of Health has the final authority to interpret and enforce the Canada Health Act. In deciding whether to invoke the non-compliance provisions of the Act, the Minister will take the panel's report into consideration.
In September 2004, the agreement reached between the provinces and territories in 2002 was formalized by First Ministers, thereby reaffirming their commitment to use the Canada Health Act Dispute Avoidance and Resolution process to deal with Canada Health Act interpretation issues.

On the following pages you will find the full text of Minister McLellan's Letter to the Honourable Gary Mar, as well as a fact sheet on the Canada Health Act Dispute Avoidance and Resolution Process.

April 2, 2002

The Honourable Gary Mar, M.L.A.
Minister of Health and Wellness
Province of Alberta
Room 323, Legislature Building
Edmonton, Alberta
T5K 2B6

Dear Mr. Mar:

I am writing in fulfilment of my commitment to move forward on dispute avoidance and resolution as it applies to the interpretation of the principles of the Canada Health Act.

I understand the importance provincial and territorial governments attach to having a third party provide advice and recommendations when differences occur regarding the interpretation of the Canada Health Act. This feature has been incorporated in the approach to the Canada Health Act Dispute Avoidance and Resolution process set out 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:

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 Act Dispute Avoidance and Resolution Process

Scope

The provisions described apply to the interpretation of the principles of the Canada Health Act.

Dispute Avoidance

To avoid and prevent disputes, governments will continue to:

Health Canada commits to provide advance assessments to any province or territory upon request.

Dispute Resolution

Where the dispute avoidance activities between the federal government and a provincial or territorial government prove unsuccessful, either Minister of Health involved may initiate dispute resolution by writing to his or her counterpart. Such a letter would describe the issue in dispute. If initiated, dispute resolution will precede any action taken under the non-compliance provisions of the Act.

As a first step, governments involved in the dispute will, within 60 days of the date of the letter initiating the process, jointly:

If however, there is no agreement on the facts, or if negotiations fail to resolve the issue, any Minister of Health involved in the dispute may initiate the process to refer the issue to a third party panel by writing to his or her counterpart.

The Minister of Health for Canada has the final authority to interpret and enforce the Canada Health Act. In deciding whether to invoke the non-compliance provisions of the Act, the Minister of Health for Canada will take the panel's report into consideration.

Public Reporting

Governments will report publicly on Canada Health Act dispute avoidance and resolution activities, including any panel report.

Review

Should adjustments be necessary in the future, the Minister of Health for Canada commits to review the process with Provincial and Territorial Ministers of Health.

Annex D - Financial Statements of Actual Amounts of Extra-Billing and User Charges for the Period April 1, 2017 to March 31, 2018

The Canada Health Act and Extra-billing and User Charges Information Regulations require provinces/territories to report annually to the federal Minister of Health. This report takes the form of a financial statement of actual amounts of extra-billing and user charges levied in the province/territory for the fiscal year in question, along with an explanation regarding the method used to determine the reported amount as indicated in below.

The information reported in the financial statements may be used to determine amounts deducted from the Canada Health Transfer payments of a province/territory where extra-billing and user charges are occurring. However, pursuant to Section 20 of the Act, the federal Minister of Health may estimate amounts of extra-billing and user charges levied, if there is evidence that the information reported in the financial statement does not accurately reflect amounts actually charged to patients in the province or territory.

Under the Act, Extra-billing is defined as a charge by an enrolled physician or dentist to an insured person for an insured service in addition to the amount paid by the provincial/territorial health insurance plan.

Under the Act, A user charge is defined as any charge for an insured health service, other than extra-billing. This includes any charge levied for insured hospital services, or any non-physician related services provided in conjunction with an insured physician service at a non-hospital facility (e.g., private clinic or private practice).

While Quebec did not submit a financial statement in the standard form provided, amounts of extra-billing and user charges levied in the province during 2017-2018 were confirmed in the form of two letters, which are reproduced in this annex.

Newfoundland and Labrador

Canada Health Act

Financial Statement of actual amounts of extra-billing and user charges

For the period April 1, 2017 to March 31, 2018

1. Amounts of extra-billing

Extra-billing is defined as a charge by an enrolled physician or dentist to an insured person for an insured service in addition to the amount paid by the provincial/territorial health insurance plan.

Amount of extra-billing levied by enrolled physicians and dentists for insured health services: $0

2. Amounts of user charges

A user charge is defined as any charge for an insured health service, other than extra-billing. This includes any charge levied for insured hospital services, or any non-physician related services provided in conjunction with an insured physician service at a non-hospital facility (e.g., private clinic or private practice).

Amount of user charges levied for insured services: $ 70,819.35

N.B.  Charges may be levied for accommodation and meal costs related to a patient who, in the opinion of the attending physician, is a permanent resident in a hospital or other chronic care institution as per the limitation of Section 19 (2).  Charges related to this limitation should not be included in the financial statement.

Total for extra-billing and user charges $ 70,819.35

3. Description of method used to determine amounts of extra-billing and user charges

The following information should be included in description of the method used to determine the amounts of extra-billing and user charges (EBUC) reported, including if a NIL amount is submitted: 

a) Name of applicable pieces of PT legislation that prohibit extra-billing and user charges (including facility fees).

Please use as much space needed below or add extra pages as necessary.

In Newfoundland and Labrador, HCS administers the Medical Care Insurance Plan. Subsection 7(1) of the Medical Care and Hospital Insurance Act, states that a practitioner shall not charge or collect from a beneficiary a fee for those insured services in excess of the amount payable under this Act and the regulations. Administration of the Medical Care Insurance Plan, including deterrence of extra-billing, is in accordance with the Act and the associated regulations. Of particular note are the Medical Care Insurance Insured Services Regulations, NLR 21/96 (the "Regulations").

b) Details about the process used to investigate extra-billing and user charges (e.g., proactive regular audits of provider billings; reactive investigations triggered by patient complaints, media reports or other sources).

Please use as much space needed below or add extra pages as necessary.

HCS conducts regular audits of provider billings. No instances of extra-billing or user charges (EBUC) were identified during the relevant period through the regular auditing process.

Cases of extra-billing and user charges may be identified through the audit process described under section 21 of the Medical Care and Hospital Insurance Act or may be reported from beneficiaries. These instances may be discovered when beneficiaries submit claims to the Department of Health and Community Services (the Department) for reimbursement.

Complaints from beneficiaries regarding charges for insured health services are managed by the Department. Depending on the circumstance, the Department may investigate or refer the matter to the College of Physicians and Surgeons of Newfoundland and Labrador, the regulatory body for physicians in the province, for potential disciplinary action. Beneficiaries may also contact the College directly if they feel that they have been subject to improper billing by their physician.

Regarding repayment, section 25 of the Medical Care and Hospital Insurance Act provides the Minister with powers to recover overpayments and interest that were discovered via audit. The Minister of Health and Community Services may do this by entering into an agreement with the practitioner or their professional corporation or the Minister may order the practitioner to pay to the Minister the overpaid amount plus interest.

Beneficiaries wishing to file a complaint regarding medical care that they have received are encouraged to call or email the Complaints Coordinator at the College (1-709-726-8546 or complaints@cpsnl.ca) or call the Medical Care Plan general inquiries line (Avalon area: 1-866-449-4459; all other regions:1-800-563-1557).

c) A summary of any extra-billing and user charges investigations during the fiscal year including:

Please use as much space needed bellow or add extra pages as necessary.

In 2017-2018, HCS received six complaints from beneficiaries of direct billing for cataract surgery. HCS issued a Public Service Announcement on February 7, 2018 inviting individuals to contact HCS with suspected instances of EBUC related to cataract surgery. The phone line received over six hundred calls. There were one hundred and five (105) known instances of user charges related to cataract surgery affecting sixty-one patients for the applicable reporting period indicated. In other words, sixty-one patients paid out-of-pocket expenses for cataract surgery on one or both eyes during this timeframe.

The insured portion of the cataract surgeries amounts to $674.47 for professional fees and the basic lens.

Table 1
  Cost of item when covered by provincial plan Is This An Insured Service?
Professional fees for cataract surgery $574.47 Yes
Basic soft foldable lens $100.00 No. At the time, this lens was considered an upgrade. As of January 1, 2019, the soft or foldable lens was accepted as standard of care and patients no longer pay out of pocket for this item.
Total user charges per eye $674.47 -

Examination of documents obtained from callers to the phone line relevant to this reporting period showed a base fee of $1,195 for a "bronze" or "standard" surgical package. Itemized invoices were not available for examination for all patients. On examination of documents where available, the base fee generally included the following services for non-insured "advanced diagnostics":

Table 2 - Services paid by beneficiary that are not covered
Invoiced Item Amount Charged to Patient Per Eye Is This An Insured Service?
Optical coherence biometry and auto-refraction $195.00 No
Corneal vector analysis and astigmatism planning $400.00 No
Optical coherence tomography (OCT) of anterior segment $150.00 MCP does not insure this test when performed for cataract surgery. OCT is an insured service in the hospital or clinic only when specific clinical indications are met.
No
Total amount of non-insured diagnostic charges to patient $895.00 -

Higher cost surgical packages included all of the above non-insured diagnostics with the addition of more advanced lens implant options, which also represent non-insured services. In addition to these non-insured diagnostic charges, patients were offered the option to pay an additional $1000 per eye for the use of Femto laser technology. This type of technology is not payable in addition to existing insured professional fees for cataract surgery. The Medical Care Plan (MCP) Medical Payment Schedule specifies that fees for cataract surgery include cataract extraction "by any procedure". As such, any costs for Femto laser technology would already be included in professional fees paid by MCP.

As there were 105 "eyes" which incurred direct charges for cataract surgery during the time indicated, the total amount of user charges identified for this reporting period is 105 eyes multiplied by $674.47, which is equal to $70,819,35.

d) Details on mechanisms to deter patient extra-billing and user charges (e.g., provider fines; plan payment withholding; provider/patient education initiatives; loss of facility accreditation).

Please use as much space needed below or add extra pages as necessary.

Section 7 of the Medical Care and Hospital Insurance Act outlines that a practitioner who provides insured services, whether or not he or she has made an election to opt out of participation in the MCP, shall not charge or collect from a beneficiary a fee for those insured services in excess of the amount payable under the Act and the regulations. A practitioner or other person who contravenes this is guilty of an offence and liable on summary conviction to a fine of up to but not more than $20,000 for each contravention.

The Medical Care and Hospital Insurance Act authorizes the Minister to appoint auditors to audit the accounts and claims for payment submitted by physicians and dentists. The Act prescribes the power and duties of auditors, sets out the remedies available and details the processes to be followed. The Act also details the review and appeal processes available to practitioners. Individual providers are randomly selected on a bi-weekly basis for audit.

Prince Edward Island

Canada Health Act

Financial Statement of actual amounts of extra-billing and user charges

For the period April 1, 2017 to March 31, 2018

1. Amounts of extra-billing

Extra-billing is defined as a charge by an enrolled physician or dentist to an insured person for an insured service in addition to the amount paid by the provincial/territorial health insurance plan.

Amount of extra-billing levied by enrolled physicians and dentists for insured health services: $ NIL

2. Amounts of user charges

A user charge is defined as any charge for an insured health service, other than extra-billing. This includes any charge levied for insured hospital services, or any non-physician related services provided in conjunction with an insured physician service at a non-hospital facility (e.g., private clinic or private practice).

Amount of user charges levied for insured services: $ NIL

N.B.  Charges may be levied for accommodation and meal costs related to a patient who, in the opinion of the attending physician, is a permanent resident in a hospital or other chronic care institution as per the limitation of Section 19 (2).  Charges related to this limitation should not be included in the financial statement.

Total for extra-billing and user charges $ NIL

3. Description of method used to determine amounts of extra-billing and user charges

The following information should be included in description of the method used to determine the amounts of extra-billing and user charges (EBUC) reported, including if a NIL amount is submitted: 

a) Name of applicable pieces of PT legislation that prohibit extra-billing and user charges (including facility fees).

Please use as much space needed below or add extra pages as necessary.

Extra billing is not permitted, as per the Province of Prince Edward Island’s Health Services Payment Act.

PEI's Hospital and Diagnostic Services Insurance Act (HDSIA) does not explicitly prohibit user charges for insured health services. However, there are a number of sections in the HDSIA Regulations that infer that user charges would be prohibited, as described below.

Section 1.1(l): "insured services" means, subject to subsection (2), the in-patient and out-patient hospital services available to an entitled person without charge, as determined by the Minister but does not include any services to which a person is entitled, and for which a person is eligible, under any law mentioned in Schedule C"

Section 6.1: An approved hospital shall make a direct charge in respect of the patient who is an entitled person for the difference between the per diem cost of providing insured services and the hospital charges approved by the Minister for private or semi-private accommodation and for any other services which are not insured services requested by or on behalf of the patient.

b) Details about the process used to investigate extra-billing and user charges (e.g., proactive regular audits of provider billings; reactive investigations triggered by patient complaints, media reports or other sources).

Please use as much space needed below add extra pages as necessary.

Health PEI administers a system of internal controls when reviewing physician billings, and investigates irregularities in billing. Physicians are subject to internal audit of billing practices to ensure all amounts billed to Health PEI are appropriate.

Annual financial results for Health PEI are reviewed to identify irregularities and significant variances. This includes a review of revenues to identify any new revenue items (ie. user charges). These revenues are also subject to review by the Auditor General.

The Province of Prince Edward Island offers several avenues for patients and the general public to provide feedback and complaints, including a “Compliments and Complaints” link on the Health PEI website. The Minister of Health and Wellness, the CEO of Health PEI and staff can also be contacted by anyone who may have been subject to any extra billing or user charges. Health PEI follows up on any complaints, including those around billing practices.

c) A summary of any extra-billing and user charges investigations during the fiscal year including:

Please use as much space needed bellow or add extra pages as necessary.

Health PEI conducts physician billing audits on the appropriateness of amounts billed to Health PEI by physicians for insured services. Health PEI does not have access to physicians’ financial records to determine whether any insured services were billed separately to individuals or third parties other than Health PEI. No incidences of extra billing or user charges were noted during these audits.

d) Details on mechanisms to deter patient extra-billing and user charges (e.g., provider fines; plan payment withholding; provider/patient education initiatives; loss of facility accreditation).

Please use as much space needed below or add extra pages as necessary.

Potential new revenue sources for Health PEI are subject to evaluation and approval by Finance and executive leadership, where user charges for insured services would be noted and rejected.

Nova Scotia

Canada Health Act

Financial Statement of actual amounts of extra-billing and user charges

For the period April 1, 2017 to March 31, 2018           

1. Amounts of extra-billing

Extra-billing is defined as a charge by an enrolled physician or dentist to an insured person for an insured service in addition to the amount paid by the provincial/territorial health insurance plan.

Amount of extra-billing levied by enrolled physicians and dentists for insured health services: $ 0

2. Amounts of user charges

A user charge is defined as any charge for an insured health service, other than extra-billing. This includes any charge levied for insured hospital services, or any non-physician related services provided in conjunction with an insured physician service at a non-hospital facility (e.g., private clinic or private practice).

Amount of user charges levied for insured services: $ 0

N.B.  Charges may be levied for accommodation and meal costs related to a patient who, in the opinion of the attending physician, is a permanent resident in a hospital or other chronic care institution as per the limitation of Section 19 (2).  Charges related to this limitation should not be included in the financial statement.

Total for extra-billing and user charges $ 0

3. Description of method used to determine amounts of extra-billing and user charges

The following information should be included in the description of the method used to determine the amounts of extra-billing and user charges (EBUC) reported, including if a NIL amount is submitted: 

a) Name of applicable pieces of PT legislation that prohibit extra-billing and user charges (including facility fees).

Please use as much space needed below or add extra pages as necessary.

b) Details about the process used to investigate extra-billing and user charges (e.g., proactive regular audits of provider billings; reactive investigations triggered by patient complaints, media reports or other sources).

Please use as much space as needed below.

Nova Scotia relies on a complaints-based system whereby concerns are brought to the attention of the Minister on a case by case basis

c) A summary of any extra-billing and user charges investigations during the fiscal year including:

Please use as much space as needed bellow.

There were no investigations in 2017-2018 fiscal year.

d) Details on mechanisms to deter patient extra-billing and user charges (e.g., provider fines; plan payment withholding; provider/patient education initiatives; loss of facility accreditation).

Please use as much space as needed below.

New Brunswick

Canada Health Act

Financial Statement of actual amounts of extra-billing and user charges

For the period April 1, 2017 to March 31, 2018           

1. Amounts of extra-billing

Extra-billing is defined as a charge by an enrolled physician or dentist to an insured person for an insured service in addition to the amount paid by the provincial/territorial health insurance plan.

Amount of extra-billing levied by enrolled physicians and dentists for insured health services: $ 0

2. Amounts of user charges

A user charge is defined as any charge for an insured health service, other than extra-billing. This includes any charge levied for insured hospital services, or any non-physician related services provided in conjunction with an insured physician service at a non-hospital facility (e.g., private clinic or private practice).

Amount of user charges levied for insured services: $ 0

N.B.  Charges may be levied for accommodation and meal costs related to a patient who, in the opinion of the attending physician, is a permanent resident in a hospital or other chronic care institution as per the limitation of Section 19 (2).  Charges related to this limitation should not be included in the financial statement.

Total for extra-billing and user charges $ 0

3. Description of method used to determine amounts of extra-billing and user charges

The following information should be included in descriptions of the method used to determine the amounts of extra-billing and user charges (EBUC) reported, including if a NIL amount is submitted: 

1. Name of applicable pieces of PT legislation that prohibit extra-billing and user charges (including facility fees).

Please use as much space needed below or add extra pages as necessary.

New Brunswick’s Medical Services Payment Act and its Regulations (MSPA) describe mechanisms creating a health system which is Publicly Administered, Comprehensive, Universally available to its beneficiaries, Portable, and Accessible.  It defines who may receive or provide an entitled service and how fee schedules are determined, and prohibits extra-billing or user charges for any such service remunerated through the Medicare Branch.

Some providers may choose to practise outside the MSPA. The MSPA establishes a wall between the publicly funded system (which meets the principles outlined above) and entrepreneurial private business, prohibiting any practitioner payments which exceed the established fee schedules, and payments to private hospitals. It also establishes a private practitioner’s duty to inform prospective patients.

2. Details about the process used to investigate extra-billing and user charges (e.g., proactive regular audits of provider billings; reactive investigations triggered by patient complaints, media reports or other sources).

Please use as much space needed below or add extra pages as necessary.

New Brunswick uses a robust “comment based” approach to identifying individual citizens’ concerns on a wide range of health issues. In a typical month in the 2017-2018 fiscal year the Department of Health received, logged, and responded to 100-150 concerns from individual New Brunswickers on issues including access to primary or specialized care, pharmaceutical approvals, access to services in a citizen’s language of choice, wait times for specific services, the structure of specific programs, etc. The Department’s web page provides several mechanisms to make such comments, including mailing addresses, e-mail addresses, telephone numbers, and a web-based message service. No concerns respecting extra-billing and user charges were received in the 2017-2018 fiscal year.

3. A summary of any extra-billing and user charges investigations during the fiscal year including:

Please use as much space as needed bellow.

4. Details on mechanisms to deter patient extra-billing and user charges (e.g., provider fines; plan payment withholding; provider/patient education initiatives; loss of facility accreditation).

Please use as much space needed below or add extra pages as necessary.

New Brunswick’s Medical Services Payment Act and its Regulations (MSPA) describe mechanisms creating a health system which is Publicly Administered, Comprehensive, Universally available to its beneficiaries, Portable, and Accessible. It defines who may receive or provide an entitled service and how fee schedules are determined, and prohibits extra-billing or user charges for any such service remunerated through the Medicare Branch. • Schedule 2 of the Regulation describes services which are ineligible for payment under the Act; paragraph (n.l ) specifically prohibits payments to practitioners within New Brunswick whose fee exceeds the amount payable under the Regulation.

Quebec

Direction générale de la coordination, de la planification, de la performance et de la qualité
[Coordination, planning, performance and quality assurance branch]

BY EMAIL

Québec, December 16, 2019

Gigi Mandy
Executive Director
Canada Health Act Division
Strategic Policy Branch
Health Canada
Brooke Claxton Building, Floor 8
70 Colombine Driveway, Tunney's Pasture
Postal locator 0908C
Ottawa, Ontario  K1A 0K9

Dear Ms. Mandy,

This is further to the letter to the Deputy Minister of Health and Social Services, Yvan Gendron, dated November 22. The letter requested the aggregate amount of extra-billing and user fees for 2017-2018.

In Quebec, the health insurance plan is regulated by the Health Insurance Act. This Act does not allow user fees to be imposed. It also prohibits any person from demanding or receiving any payment from a person for incidental fees related to an insured service, except in cases prescribed by regulation or provided for in an agreement and the conditions mentioned therein.

In order to provide further clarification about this prohibition, the Government of Quebec has approved a draft regulation expressly prohibiting any fees related to services insured by Quebec's health insurance plan as well as all accessory fees provided for in compensation agreements with physicians. This regulation has been in effect since January 2017. Of course, in the event of actions, whatever they may be, that are contrary to Quebec's statutes and regulations, the Régie de l'assurance maladie du Québec will take the appropriate measures to rectify the situation.

As you are no doubt aware, health and social services are within the exclusive jurisdiction of the provinces. As such, Quebec intends to remain responsible for the management, organization and planning of care and services on its territory.

Moreover, the government is accountable to the National Assembly and to the people of Quebec with respect to how its healthcare system is run. Thus, Quebec shall continue to fulfill this responsibility to Quebec's citizens, who are the ultimate arbiters as to the quality and accessibility of the services provided to them by our healthcare system.

You may consult, for your information, the Ministère de la Santé et des Services Sociaux's (MSSS) 2017-2018 annual management report tabled in the National Assembly, which provides an accounting of how Quebec manages its healthcare system. The report is available in the Publications section of the MSSS website.

Sincerely,

Valérie Fontaine, Director
International and Intergovernmental Affairs Directorate
Our ref: 19-CP-0041

Ontario

Canada Health Act

Financial Statement of actual amounts of extra-billing and user charges

For the period April 1, 2017 to March 31, 2018           

1. Amounts of extra-billing

Extra-billing is defined as a charge by an enrolled physician or dentist to an insured person for an insured service in addition to the amount paid by the provincial/territorial health insurance plan.

Amount of extra-billing levied by enrolled physicians and dentists for insured health services: $ NIL

2. Amounts of user charges

A user charge is defined as any charge for an insured health service, other than extra-billing. This includes any charge levied for insured hospital services, or any non-physician related services provided in conjunction with an insured physician service at a non-hospital facility (e.g., private clinic or private practice).

Amount of user charges levied for insured services: $ NIL

N.B.  Charges may be levied for accommodation and meal costs related to a patient who, in the opinion of the attending physician, is a permanent resident in a hospital or other chronic care institution as per the limitation of Section 19 (2).  Charges related to this limitation should not be included in the financial statement.

Total for extra-billing and user charges $ NIL

3. Description of method used to determine amounts of extra-billing and user charges

The following information should be included in the description of the method used to determine the amounts of extra-billing and user charges (EBUC) reported, including if a NIL amount is submitted: 

Name of applicable pieces of PT legislation that prohibit extra-billing and user charges (including facility fees).

Please use as much space needed below or add extra pages as necessary.

The Ontario Health Insurance Plan (OHIP) and all insured services are set out under the Health Insurance Act (HIA) and Regulations.

In Ontario, a combination of two pieces of legislation prohibits any person or entity from charging for all or part of an OHIP-insured service rendered to an insured person (i.e. EBUC, including illegal facility fees). These statutes are as follows:

  1. The Commitment to the Future of Medicare Act (CFMA) prohibits any person or entity from charging unauthorized payments for all or part of an OHIP-insured service rendered to an insured person. Such charges include extra-billing (i.e. charges to insured persons for insured physician and dental-surgical services) and user charges (i.e. charges to insured persons for non-physician/dental-surgical services provided in conjunction with insured services at a hospital).

    The CFMA also prohibits providers and other entities from providing preferred access to an insured service conditional on the payment of a fee, which is called queue-jumping, and from making the provision of an insured service conditional on paying a block fee for uninsured services.

    The CFMA applies regardless of the type of facility or setting in which a service is rendered.

  2. For services rendered outside of a hospital, the Independent Health Facilities Act (IHFA) prohibits any person from charging for the cost of any premises, equipment, supplies and personnel that support, assist and/or provide a necessary adjunct to certain OHIP-insured services (i.e. facility fees).

    Regardless of whether a service is provided in an IHF or any other non-hospital setting, a charge for a service that is a necessary adjunct to an insured service, but is not part of the insured service, is an illegal facility fee under the IHFA.

Through a dedicated program (CFMA Program), the Ontario Ministry of Health (the ministry) reviews all possible cases of EBUC brought to its attention according to the process set out under the CFMA. Charging facility fees contrary to the IHFA may also have implications under the CFMA, and therefore, the ministry's CFMA Program also reviews allegations of illegal facility fees under the IHFA in conjunction with the ministry's IHF program.

If, as a result of a review, it is determined that a patient has paid an unauthorized payment (i.e. extra-billing) and/or user charge, the ministry ensures that the full amount is reimbursed to the patient.

a) Details about the process used to investigate extra-billing and user charges (e.g., proactive regular audits of provider billings; reactive investigations triggered by patient complaints, media reports or other sources).

Please use as much space needed below or add extra pages as necessary.

The ministry reviews all possible instances of EBUC that come to its attention. Patient complaints regarding possible EBUC and questions from the public are received via a dedicated toll-free number and email address. Information regarding possible EBUC arises primarily from patient complaints; however, the ministry may also review possible violations that are brought to its attention by other sources such as Health Canada, regulatory colleges, MPPs, the media, advertisements, etc.

All inquiries from patients and other sources regarding out-of-pocket charges for health care services are responded to and are assessed to determine whether or not a CFMA review is opened (i.e., was the service charged for clearly uninsured or is further review required?). If it is determined that EBUC may have occurred, according to CFMA Program policy, patients are asked to complete a CFMA Program form providing their consent for the ministry to open a review and contact the provider or entity on their behalf.

Reviews regarding EBUC follow a process outlined in legislation (CFMA). At the onset of a review, there is normally insufficient information to determine whether or not EBUC has occurred. Therefore, in most cases, the ministry requests relevant records and/or information from providers under authority of the CFMA (e.g. medical and/or hospital/facility records related to the service the patient was charged for, copies of all invoices and receipts, a breakdown of any patient charges, etc.). Once the requested information has been received, it is reviewed by CFMA Program staff in order to determine whether a specific service provided to a patient was insured. In almost all cases, ministry medical advisors are consulted for assistance in interpreting medical records. Staff may also consult with other areas of the ministry, including legal services and other branches.

The ministry can and does review possible EBUC on a proactive basis (i.e. without receiving a complaint). However, as noted above, reviews often require examinations of specific patient records to determine whether a specific service provided to a patient was insured, and therefore, without a specific patient complaint, the ministry primarily seeks information regarding general practices and does not review patient medical records.

If the ministry finds through a CFMA review that a patient has paid an illegal extra-billing fee or user charge, the ministry ensures that the full amount is reimbursed to the patient. Although not required under the Act, it is the ministry's policy that if a provider or entity has been determined to have received an unauthorized payment, they are given an opportunity to repay the patient directly. If the provider or entity declines to repay the patient, the ministry will repay the patient directly and the provider or entity will become indebted to OHIP for the amount of the unauthorized payment plus an administrative charge of $150.00 for each payment made by OHIP to the patient.Footnote 23

Most providers and entities who are notified of the ministry's determination that they have received an unauthorized payment agree to reimburse the patient directly. However, on rare occasions, the CFMA Program has initiated direct recoveries from providers or entities.

As required, the CFMA contains provincial offence provisions, where individuals and corporations in violation of the CFMA are subject to fines if convicted of an offence under the Provincial Offences Act (POA). Additionally, when a CFMA review identifies possible inappropriate OHIP billing or fraud, the matter is referred to either the ministry's Payment Accountability Unit or to the Ontario Provincial Police Health Fraud Investigation Unit.

b) A summary of any extra-billing and user charges investigations during the fiscal year including:

Please use as much space as needed bellow.

For each review that took place in FY 2017-18 in which the ministry determined that an unauthorized payment was received for extra-billing and/or user charges, the patient was reimbursed the full amount by either the person or entity that received the payment or by the ministry directly. Therefore, the total extra-billing amount reported above ($ NIL) represents the net amount of unauthorized payments for insured physician and dental-surgical services levied in Ontario in FY 2017-18.

In FY 2017-18, the ministry conducted 84 reviews of potential EBUC as follows:

49 reviews resulted in a determination that a patient was not charged for an insured service as per Ontario legislation and Regulation:

# of Reviews Nature of Review
43 Patient-Initiated
6 Non-Patient Specific and Initiated by Other Sources (e.g. Abortion Education Group, Regulatory College, Concerned Citizen, etc.)

35 reviews resulted in a determination that a patient was charged for an insured service as per Ontario Legislation and Regulation. In each of these cases, patients were reimbursed the total  amount they paid:

# of Reviews Nature of Reviews # of Patients Reimbursed Charge Type Charge Per Service Total Amount Charged Total Amount Reimbursed
26 Patient Initiated 26 Extra-Billing $25.00-$2,651.25 $16,160.91 $16,160.91
8 Patient Initiated 8 User Charges $25.98-$1,410.99 $3,325.17 $3,325.17
1 MPP Referred 1 User Charges $672.88 $672.88 $672.88
35 Total # of Reviews Involving Confirmed EBUC (Including Facility Fees) Total Amount Charges and Reimbursed for Confirmed Reviews $20,158.96 $20,158.96

In his letter dated November 20, 2019 to Ontario Deputy Minister of Health Helen Angus, Federal Deputy Minister of Health Stephen Lucas specifically referenced concerns that patients may be required to pay fees in order to access insured abortion services in Ontario. As noted above, under the authority of the CFMA, the ministry reviews all possible instances of EBUC for insured services that come to its attention. In FY 2017-18, five investigative reviews were undertaken by the ministry in relation to potential patient charges by non-hospital clinics in association with insured abortion services. These clinics are the same as those referenced in letters from the former federal Minister of Health Ginette Petitpas-Taylor to the Ontario Minister of Health Christine Elliott and from the Executive Director of Health Canada's Canada Health Act Division to Ontario's Health Services Branch in the summer of 2019. No CFMA and/or IHFA violations were identified as a result of those reviews. It was determined in all cases that no OHIP-insured persons had been charged for an insured abortion service (or part thereof) or for access to an insured abortion service. Therefore, no reimbursements for extra-billing or user charges were made by the ministry in FY 2017/18 in relation to insured abortion services.

c) Details on mechanisms to deter patient extra-billing and user charges (e.g., provider fines; plan payment withholding; provider/patient education initiatives; loss of facility accreditation).

Please use as much space needed below or add extra pages as necessary.

The ministry takes steps to prevent EBUC by maintaining a webpage which provides public information regarding the CFMA, including what is prohibited under the Act (i.e., extra-billing, queue-jumping, illegal block fees), how to determine if they have been charged for an insured service or for access to an insured service, and how to contact the ministry via a dedicated toll free number and email address in order to open an review or ask a question regarding a possible CFMA violation.

The ministry also regularly undertakes proactive CFMA review(s) that are not tied to a specific patient complaint but are instead initiated by the ministry to target providers in high-risk areas of practice known to have frequent instances of EBUC. In many cases, these investigations are done for the purposes of provider education, in order for the ministry to communicate the provider's obligations under the Canada Health Act (CHA) and CFMA, and to ensure that their billing practices are amended as appropriate to comply with Ontario legislation. The ministry has also in the past undertaken patient education initiatives to increase awareness among members of the general public about the protections under the CFMA and to encourage filing complaints to the CFMA program so that reviews can be initiated.

In rare but serious cases where the person or entity fails comply with a CFMA review without just cause (e.g., if a provider or entity fails to provide the ministry with requested information relevant to the determination of whether or not EBUC has occurred), the Act authorizes the ministry to suspend all OHIP payments to the person or entity pending receipt of the requested information, as per the review process set out under the Act

As noted above, the CFMA also contains provincial offence provisions, where individuals and corporations in violation to the CFMA are subject to fines if convicted of an offence under the POA. Additionally, when a CFMA review identifies possible inappropriate OHIP billing or fraud, the matter is referred to either the ministry's Payment Accountability Unit or to the Ontario Provincial Police for more serious cases.

Manitoba

Canada Health Act

Financial Statement of actual amounts of extra-billing and user charges

For the period April 1, 2017 to March 31, 2018

1. Amounts of extra-billing

Extra-billing is defined as a charge by an enrolled physician or dentist to an insured person for an insured service in addition to the amount paid by the provincial/territorial health insurance plan.

Amount of extra-billing levied by enrolled physicians and dentists for insured health services: $ 0

2. Amounts of user charges

A user charge is defined as any charge for an insured health service, other than extra-billing. This includes any charge levied for insured hospital services, or any non-physician related services provided in conjunction with an insured physician service at a non-hospital facility (e.g., private clinic or private practice).

Amount of user charges levied for insured services: $ 0

N.B.  Charges may be levied for accommodation and meal costs related to a patient who, in the opinion of the attending physician, is a permanent resident in a hospital or other chronic care institution as per the limitation of Section 19 (2).  Charges related to this limitation should not be included in the financial statement.

Total for extra-billing and user charges $ 0

3. Description of method used to determine amounts of extra-billing and user charges

The following information should be included in description of the method used to determine the amounts of extra-billing and user charges (EBUC) reported, including if a NIL amount is submitted: 

a) Name of applicable pieces of PT legislation that prohibit extra-billing and user charges (including facility fees).

Please use as much space needed below or add extra pages as necessary.

b) Details about the process used to investigate extra-billing and user charges (e.g., proactive regular audits of provider billings; reactive investigations triggered by patient complaints, media reports or other sources).

Please use as much space needed below or add extra pages as necessary.

c) A summary of any extra-billing and user charges investigations during the fiscal year including:

Please use as much space needed bellow or add extra pages as necessary.

There were no formal investigations conducted in 2017-2018 on the basis of complaints from residents of Manitoba. There were no confirmed cases of extra-billing or user charges.

d) Details on mechanisms to deter patient extra-billing and user charges (e.g., provider fines; plan payment withholding; provider/patient education initiatives; loss of facility accreditation).

Please use as much space needed below or add extra pages as necessary.

Saskatchewan

Canada Health Act

Financial Statement of actual amounts of extra-billing and user charges

For the period April 1, 2017 to March 31, 2018

1. Amounts of extra-billing

Extra-billing is defined as a charge by an enrolled physician or dentist to an insured person for an insured service in addition to the amount paid by the provincial/territorial health insurance plan.

Amount of extra-billing levied by enrolled physicians and dentists for insured health services: $ 0

2. Amounts of user charges

A user charge is defined as any charge for an insured health service, other than extra-billing. This includes any charge levied for insured hospital services, or any non-physician related services provided in conjunction with an insured physician service at a non-hospital facility (e.g., private clinic or private practice).

Amount of user charges levied for insured services: $ 0

N.B.  Charges may be levied for accommodation and meal costs related to a patient who, in the opinion of the attending physician, is a permanent resident in a hospital or other chronic care institution as per the limitation of Section 19 (2).  Charges related to this limitation should not be included in the financial statement.

Total for extra-billing and user charges $ 0

3. Description of method used to determine amounts of extra-billing and user charges

The following information should be included in description of the method used to determine the amounts of extra-billing and user charges (EBUC) reported, including if a NIL amount is submitted: 

a) Name of applicable pieces of PT legislation that prohibit extra-billing and user charges (including facility fees).

Please use as much space needed below or add extra pages as necessary.

The Saskatchewan Medical Care Insurance Act precludes physicians/dentists who provide insured services from charging patients more than the amount paid for that service under the Act, unless the physician/dentist has opted out entirely from receiving payments under the Act. Notice must also be given to the province where a physician/dentist opts out. No notices have been received for the reporting period.

The Saskatchewan Medical Care Insurance Act includes provisions which indicate that any amount that a physician who provides insured services requires a beneficiary to pay or to have paid as a condition of receiving an insured service which exceeds the amount to be paid for that service under the Act, is considered to be a charge.

The Health Facilities Licensing Act precludes any licensee from charging or permitting any other person to charge any fee to any beneficiary for any insured health service performed at the health facility.

b) Details about the process used to investigate extra-billing and user charges (e.g., proactive regular audits of provider billings; reactive investigations triggered by patient complaints, media reports or other sources).

Please use as much space needed below or add extra pages as necessary.

With regard to extra-billing compliance is monitored through consultations with the provincial health authority, physicians and dentists, as well as complaints from members of the public. When requests are made by a beneficiary seeking reimbursement of monies paid directly to a physician for insured physician services that are extra-billing charges, correspondence is sent to the beneficiary (copying the physician) advising them of Section 18 (1.1) of the Saskatchewan Medical Care Insurance Payment Act that a physician must accept the negotiated rate as payment in full for insured services provided to a beneficiary. Once the physician has received payment from Medical Services for the eligible service(s), reimbursement for any difference in the amount charged by the practitioner and the amount paid by Medical Services should be collected directly from the practitioner. If a further complaint is made, the beneficiary is directed to address complaints to the Saskatchewan College of Physicians and Surgeons.

Persons who have a complaint of an extra-billing charge may raise the concern with the College of Physicians and Surgeons of Saskatchewan. Section 7.1 (Code of Ethics) in the College's bylaws notes the following:

With regard to user charges, compliance is monitored through consultations with the provincial health authority, physicians and dentists, as well as complaints from members of the public.

Persons who have a complaint of user charges may raise the concern with the College of Physicians and Surgeons of Saskatchewan. Section 7.1 (Code of Ethics) in the College's bylaws notes the following:

c) A summary of any extra-billing and user charges investigations during the fiscal year including:

Please use as much space needed bellow or add extra pages as necessary.

For the 2017-2018 fiscal year Saskatchewan is reporting $0 in extra-billing. Saskatchewan has no information that extra-billing charges have been levied during the reporting period.

For the 2017-2018 fiscal year Saskatchewan is reporting $0 in User Charges. Saskatchewan has no information that user charges have been levied during the reporting period. Saskatchewan is not aware of charges being levied for insured services provided in a hospital. Nor is Saskatchewan aware of any additional charges for insured services being levied in a physician clinic as defined in the federal private clinics policy.

d) Details on mechanisms to deter patient extra-billing and user charges (e.g., provider fines; plan payment withholding; provider/patient education initiatives; loss of facility accreditation).

Please use as much space needed below or add extra pages as necessary.

The Saskatchewan Medical Care Insurance Act and the Health Facilities Licensing Act stipulate monetary penalties for individuals guilty of contravening the Act(s), including extra-billing and user charges of insured health services.

Alberta

Canada Health Act

Financial Statement of actual amounts of extra-billing and user charges

For the period April 1, 2017 to March 31, 2018

1. Amounts of extra-billing

Extra-billing is defined as a charge by an enrolled physician or dentist to an insured person for an insured service in addition to the amount paid by the provincial/territorial health insurance plan.

Amount of extra-billing levied by enrolled physicians and dentists for insured health services: $ 0

2. Amounts of user charges

A user charge is defined as any charge for an insured health service, other than extra-billing. This includes any charge levied for insured hospital services, or any non-physician related services provided in conjunction with an insured physician service at a non-hospital facility (e.g., private clinic or private practice).

Amount of user charges levied for insured services: $ 0

N.B.  Charges may be levied for accommodation and meal costs related to a patient who, in the opinion of the attending physician, is a permanent resident in a hospital or other chronic care institution as per the limitation of Section 19 (2).  Charges related to this limitation should not be included in the financial statement.

Total for extra-billing and user charges $ 0

3. Description of method used to determine amounts of extra-billing and user charges

The following information should be included in description of the method used to determine the amounts of extra-billing and user charges (EBUC) reported, including if a NIL amount is submitted: 

a) Name of applicable pieces of PT legislation that prohibit extra-billing and user charges (including facility fees).

Please use as much space needed below or add extra pages as necessary.

b) Details about the process used to investigate extra-billing and user charges (e.g., proactive regular audits of provider billings; reactive investigations triggered by patient complaints, media reports or other sources).

Please use as much space needed below or add extra pages as necessary.

Alberta Health has reviewed the Canada Health Act form Financial Statement of Actual Amounts of Extra-Billing and User Charges for the Period April 1, 2017 to March 31, 2018 and reporting guidelines.

Alberta Health uses the following processes to determine and investigate EBUC:

  1. Alberta Health has conducted audits and compliance reviews in accordance with the authority and the provisions of the Alberta Health Care Insurance Act (AHCIA) that mirrors the fundamental principles of the Canada Health Act.
  2. Alberta Health uses a proactive risk based planning process to identify potential areas of inappropriate billing under the AHCIA, which includes provisions to address non-compliance with regard to extra-billing and prohibited fees by any person. Based on this process, high risk subjects for audit and/or compliance review are selected. The scope of work includes all physicians and other practitioners receiving compensation through the Plan on a fee-for-service basis or through Clinical Alternative Relationship Plans. Payments to hospitals, which Alberta Health Services operates and funds, are not in scope.
  3. If patients in Alberta have questions or concerns regarding potential extra-billing or user charges they can direct their inquiries to Alberta Health.  The primary mechanisms of inquiry or complaint are:
    • Contacting the Alberta Health Care Insurance Plan (AHCIP) by phone, fax, mail, or email.
    • The Alberta Health TIPS line. Patients can call to express concerns and those that are physician or claims related will be directed to Claims Specialist Unit. 
    • Statement of Benefits Paid (SOBP).  The SOBP is a list of practitioner services a patient receives during a specified period that have been paid for by the AHCIP.  The statement lists dates, general types of service, physician names, and the amount paid to physicians.  Albertans who find health services on their SOBP that they do not recognize can outline the discrepancies and return the SOBP to Alberta Health for investigation.
  4. Alberta Health staff may investigate claims if billing irregularities are noticed as they are being processed.
  5. Once an inquiry or complaint is received Alberta Health personnel will enter the information on a tracking sheet, conduct a preliminary review, and consult further with the complainant, and the practitioner if needed, to gather additional information regarding the billing scenario and from there typically one of three things occur:   
    • The billing inquiry may be resolved with the patient and/or the health practitioner by clarifying coverage under the Alberta Health Care Insurance Plan. 
    • If a billing error has been identified the health practitioner will be notified and the claim will be reversed and, if needed, the patient reimbursed.
    • If the matter cannot be resolved with the health practitioner through communication or education, or if a trend of inappropriate billings is identified, the matter is escalated to a compliance review.
c) A summary of any extra-billing and user charges investigations during the fiscal year including:

Please use as much space needed bellow or add extra pages as necessary.

  1. Alberta Health does not report on audit and/or compliance reviews that are not yet concluded.
  2. In 2017-2018, Alberta Health investigated and resolved two cases of possible extra-billing based on inquiries received from Albertans.
d) Details on mechanisms to deter patient extra-billing and user charges (e.g., provider fines; plan payment withholding; provider/patient education initiatives; loss of facility accreditation).

Please use as much space needed below or add extra pages as necessary.

  1. In addition to the Alberta Health processes provided in answer b), the AHCIA prohibits EBUC in the following sections of legislation:
    • Section 9(1) of the AHCIA, Extra billing, prescribes that “No physician or dentist who is opted into the [Alberta Health Care Insurance Plan (the Plan)] who provides insured services to a person shall charge or collect from any person an amount in addition to the benefits payable by the Minister for those insured services.”
    • Section 11(1) of the AHCIA, Other prohibited fees, prescribes that “No person shall charge or collect from any person (a) an amount for any goods or services that are provided as a condition to receiving an insured service provided by a physician or dentist who is opted into the Plan, or (b) an amount the payment of which is a condition to receiving an insured service provided by a physician or dentist who is opted into the Plan where the amount is in addition to the benefits payable by the Minister for the insured service.”
    • Section 14 prescribes that a person who contravenes section 9, 11 or 12 is guilty of an offence and liable to a fine.
    • Section 26(1)(2)(3) prescribes that an insurer (carrier, employer, corporation or unincorporated group that administers a self-insurance plan) shall not enter into, issue, maintain in force or renew a contract or initiate or renew a self-insurance plan under which any resident or group of residents is provided with any prepaid basic health services or extended health services or indemnification for all or part of the cost of any basic health services or extended health services.
    • Sections 18 and 39 authorize Alberta Health to reassess claims and conduct audits and compliance reviews after the Minister has paid the claim.
    • Sections 9(2), 11(3)(4), 12(1), 13(3) and 14(a)(b) of the AHCIA prescribe that the Minister may send warnings to practitioners, refer contraventions to the practitioners’ professional regulators, opt practitioners out the Plan, recover benefits paid, recover and reimburse the amount charged or collected as other prohibited fees, not pay benefits for insured services if section 11 is contravened, and apply fines for offences.

Alberta Health issued Bulletin Med 184 on May 25, 2016 to provide information to physicians and billing staff about prohibited billing activities under sections 9 and 11 of the AHCIA. This bulletin is available on the Alberta Health website (https://open.alberta.ca/publications/bulletin-alberta-health-care-insurance-plan-medical-services) and is attached for your reference.

British Columbia

Canada Health Act

Financial Statement of actual amounts of extra-billing and user charges

For the period April 1, 2017 to March 31, 2018

1. Amounts of extra-billing

Extra-billing is defined as a charge by an enrolled physician or dentist to an insured person for an insured service in addition to the amount paid by the provincial/territorial health insurance plan.

Amount of extra-billing levied by enrolled physicians and dentists for insured health services:

2. Amounts of user charges

A user charge is defined as any charge for an insured health service, other than extra-billing. This includes any charge levied for insured hospital services, or any non-physician related services provided in conjunction with an insured physician service at a non-hospital facility (e.g., private clinic or private practice).

Amount of user charges levied for insured services: $ 332

N.B.  Charges may be levied for accommodation and meal costs related to a patient who, in the opinion of the attending physician, is a permanent resident in a hospital or other chronic care institution as per the limitation of Section 19 (2).  Charges related to this limitation should not be included in the financial statement.

Total for extra-billing and user charges $ 16,753,833

3. Description of method used to determine amounts of extra-billing and user charges

The following information should be included in description of the method used to determine the amounts of extra-billing and user charges (EBUC) reported, including if a NIL amount is submitted: 

a) Name of applicable pieces of PT legislation that prohibit extra-billing and user charges (including facility fees).

Please use as much space needed below or add extra pages as necessary.

The Medicare Protection Act (the Act) pays for insured medical services (also known as benefits) provided to residents of British Columbia. The Act establishes rules regarding billing for services provided by physicians who are enrolled with the Medical Service Plan (MSP). The Act also prohibits anyone from charging patients for “materials, consultations, procedures, use of an office, clinic, or for any other matters that relate to the rendering of a benefit” unless specifically permitted by the Medical Services Commission (MSC)

b) Details about the process used to investigate extra-billing and user charges (e.g., proactive regular audits of provider billings; reactive investigations triggered by patient complaints, media reports or other sources).

Please use as much space needed below or add extra pages as necessary.

c) A summary of any extra-billing and user charges investigations during the fiscal year including:

Please use as much space needed bellow or add extra pages as necessary.

d) Details on mechanisms to deter patient extra-billing and user charges (e.g., provider fines; plan payment withholding; provider/patient education initiatives; loss of facility accreditation).

Please use as much space needed below or add extra pages as necessary.

In the spring of 2018, BC’s Minister of Health announced, in part to bring BC in compliance with the Canada Health Act, that the Government would bring into force the remaining provisions of the 2003 Bill 92 to address the province’s ability to respond to and address extra billing. Most of these provisions came into force on October 1, 2018. The key changes include:

In addition to the above changes, Bill 92 includes a prohibition for charging in relation to diagnostic services (s. 18.1). This provision, previously scheduled to take effect on April 1, 2019, will come into force on March 31, 2020.

Bringing into force these provisions serves to strengthen enforcement against extra billing and reinforces the province’s commitment to universal public health care.

Impact of Litigation on Extra-billing Elimination Actions

The enforceability of the Bill 92 provisions has been challenged in Court in Cambie Surgeries Corporate v. British Columbia (Attorney General). On November 23, 2018, the BC Supreme Court issued an injunction enjoining the enforcement of the extra billing provisions (Sections 17, 18, and 45) in the MPA until June 1, 2019 or further order of the Court (the Court Order). BC’s application to appeal this injunction has been denied. This Court Order has required BC to reevaluate a number of its strategies for extra-billing elimination in order to be compliant with this judicial decision.

Physician/Clinic Notification

A letter serving notice of the changes was issued to all registered medical practitioners, accredited diagnostic facilities and private surgical clinics on September 10, 2018. These letters were sent via registered mail to ensure there is a record of them being delivered.

Partners/Stakeholders

Briefings were conducted prior to October 1, 2018, with various associations including: Doctors of BC, the BC College of Physicians and Surgeons, the Canadian Medical Protective Association and the Vice Presidents of Medicine for the Health Authorities, to ensure awareness around the legislative changes and new expectations.

Public Awareness

On April 4, 2018, the MoH issued a press release announcing the province would be bringing into force the remaining provisions of Bill 92, effective October 1, 2018. An additional press release was issued on September 7, 2018, providing an overall update on Bill 92 and reporting a six-month extension to April 1, 2019 of the Medicare Protection Act measures applicable to diagnostic services.

The MoH has taken a number of steps to enable an increased understanding of extra billing, updating a number of relevant sections of the BC government website aimed at the public that link patients directly, through multiple paths, to information concerning extra billing. These include:

On the BC government’s Health homepage, the language under Popular Topics has been amended to indicate that extra billing information is available under the MSP for BC Residents webpage. Additional links to extra billing information can be accessed from the homepage, under Health Care Complaints.

Applicable patient information on the changes to the Medicare Protection Act and the ability to seek reimbursement from the Medical Services Commission is profiled online.

The MoH will monitor ongoing patient inquiries and consider additional formats to make information available to the public, as required.

Health Authority Contracts

At present there are 15 private surgical clinics operating in British Columbia. As part of the province’s ongoing and focused efforts to address the requirements of the CHA Health Authorities have negotiated contracts with eight of the clinics, and negotiations are currently underway to establish a contract with one of the largest private clinics that has historically been a source of extra billing. When successfully concluded this will bring the total number of contracted clinics to nine, covering the vast majority of surgeries undertaken by the private surgical clinics, with the exception of the Cambie Surgery Centre, which is still before the courts.

The MoH issued a letter on September 13, 2018 notifying all Health Authorities of expectations about contracting between Health Authorities and private clinics for the provision of medical services. This included a requirement for all Health Authorities to amend their current surgical services contracts with private clinics to include termination provisions in the event of extra billing. As a requirement of the amended contracts, medical practitioners and clinics have been required to sign compliance statements. This letter of expectations was revised following the Court Order, as was the compliance statement – which is now referred to as a “notice to physician”.

With the move to contracting with private surgery clinics and ongoing engagement as part of Bill 92, the volume of extra billing continues to decline across the province. Health Authorities continue to engage with the smaller private surgical clinics to establish contracts with the clinics as part of the ongoing plan to reduce extra-billing.

Medical Services Commission – Compliance and Monitoring

The MoH has developed a series of operational processes to protect patients from extra billing, including protocols with the Medical Services Commission to adjudicate compliance. These processes include: processing complaints, investigating allegations and making a determination as to whether extra billing has taken place.

Due to the recent Court Order, the MoH has adjusted these processes. The MoH will continue to work closely with the Medical Services Commission to identify the most appropriate roles given its limited scope of action. Once the MoH is able to move forward, these processes will enable the Medical Services Commission to reimburse beneficiaries directly, assume debt on behalf of a beneficiary and recover the charge from the practitioner and/or clinic. In addition, once enforcement is no longer prohibited by the Court Order, extra billing offences may be referred to the MoH’s Audit and Investigations Branch and the Special Investigations Unit for the purpose of recommending charges and penalties, where appropriate.

Yukon

Canada Health Act

Financial Statement of actual amounts of extra-billing and user charges

For the period April 1, 2017 to March 31, 2018

1. Amounts of extra-billing

Extra-billing is defined as a charge by an enrolled physician or dentist to an insured person for an insured service in addition to the amount paid by the provincial/territorial health insurance plan.

Amount of extra-billing levied by enrolled physicians and dentists for insured health services: $ 0

2. Amounts of user charges

A user charge is defined as any charge for an insured health service, other than extra-billing. This includes any charge levied for insured hospital services, or any non-physician related services provided in conjunction with an insured physician service at a non-hospital facility (e.g., private clinic or private practice).

Amount of user charges levied for insured services: $ 0

N.B.  Charges may be levied for accommodation and meal costs related to a patient who, in the opinion of the attending physician, is a permanent resident in a hospital or other chronic care institution as per the limitation of Section 19 (2).  Charges related to this limitation should not be included in the financial statement.

Total for extra-billing and user charges $ 0

3. Description of method used to determine amounts of extra-billing and user charges

The following information should be included in description of the method used to determine the amounts of extra-billing and user charges (EBUC) reported, including if a NIL amount is submitted: 

a) Name of applicable pieces of PT legislation that prohibit extra-billing and user charges (including facility fees).

Please use as much space needed below or add extra pages as necessary.

There are no user fees or co-insurance charges for Insured Health Services under the Yukon Health Care Insurance Plan or the Yukon Hospital Insurance Services Plan. All services are provided on a uniform basis and are not impeded by financial or other barriers. There is no extra-billing in Yukon for any services covered by the Plan.

The Yukon Health Care Insurance Plan Act defines an Insured Health Services as: "those physician services, surgical-dental services, and other health services including the supply of drugs, medical and dental supplies, prosthesis, ..."

In FY 17-18 Yukon did not have any private for-profit health care facilities delivering insured health services. Information submitted excludes government operated continuing care facilities in Yukon.

b) Details about the process used to investigate extra-billing and user charges (e.g., proactive regular audits of provider billings; reactive investigations triggered by patient complaints, media reports or other sources).

Please use as much space needed below or add extra pages as necessary.

Regular audits of physician claims along with reactive investigations triggered by client and/or other physician complaints. Annual audit by the Auditor General.

If a patient has a complaint related to physician services including extra-billing or user charges they can contact the Yukon Medical Council.

c) A summary of any extra-billing and user charges investigations during the fiscal year including:

Please use as much space needed bellow or add extra pages as necessary.

d) Details on mechanisms to deter patient extra-billing and user charges (e.g., provider fines; plan payment withholding; provider/patient education initiatives; loss of facility accreditation).

Please use as much space needed below or add extra pages as necessary.

The preamble to the Yukon Physician Fee Guide contains the following:

"No fee above or in addition to this prescribed schedule may be charged to either Yukon Health Care Insurance Plan or to the patient in the case of insured services provided to insured persons."

Northwest Territories

Canada Health Act

Financial Statement of actual amounts of extra-billing and user charges

For the period April 1, 2017 to March 31, 2018           

1. Amounts of extra-billing

Extra-billing is defined as a charge by an enrolled physician or dentist to an insured person for an insured service in addition to the amount paid by the provincial/territorial health insurance plan.

Amount of extra-billing levied by enrolled physicians and dentists for insured health services: $ 0

2. Amounts of user charges

A user charge is defined as any charge for an insured health service, other than extra-billing. This includes any charge levied for insured hospital services, or any non-physician related services provided in conjunction with an insured physician service at a non-hospital facility (e.g., private clinic or private practice).

Amount of user charges levied for insured services: $ 0

N.B.  Charges may be levied for accommodation and meal costs related to a patient who, in the opinion of the attending physician, is a permanent resident in a hospital or other chronic care institution as per the limitation of Section 19 (2).  Charges related to this limitation should not be included in the financial statement.

Total for extra-billing and user charges $ 0

3. Description of method used to determine amounts of extra-billing and user charges

The following information should be included in description of the method used to determine the amounts of extra-billing and user charges (EBUC) reported, including if a NIL amount is submitted: 

a) Name of applicable pieces of PT legislation that prohibit extra-billing and user charges (including facility fees).

Please use as much space needed below or add extra pages as necessary.

There are two pieces of legislation in the Northwest Territories which prohibit extra billing and user charges. Section 14(1) of the Northwest Territories Medical Care Act states that: “No medical practitioner shall charge to or collect from an insured person a fee in excess of the benefit in respect of the insured service, unless the medical practitioner has made an election that is still in effect.” In addition, section 8(2) of the Hospital Insurance Regulations under the Hospital Insurance and Health and Social Services Administration Act also states that: “The rate payable to a hospital or federal hospital that is situated in a province or territory participating under the federal Act (i.e. Canada Health Act) shall not exceed the rate established for the hospital by that province or territory, less the authorized charge.” Therefore, residents of the NWT are protected from extra billing and charges when receiving insured services both within the territory, and when receiving insured services outside the territory under a reciprocal billing agreement.

b) Details about the process used to investigate extra-billing and user charges (e.g., proactive regular audits of provider billings; reactive investigations triggered by patient complaints, media reports or other sources).

Please use as much space needed below or add extra pages as necessary.

Medical Care Act 8.m (2) (3) (4)

8.(1) The Director may reassess an account for insured services submitted by a medical practitioner, where, as a result of an inspection under section 7, it appears to the Director that(a) all or part of the insured services were not in fact rendered;(b) all or part of the insured services were not medically necessary;(c) all or part of the insured services were not provided in accordance with accepted professional standards and practice; or(d) the nature of the insured services is misrepresented.

(2) Where the Director makes a reassessment under subsection (1),the Director may make any appropriate adjustment in the amount paid to the medical practitioner in respect of the insured services.

(3) If the amount paid to a medical practitioner for insured services was in excess of the benefit payable under the adjustment referred to in subsection(2),the difference between the amount paid and the adjusted amount constitutes a debt to the Government of the Northwest Territories and the Director may recover the amount from the medical practitioner(a) by withholding from benefits payable to the medical practitioner an amount equivalent to the difference between the amount paid and the adjusted amount;(b) by civil action; or(c) pursuant to an agreement between the Director and the medical practitioner providing for the payment of the amount.

(4) If the amount paid to a medical practitioner for insured services was less than the benefit payable under the adjustment referred to in subsection (2), the Director shall pay to the medical practitioner an amount equal to the difference between the amount paid and the adjusted amount.

The NWT has a “complaint-based" system in place, and takes steps to respond to concerns and improve care and services for NWT residents. When a resident has a concern or issue with the care they have received they are first encouraged to speak with their local health provider. If the issue is not resolved they are encouraged to contact their designated Patient Representative to help address the issue and file a formal complaint.

The Medical Care Act includes a provision to allow the Minister of Health and Social Services (the Minister) to establish a Benefits Appeal Committee that could address any matter referred to it by the Minister, including complaints where a physician engaged in extra-billing and charged user fees. At present, there has been no need to establish this committee, because almost all physicians are compensated through contractual agreements with the Government of the NWT.

No audits completed. Mostly salaried physicians All but two physicians in the NWT are on contract with the NT Health Authority and do not bill fee for service. The two NWT Fee for Service Physicians and all visiting specialist use the services of local NWT billing clerks who bill the appropriate fees according to the NWT fee tarif

c) A summary of any extra-billing and user charges investigations during the fiscal year including:

Please use as much space needed bellow or add extra pages as necessary

d) Details on mechanisms to deter patient extra-billing and user charges (e.g., provider fines; plan payment withholding; provider/patient education initiatives; loss of facility accreditation).

Please use as much space needed below or add extra pages as necessary.

Mostly salaried physicians

All but two physicians in the NWT are on contract with the NT Health Authority and do not bill fee for service. The two NWT Fee for Service Physicians and all visiting specialist use the services of local NWT billing clerks who bill the appropriate fees according to the NWT fee tariff

Nunavut

Canada Health Act

Financial Statement of actual amounts of extra-billing and user charges

For the period April 1, 2017 to March 31, 2018

1. Amounts of extra-billing

Extra-billing is defined as a charge by an enrolled physician or dentist to an insured person for an insured service in addition to the amount paid by the provincial/territorial health insurance plan.

Amount of extra-billing levied by enrolled physicians and dentists for insured health services: $ Nil

2. Amounts of user charges

A user charge is defined as any charge for an insured health service, other than extra-billing. This includes any charge levied for insured hospital services, or any non-physician related services provided in conjunction with an insured physician service at a non-hospital facility (e.g., private clinic or private practice).

Amount of user charges levied for insured services: $ Nil

N.B.  Charges may be levied for accommodation and meal costs related to a patient who, in the opinion of the attending physician, is a permanent resident in a hospital or other chronic care institution as per the limitation of Section 19 (2).  Charges related to this limitation should not be included in the financial statement.

Total for extra-billing and user charges $ Nil

3. Description of method used to determine amounts of extra-billing and user charges

The following information should be included in description of the method used to determine the amounts of extra-billing and user charges (EBUC) reported, including if a NIL amount is submitted: 

a) Name of applicable pieces of PT legislation that prohibit extra-billing and user charges (including facility fees).

Please use as much space needed below or add extra pages as necessary.

Not applicable - the Government of Nunavut contracts directly with physicians and dentists and has direct ownership of all health facilities - insured patients are not billed for insured services. The Medical Care Act, section 14, prohibits extra-billing by physicians unless the medical practitioner has made an election that is still in effect.

b) Details about the process used to investigate extra-billing and user charges (e.g., proactive regular audits of provider billings; reactive investigations triggered by patient complaints, media reports or other sources).

Please use as much space needed below or add extra pages as necessary.

Not needed - the Government of Nunavut contracts directly with physicians and dentists and has direct ownership of all health facilities - insured patients are not billed for insured services.

The Department does not have a specific complaints office solely for extra-billing. However, the Department has other mechanisms for Nunavummiut to register concerns regarding their health care service and can be reached at

NHIP@gov.nu.ca
Nunavut Health Insurance Programs Office
Department of Health
Box 889
Rankin Inlet, NU
XOC 0G0
Toll Free: (800) 661-0833

c) A summary of any extra-billing and user charges investigations during the fiscal year including:

Please use as much space needed bellow or add extra pages as necessary.

Not needed - the Government of Nunavut contracts directly with physicians and dentists and has direct ownership of all health facilities - insured patients are not billed for insured services.

d) Details on mechanisms to deter patient extra-billing and user charges (e.g., provider fines; plan payment withholding; provider/patient education initiatives; loss of facility accreditation).

Please use as much space needed below or add extra pages as necessary.

Not needed - the Government of Nunavut contracts directly with physicians and dentists and has direct ownership of all health facilities - insured patients are not billed for insured services.

Annex E - Reimbursement Action Plans & Progress Reports

Under the Reimbursement Policy, provinces and territories (PT) subject to a Canada Health Transfer (CHT) deduction as a result of patient charges are eligible for reimbursement should they demonstrate action has been taken to come into compliance with the Canada Health Act and the patient charges have been eliminated.

Following a CHT deduction as a result of patient charges, Health Canada officials work collaboratively with PT officials to reach a mutually agreed upon Action Plan. Given the circumstances leading to deductions will vary by jurisdiction, so too will the conditions for reimbursement, and the resulting Action Plans. However, the overarching objective of the Reimbursement Policy is the effective elimination of patient charges.

In addition to the Reimbursement Action Plan, PTs must submit annual progress reports to Health Canada that outline the degree to which the plan has been implemented. Upon review of the jurisdiction's report, if Health Canada is satisfied that key elements of the Action Plan have been fulfilled, the PT could receive a partial or full reimbursement. Following an initial deduction and reimbursement cycle, if Health Canada remains satisfied that patient charges have been eliminated, the Reimbursement Policy allows for the immediate reimbursement of subsequent CHT deductions.

Action plans, and PT progress reports on meeting their plans, are published on the following pages.

For further details on the Reimbursement Policy please refer to Annex B which includes the full text.

[Following is the text of the British Columbia Extra-Billing Elimination Action Plan and December 2020 Status Update]

British Columbia’s Extra Billing Elimination Action Plan

This report outlines British Columbia’s (BC) Action Plan to address extra-billing. Central to the plan is the implementation of Bill 92, the amendment to the BC Medicare Protection Act (Appendix A), which strengthens the province’s legislative provisions against extra billing.

Background

The Canada Health Act requires the Federal Government to impose financial penalties on provinces where extra billing has occurred. As a result, BC has been subject to reductions in the amount it receives under the Canada Health Transfer. Previous federal deductions reported by BC to Health Canada have been approximately $200,000 per year. In 2017-2018, the Ministry of Health (MoH) audited three private clinics. Based on the audits, Health Canada estimated that extra billing in BC for the 2015-2016 fiscal year was $15.9 million and as a result, BC’s federal health funding was reduced by that amount.

In the spring of 2018, BC’s Minister of Health announced, in part to bring BC in compliance with the Canada Health Act, that the Government would bring into force the remaining provisions of the 2003 Bill 92 to address the province’s ability to respond to and address extra billing. Most of these provisions came into force on October 1, 2018. The key changes include:

In addition to the above changes, Bill 92 includes a prohibition for charging in relation to diagnostic services (s. 18.1). This provision is scheduled to take effect on April 1, 2019.

Bringing into force these provisions serves to strengthen enforcement against extra billing and reinforces the province’s commitment to universal public health care.

The enforceability of the Bill 92 provisions has been challenged in Court in Cambie Surgeries Corporate v. British Columbia (Attorney General). On November 23, 2018, the BC Supreme Court issued an injunction enjoining the enforcement of the extra billing provisions in the Act until June 1, 2019 or further order of the Court (the Court Order). BC is appealing this decision.

Since BC’s announcement to bring into force Bill 92, a number of steps have been taken. The following provides a summary of the province’s approach to implementation.

Physician/Clinic Notification

A letter serving notice of the changes was issued to all registered medical practitioners, accredited diagnostic facilities and private surgical clinics on September 10, 2018 (Appendix B). These letters were sent via registered mail to ensure there is a record of them being delivered.

Sections of the BC government website aimed at medical practitioners – have been updated to articulate the changes that have been made. This includes an FAQ document for practitioners, as well as contact information for further questions (Appendix C).

Partners/Stakeholders

Briefings were conducted prior to October 1, 2018, with various associations including: Doctors of BC, the BC College of Physicians and Surgeons, the Canadian Medical Protective Association and the Vice Presidents of Medicine for the Health Authorities, to ensure awareness around the legislative changes and new expectations.

Public Awareness

On April 4, 2018, the MoH issued a press release announcing the province would be bringing into force the remaining provisions of Bill 92, effective October 1, 2018. An additional press release was issued on September 7, 2018, providing an overall update on Bill 92 and reporting a six-month extension to April 1, 2019 of the Medicare Protection Act measures applicable to diagnostic services.

A number of relevant sections of the BC government website aimed at the public have been updated to prominently feature alerts that will link patients directly, through multiple paths, to information concerning extra billing. These include:

The MoH will monitor ongoing patient inquiries and consider additional formats to make information available to the public, as required.

Health Authority Contracts

Currently, there are ten contracts between Health Authorities and private clinics for surgical services. The MoH issued a letter on September 13, 2018 notifying all Health Authorities of expectations about contracting between Health Authorities and private clinics for the provision of medical services (Appendix E). This included a requirement for all Health Authorities to amend their current surgical services contracts with private clinics to include termination provisions in the event of extra billing. As a requirement of the amended contracts, medical practitioners and clinics have been required to sign compliance statements (Appendix F). This letter of expectations was revised following the Court Order (Appendix G), as was the compliance statement – which is now referred to as a “notice to physician” (Appendix H).

Medical Services Commission – Compliance and Monitoring

The MoH has developed a series of operational processes to protect patients from extra billing. However, due to the recent Court Order, the Ministry is not able to implement these processes at this time. These processes include: processing complaints, investigating allegations and making a determination as to whether extra billing has taken place. Once the Ministry is able to move forward, these processes will enable the Medical Services Commission to reimburse beneficiaries directly, assume debt on behalf of a beneficiary and recover the charge from the practitioner and/or clinic. In addition, once enforcement is not prohibited by the Court Order, extra billing offences may be referred to the MoH’s Audit and Investigations Branch and the Special Investigations Unit for the purpose of recommending charges and penalties, where appropriate. As noted above, the Ministry is appealing the recent Court Order and will be seeking for the injunction to be overturned.

Diagnostic Imaging and Laboratory Services

On August 8, 2018, the Honourable Ginette Petitpas Taylor, Minister of Health Canada, wrote to BC Minister of Health, Adrian Dix, regarding the Federal Government’s Diagnostic Services Policy. In the letter, Minister Petitpas Taylor stated:

“I fully appreciate that it may take time in some jurisdictions to align provincial and territorial systems with the Diagnostic Services Policy. As I indicated in Winnipeg, the policy will not take effect until April 1, 2020, and reporting on any patient charges for diagnostic services will begin in December 2022 (for the fiscal year 2020-2021.) That would mean, in accordance with the Canada Health Act, that any Canada Health transfer deductions would only be made in March 2023. If in the interim, a jurisdiction has eliminated patient charges for diagnostic services, that jurisdiction would be eligible for reimbursement of deducted funds through the new Reimbursement Policy.”

Further, on September 20, 2018, Deputy Minister of Health Canada, Simon Kennedy emailed all of the provinces and territories on the issue of the diagnostic services. In his email, it stated:

“You will note the Minister has indicated that the Diagnostic Services Policy will take full effect from April 1, 2020. This policy is a clarification of the application of the CHA to diagnostic services. It confirms the federal position that medically necessary diagnostic services are insured services, regardless of the venue where the services are delivered. This means that provinces and territories not currently reporting to Health Canada on patient charges in respect of medically necessary diagnostic services will be required to do so as of December 2022 (for the fiscal year 2020-21). This extended phase-in period is to allow any jurisdiction where patient charges for diagnostic services are permitted to make the changes necessary to align with the Policy. Naturally, moving earlier than 2020-21 to eliminate such charges is strongly encouraged.”

BC is committed to addressing patient charges for diagnostic services. To that end, in March 2018, the BC Surgical and Diagnostic Imaging Strategy was announced which seeks to provide faster access and to reduce wait times for all medical imaging modalities within the province. The priority focus for 2018-2019 was providing faster access to magnetic resonance imaging (MRI), which included by performing 37,000 more MRI exams by the end of March 2019, establishing a centralized intake and pooled referrals approach (where appropriate) and to reduce wait times for high priority patients. To support these initiatives, $11 million in additional funding was made available to the Health Authorities.

  1. MRI Volumes
    • In 2018-2019, the target number of publicly-funded MRI exams performed is 225,000.
    • This is approximately 35,000 more MRI exams performed than in 2017-2018.
    • Year-to-Date (Period 6, up to September 20, 2018), BC has performed 103,683 MRI publicly-funded MRI exams, which is:
      • 971 above the 2018-2019 YTD Period 6 target; and
      • 25,607 more MRI exams performed compared to 2017-2018 YTD Period 6.
  2. MRI Inventory
    • There are 31 MRI units in the province operating over 800 hours per week.
    • There is an expected deployment of 9 net new MRI units over the next two years. There may be more net new MRI units as further business cases are approved by the Ministry.
    • The 9 net new MRI units include 2 private MRI clinics that were recently purchased by Fraser Health Authority and the new clinics will start seeing patients in early 2019.
    • There are no active contracts between Health Authorities and private clinics to perform MRI exams, but there are 7 contracts that are ready for demand if needed.
  3. HHR Recruitment and Retention
    • All Health Authorities, except Northern Health Authority, were able to recruit more MRI technologists to meet their needs. This includes the addition of 17 MRI technologists in the Lower Mainland.
    • The Northern Health Authority has had issues with recruiting and retaining MRI technologists. To secure MRI technologists coverage, they are contracting with an out-of-province agency for locums, aggressively recruiting for full-time FTEs (three positions currently posted), and investigating other options to overcome the shortage, such as working with other Health Authorities to share resources.

BC believes the above steps will address the demand for medically necessary MRIs in the province. In addition, as of April 1, 2019, BC will bring into effect Section 18.1 of the Medicare Protection Act, which will make it illegal for a medical practitioner to charge for diagnostic imaging. This will deter the private delivery of the service and provide greater protection to patients being charged for medically necessary diagnostic services.

With regard to the Laboratory Services Act, the Ministry plans to bring forward in the fall/winter of 2019-2020 a proposed series of consequential amendments for Cabinet to consider. These changes are not anticipated to be material in nature; rather, they are to ensure elements in the Laboratory Services Act are consistent with the updated Medicare Protection Act.

Audits of Private Clinics

The MoH has completed three audits of private clinics – False Creek Healthcare Centre, Seafield Surgical Centre, and Okanagan Health Surgical Centre. The results of these audits were shared with Health Canada in accordance with the agreement signed by our respective ministers in 2017.

The MoH has established an audit unit that is responsible for the ongoing audit of existing private surgical centers, and in the 2018-2019 fiscal year is aiming to complete a further three audits, subject to impediments due to the Court Order, bringing the total completed and underway to ten, including Cambie. The clinics are selected on a risk-based approach, taking into account factors such as complaints made by patients, types of services offered, number of physicians providing services and evidence from clinics’ websites that they extra bill.

The purpose of the audits is two-fold:

  1. To monitor and assess compliance with the Medicare Protection Act, and
  2. To help determine an accurate estimate of the extent of extra billing in the province.

Subject to clarification from the Court, the MoH is committed to full transparency and will continue to work with Health Canada in reviewing audit findings as the work is completed. Going forward, it is suggested that the monthly conference calls to discuss audit findings are re-established.

Reporting Requirements

BC commits to submitting a complete and accurate 2016-2017 extra billing and user charges financial statement to Health Canada in December 2018, per the reporting requirements set out in the Canada Health Act and Regulations.

As per the Reimbursement Policy, BC also commits to submitting a January 2019 report to Health Canada, assessing the degree to which the elements of the Action Plan have been completed. This report will include:

Conclusion:

In summary, BC’s MoH is appealing the Court Order to be able to use the Bill 92 provisions, and, if successful, will monitor and assess the impact of the implementation of Bill 92. BC’s MoH will also determine whether further changes to policy and/or legislation are warranted to address extra billing. By moving forward with the above noted actions, BC believes it has taken the necessary steps to address extra billing within the province and is seeking reimbursement from Health Canada for the 2018-2019 $15.9 million penalty.

Status Update: Implementation of BC’s Extra-billing Elimination Action Plan December 2020

Pursuant to sections 18 and 19 of the Canada Health Act (CHA), we submit the December 2020 status update to British Columbia’s Extra-billing Elimination Action Plan.

We believe that the status update below demonstrates BC’s ongoing commitment to upholding the principles of the CHA under challenging circumstances, and we reiterate the expectation that steps are taken under the Federal reimbursement policy to reimburse BC for all extra-billing penalties levied to date, including any penalty that may arise from the filing related to practices in effect in 2018-2019.

On September 10, 2020, the Honourable Mr. Justice Steeves delivered his reasons for judgement in the Cambie Surgeries Corporation v. British Columbia (Attorney General) trial. The decision ruled in the Province’s favour on all counts; all sections of the Medicare Protection Act (MPA) being challenged were upheld. Lawyers for Cambie Surgeries Corporation have applied to appeal the decision.

The Province is pleased to see a successful outcome in this litigation and while this year’s annual report on extra-billing and user charges is focused on the 2018-2019 reporting year, it is important to acknowledge that during the 2018-2019 reporting year, the Province took all actions reasonably within its power to enforce the provisions of the MPA and uphold the principles of the CHA given the various forms of injunction that were in place throughout that reporting year. A timeline of the various injunctions follows.

Given the success of the Province in the litigation, the expectation is that BC will receive the balance of $32.8 million of Canada Health Transfer funds previously withheld by the Federal Government and that future deductions are not applied.

Background

In October 2018, BC brought the remaining provisions of the 2003 Bill 92 into force to address the province’s ability to respond to extra-billing and to bring BC into compliance with the CHA.

The key changes to the MPA include the following:

Impact of Litigation

The following timeline covers the cumulative impact of Cambie Surgeries Corporate vs. British Columbia (Attorney General) on the implementation of Bill 92.

BC has committed significant resources and incurred significant expense to the successful conclusion of this trial as we work towards the appeal hearing next year, and will continue to exercise its legislative authority to ensure compliance with the MPA (within the legal parameters of the new injunction issued on December 8, 2020). The Ministry will focus ongoing enforcement across all potential operations at risk of extra-billing, including previously audited clinics if there are indicators that practices have not changed.

Physician/Clinic Notification

Sections of the BC government website aimed at medical practitioners have been updated and placed on the main landing page to raise awareness amongst physician about what is being communicated to patients regarding appropriate and inappropriate billing.

Public Awareness

The Ministry has provided patients with a description of benefits and a link to the description of extra-billing.

The Ministry also has a description of extra-billing along with the form for submitting a request for investigation for patients who believe themselves to have been extra billed.

Links to the description of extra-billing and the form are also available with the description of Services covered by the Medical Services Plan (MSP), and Services not covered by MSP.

Further to these webpages targeted at patients, the Ministry has also provided physicians with a link to the description of extra-billing so that they may better understand patient expectations for appropriate billing.

British Columbians have the right to expect that they will not be asked by physicians to pay out of pocket for insured services. The Ministry believes that its communication strategy has been effective at reducing those situations and remains committed to working towards their elimination. The Ministry will monitor ongoing patient inquiries and consider additional formats to make information available to the public, as required.

MSC – Compliance and Monitoring

The Ministry works closely with the MSC to ensure that operational processes are designed to protect patients from extra-billing. The Ministry processes patient complaints and investigates allegations of extra-billing to determines whether extra-billing has taken place. Where possible, throughout the investigation, the Ministry seeks to resolve the complaint by communication and education with the physician.

Throughout 2018-2019 the Ministry was subject to various court orders and injunctions related to enforcement of extra-billing which sometimes deterred the ability to investigate complaints.

In 2018-2019 there were a total of 13 patient complaints of which four were investigated. Of the four investigations, there were two investigations performed where extra-billing was determined to have likely occurred. There were two investigations where, based on information provided by the patient, no extra-billing was determined to have occurred.

There were nine patient complaints regarding charges in relation to cataract surgery. In these cases, no official investigation was performed for a variety of reasons (e.g. the Ministry requested additional information from patient and patient never followed up, patient was seeking general information only, or the Ministry was unable to assist further due to the various forms of injunctions that existed throughout 2018-2019).

The Ministry worked closely with the MSC and supporting medical and legal experts, to investigate these complaints in a timely fashion and ensure that both patients and practitioners receive clear expectations for appropriate action.

The Ministry will work with the MSC and the Attorney General to determine the impacts of the December 8, 2020 injunction on operational processes and the ability to proceed with using the powers brought into force by Bill 92. Modifications to operational processes that were being contemplated prior to receipt of the December 8, 2020 injunction included referring cases to the Ministry’s Audit and Investigations Branch and the Special Investigations Unit (SIU).

Health Authority (HA) Contracts

BC has seen successful in curbing extra-billing through government contracts with private clinics. BC is committed to curbing extra-billing and user charges in the province to enhance publicly funded health care.

In 2019-2020, there were 11 facilities which the HAs contracted with in compliance with the CHA to perform surgeries. The Ministry issued a letter on September 13, 2018 notifying all HAs of expectations (“letter of expectation”) about contracting between HAs and private clinics for the provision of medical services. This included a requirement for all HAs to amend their current surgical services contracts with private clinics to include termination provisions in the event of extra-billing. As a requirement of the amended contracts, medical practitioners and clinics have been required to sign compliance statements. Physicians can only provide contracted surgical services once the compliance statement is signed. The letter of expectation and compliance statements were revised following the November 23, 2018 BC Supreme Court injunction prohibiting the enforcement of the extra-billing provisions (s. 17, 18, and 45 of the MPA).

The compliance statement to physicians requires acknowledgement by physicians of the termination provisions in the contract between the HA and their clinic pertaining to extra-billing. These provisions apply to the physician’s service under contract (insured services) as well as services undertaken by the physician in clinics outside of the contract (the latter would be insured services provided at the clinic).

Currently, the regional HAs monitor the surgical contracts for compliance with all provisions. Since implementation in September 2018, the HAs have not terminated any contracts with private surgical clinics over performance or compliance issues. The Ministry is confident that the agreements are being followed by the physicians and HAs. Overall, the Ministry views this current productive dynamic between HAs and clinics (formerly providing private services) as demonstrative of the value of contractual arrangement to bring private surgical services back into the public system. This approach simultaneously eliminates extra-billing practices and enhances the capacity of the public health system to provide needed patient care. See the section ‘BC Surgical and Diagnostic Imaging Strategy’ for data on the number of surgeries performed under HA contracts with private clinics.

BC confirms that False Creek Healthcare Centre has entered into contracts with two HAs, the Vancouver Coastal Health Authority (VCHA), for the period May 1, 2020 to March 31, 2023, and the Fraser Health Authority (FHA), for the period March 3, 2020 to March 31, 2023. For fiscal year 2020-2021, the contract is valued at $6.18 million consisting of $2.84 million from the FHA and $3.34 million from the VCHA. False Creek Healthcare Centre was not under HA contract for the 2018-2019 reporting year. This contract should eliminate extra-billing at False Creek Healthcare Centre, which has been a significant source of extra-billing in previous years.

BC Surgical and Diagnostic Imaging Strategy

In March 2018, the BC Surgical and Diagnostic Imaging Strategy (the strategy) was announced. The strategy aims to fulfil the mandate given by the Premier to the Health Minister to work to reduce wait times and increase access to publicly funded surgeries and diagnostic imaging procedures to benefit people in communities throughout the province. The strategy received $100 million in targeted and ongoing funding in 2018-2019. In 2019-2020, the ongoing funding grew to $125 million.

In 2018-2019 there were 249,878 scheduled surgeries preformed in BC, a 5.7 percent increase over 2016-2017 when 236,491 scheduled surgeries were performed. The Ministry will be working with the HAs to quantify their increased public capacity so that we can better monitor in the future.

Key to achieving the mandate above is maximizing all the surgical capacity we have. In BC, as in other provinces, this includes private surgical centres. Contracting with these centres increases publicly funded access for patients whose surgical day procedures can be done safely and efficiently in the community, leaving our hospital capacity for more complex surgeries and procedures. BC has worked with the HAs and has now negotiated agreements valued at $67.9 million. Under contract arrangements with these clinics 11,706 surgeries were performed under contract in 2018-2019 - compared to 2017-2018 when 9,355 were performed. By negotiating contracts with private clinics to provide beneficiary services instead of extra-billing services BC has acted to prevent future extra-billing.

As an estimate of the impact, we would note that the Ministry has increased HA contracts, or extended additional contracts, to private surgical clinics found previously to be extra-billing. These contracts additions should eliminate an approximate equivalent in private billing. With these contracts, the HAs have moved from short term to multi-year terms of service (while maintaining termination clauses should extra-billing occur). The stability of these contract arrangements will keep former private capacity in the public system in a sustainable manner.

In addition to these steps, BC is also increasing public system capacity within HAs. This includes opening new operating rooms and extending the operating hours for others in our hospitals. In 2018-2019 operating rooms ran over 19,500 more hours than 2017-2018. Through this strategy BC demonstrates its continued commitment to addressing patient extra-billing, as defined under the CHA.

MRI Volumes

With respect to medical imaging, in 2018-2019, BC conducted 233,369 MRI exams compared to 173,678 MRI exams in 2016-2017 and 189,376 in 2017-2018. This is a 34.4 percent increase since 2016-2017.

This achievement was made by:

MRI Capacity

In 2017-2018 11 MRI units regularly operated for more than 112 hours per week each, of these only one unit was operating on a 24/7 rotation. By the end of 2018-2019, 18 MRI units are regularly operating above 112 hours per week, of these, 8 MRI units in growing urban areas are operating at a 24/7 staffing rotation. From the beginning of 2018-2019, MRI operating hours increased by more then 560 hours per week, with the 33 units operating over a combined 3,700 hours per week.

In 2018-2019 three net-new MRI units are operational in BC, including:

These two outpatient clinics were previously operating privately. The exams they perform are a direct reduction in the amount of private billing for diagnostic services in BC.

BC expects to make further gains in improving access through new MRI capacity that has been brought online. Since December 2018, seven net-new units are operational in BC, including:

At growing urban sites in Victoria and Surrey the new MRI units installed this past fiscal year are the latest technology, they are state-of-the-art 3T MRI units which can perform scans more quickly, with no reduction in image quality and allow for quicker patient turnaround times

These are the first 3T units within the province for adult populations. Three more net-new units are planned to be operationalized in the upcoming year.

Health Human Resources (HHR)

BC and HAs are working together to ensure the continuation of health services and supply of staff in key roles and occupations during the pandemic period, while continuing to develop and implement long-term plans for increased access.

The Ministry has developed and implemented A Commitment to Surgical Renewal in BC, which will ensure the province is positioned to handle both the backlog in surgeries and the needs of COVID-19 patients:

The Ministry is also continuing to implement other priority HHR initiatives through the pandemic period:

Certain priority occupations are also receiving additional support. The Ministry and AEST have taken the following action to support the capacity of occupational therapy and physiotherapy:

In addition to these steps, the Ministry and AEST have taken the following action to support the capacity of diagnostic services:

Finally, BC committed in July 2020 to a one-time investment of $4.4 million in for health profession-related education and training at BC post-secondary institutions:

Laboratory Services

Medically required laboratory services are publicly funded under the Laboratory Services Act (LSA). The Minister is responsible for all matters related to laboratory services including the facility approval process, governance, accountability and provision of benefits for all laboratory services in the province. The Agency for Pathology and Laboratory Medicine is now a program under the Provincial Health Services Authority (PHSA). The Agency's mandate is to provide laboratory system oversight and to ensure that clinical laboratory services are sustainable, quality driven, innovative, and support British Columbia's residents and clinicians with access to laboratory services. Since April 1, 2019 PHSA accepted accountability for operational functions assigned by the Ministry to support the LSA.

Since 2005, the Ministry has contracted with MAXIMUS Canada to deliver some of the administrative operations of MSP, PharmaCare and laboratory services (including responding to public inquiries, registering clients, and processing medical and pharmaceutical claims from health professionals). MAXIMUS Canada administers the province's medical and drug insurance plans under the Health Insurance BC program. Policy and decision-making functions remain with the Ministry.

Audits of Private Clinics

In 2017, Health Canada and the Ministry agreed upon a methodology to determine the extent and nature of patient extra-billing in BC, outlined in a Terms of Reference and Letter of Agreement. Since this agreement was put in place, the Ministry has completed six audits of private surgical clinics, bringing the total to seven, including Cambie. The results of these audits were shared with Health Canada in accordance with the agreement signed by our respective ministers in 2017.

In 2018-2019 further audits were put on hold in order to ensure the Ministry complies with the November 23, 2018 BC Supreme Court injunction prohibiting the enforcement of the extra- billing provisions (s. 17, 18, and 45 of the MPA)., but audits resumed in late 2020. As of November 2020, three of four on-sites audits have been conducted, with the fourth being delayed due to increased COVID-19 cases in the Vancouver Coastal Health Region. Although the fourth on-site audit was not conducted, financial information was received from all four clinics and this information formed the basis of our extra-billing estimates for these unaudited clinics.

The Ministry has established an audit unit that is responsible for the ongoing audit of existing private surgical centers, and in 2020-2021 is aiming to complete a further 4 audits bringing the total completed and underway to 11, including Cambie. The clinics are selected on a risk-based approach, considering factors such as complaints made by patients, types of services offered, number of physicians providing services and evidence from clinics’ websites that they extra bill.

The purpose of the audits is two-fold:

  1. To monitor and assess compliance with the MPA, and
  2. To help determine an accurate estimate of the extent of extra-billing in the province.

The Ministry will provide the final audit reports for individual clinics and/or providers to Health Canada subject to any redactions required to comply with the Freedom of Information and Personal Privacy Act (FOIPPA). The Ministry is working through concerns and legalities around posting summarized versions of audit reports online. The Ministry will be adding communication resources for this work and recruitment will be undertaken in the short term. Their first order of priority will be to make sure this is completed and posted in a timely manner.

Subject to clarification from the Court, the Ministry is committed to full transparency and will continue to work with Health Canada in reviewing audit findings as the work is completed.
Monthly conference calls to discuss extra-billing and other pertinent matters including audit findings have been re-established.

Reporting Requirements

BC submitted a complete and accurate 2018-2019 extra-billing and user charges financial statement to Health Canada as per the reporting requirements set out in the CHA and Regulations. BC reported a total of $13,949,979 in extra-billing charges occurred in 2018-2019 according to the agreed-on reporting methodology.

Conclusion

In summary, BC is continuing to monitor and assess the impact of the implementation of Bill 92 given the ongoing litigation (appeal) and injunction issued December 8, 2020. The Ministry will continue work to determine whether further changes to policy and/or legislation are warranted to address extra-billing. BC’s long-term goal is to strengthen the public health care system, eliminate extra-billing, and ensure full compliance with CHA. The specific steps and strategies to reach that goal will evolve to address changing circumstances, but BC’s multi-pronged and robust approach backed by significant resources will stay constant. By moving forward with the above noted actions, BC has taken the necessary steps to address extra-billing within the province and is seeking reimbursement from Health Canada for the 2018-2019 $13.9 million penalty.

The Province has made significant efforts and incurred substantial expense to stop extra-billing over recent years, all within the legal parameters of the ongoing litigation and various forms of injunction that BC has been subject to. Over the course of the Cambie litigation, the Province has spent considerable amount of money defending the public healthcare system.

Given the successful outcome of the Cambie litigation, ongoing efforts to educate and deter extra-billing, and a continued focus on audit and enforcement, we believe that this status update demonstrates BC’s robust commitment to upholding the principles of the Canada Health Act under challenging circumstances, and we expect steps to be taken under the authority of the Federal reimbursement policy to reimburse BC for all extra-billing penalties levied to date, including the balance of $32.8 million of Canada Health Transfer funds previously withheld by the Federal Government and any penalty that may arise from the filing related to practices in effect in 2018-2019.

Statement of Attestation

I attest that the above information captures the full extent of the Ministry of Health’s efforts to eliminate extra-billing and ensure full compliance with the CHA and its Regulations and applicable provincial/ territorial legislation.

January 28, 2021

Philip Twyford
Assistant Deputy Minister, Ministry of Health British Columbia

[Following is the text of the Newfoundland and Labrador Reimbursement Action Plan and Janary 2021 Status Update]

Newfoundland and Labrador Reimbursement Action Plan

Background

In the winter of 2017-2018, the Department of Health and Community Services (HCS) received phone calls from Medical Care Plan (MCP) beneficiaries complaining that they had paid out of pocket for cataract surgery.

Investigation

In February 2018, HCS issued a Public Service Announcement (PSA) in an effort to identify beneficiaries in the province who felt that they had been billed inappropriately for insured cataract surgery and created a hotline for reporting of such instances.

Corrective action through patient reimbursement and further investigation

HCS plans to reimburse patients for the excision of the cataract and intraocular lens replacement at a rate of $574.47 per eye when patients can produce documents verifying that they have paid for cataract surgery in a private clinic until June 15, 2018. The amount of $574.47 represents the professional fees billable for the excision of the cataract ($473.09) and insertion of the intraocular lens ($101.38). HCS is not reimbursing the costs of non-insured services associated with providing cataract surgery in a private clinic.

Legal Declaration

On March 28, 2018, in Jackman v. Newfoundland and Labrador, the Applicants filed an application for declaratory relief with the Supreme Court of Newfoundland and Labrador, General Division, on three matters:

  1. That there is no legislative prohibition to removing a cataractous lens in a private office.
  2. That the removal of a cataractous lens by an ophthalmologist in a private office is a non-insured service.
  3. That a supplementary list of services, when provided by an ophthalmologist in a private clinic, are non-insured services.

On March 6, 2019, Justice Goodridge declared that:

  1. Prior to June 15, 2018, there was no legislative prohibition to removing a cataractous lens in a private office.
  2. Prior to June 15, 2018, the removal of a cataractous lens by an ophthalmologist in a private clinic was an insured service.
  3. The supplementary list of services provided are non-insured services when provided in a private clinic.

Corrective action through legislative and policy amendments

Conclusion

This action plan was created as part of the Reimbursement Policy under the Canada Health Act and with the intention of eliminating patient charges for medically necessary cataract surgery. These efforts have been made in hopes of obtaining a reimbursement for Canada Health Transfer deductions in the amount of $1,349 taken in March 2019 for fiscal year 2016-2017, and in hopes of obtaining an immediate reimbursement for deductions resulting from the remaining patient charges that occurred in subsequent fiscal years.

January 2021 Status Report, Implementation of Newfoundland and Labrador’s Reimbursement Action Plan

Summary of Past Actions

Starting in late 2017, the Department of Health and Community Services (HCS) began receiving phone calls from Medical Care Plan (MCP) beneficiaries complaining about out-of-pocket charges being levied for cataract surgery. In February 2018, HCS issued a Public Service Announcement (PSA) and created a Cataract Surgery Information Line in an effort to identify beneficiaries who may have been billed inappropriately for insured cataract surgery.

On June 15, 2018, amendments to the Medical Care Insurance Insured Services Regulations were introduced to clarify that “the medically necessary removal and replacement of a cataractous lens by any procedure is an insured service and shall be performed in a hospital or a facility designated by the Lieutenant-Governor in Council”.

As of January 1, 2019, HSC adopted the aspheric lens as the new standard, ensuring that patients would no longer be billed for the basic lens associated with cataract surgery.

In January 2019, HCS announced that cataract surgery would be available in private offices throughout the province in the near future. In April 2019, an Amending Agreement to add Schedule “O” to the 2013-2017 Memorandum of Agreement was signed by HCS and the Newfoundland and Labrador Medical Association (NLMA).  Schedule “O” outlines an agreement between HCS and the NLMA with respect to service fees for cataract surgeries performed in designated facilities.

Corrective Action through Patient Reimbursement and Further Investigation

Following the 2018 PSA, HCS issued another PSA on the Reimbursement Process for Cataract Surgeries on February 20, 2020. As part of this process, HCS directly contacted 97 individuals who had previously reached out to HCS via the Cataract Surgery Information Line of 2018:

As part of the Reimbursement Process, HCS has reviewed information provided from an additional 83 new patients that had not previously contacted HCS. To date, the Reimbursement Process has identified 133 patients (230 eyes) for reimbursement and has denied 45 patients who did not meet the eligibility criteria established under the Reimbursement Process for Cataract Surgeries.

There were several reasons patients did not meet the eligibility criteria for reimbursement. For example, under the Reimbursement Process, June 15, 2018, was established as the cut-off date for reimbursement. This date coincided with the coming into force of the legislative amendments. As such, patients whose procedures were performed after June 15, 2018, were not eligible for reimbursement. In other instances, the documentation submitted by the patient may not have provided sufficient evidence that the service provided was an insured cataract procedure. For example, the invoice evidence may have shown that the service provided was an uninsured vision correction procedure.

The review process remains open to allow patients extra time to submit information to HCS for review. 

Proactive Action Through Policy for New Non-Hospital Designated Facilities

In 2020, HCS developed the Policy for the Provision of Cataract Surgery in Non-Hospital Designated Facilities, which outlines the requirements and expectations for these facilities. Section 14.1 of the policy specifically deals with expectations regarding extra-billing and user charges, which are prohibited. The ophthalmologist has a duty to make sure that the patient understands that all insured services are available without any charge (to the patient). Non-hospital designated facilities must provide an itemized list of services billed to ensure clarity between insured and billable non-insured services.
Non-hospital designated facilities must post a Patient Information Sheet in visible areas for public viewing in their offices. They must also provide a copy of this information sheet to all patients who are receiving cataract surgery in the designated facility to sign. HCS will investigate any patient complaints of suspected extra-billing or user charges. The Lieutenant-Governor in Council has the authority to suspend or cancel a non-hospital facility’s designation status if the non-hospital designated facility has failed to comply with the policy.

In January 2021, the Lieutenant-Governor in Council designated two non-hospital facilities to provide insured cataract surgery.

Contact Information

Contact information is provided below for residents who believe they may have been subject to inappropriate patient charges for insured health services.

Refer to Chapter 1 for key definitions under the Canada Health Act. For detailed information on what health services are insured under provincial or territorial health insurance plans, refer to section 2.0- Comprehensiveness, under each provincial and territorial section.

Newfoundland and Labrador

1-866-449-4459 (Avalon area)
1-800-563-1557 (all other regions)
1-709-726-8546 (Complaints Coordinator at the College of Physicians and Surgeons)
complaints@cpsnl.ca

Prince Edward Island

Prince Edward Island Department of Health and Wellness
P.O. Box 2000
Charlottetown, PEI
C1A 7N8
1-902-368-6414

Nova Scotia

Department of Health and Wellness
P.O.  Box 488
Halifax, NS
B3J 2R8

1-902-424-5818
1-800-387-6665 (toll-free in Nova Scotia)
1-800-670-8888 (TTY/TDD)

New Brunswick

Medicare Prescription Drug Plan

Quebec

Covered services accessory costs

Ontario

1-888-662-6613
protectpublichealthcare@ontario.ca

Manitoba

Manitoba Health Seniors and Active Living
300 Carlton Street
Winnipeg, MB
R3B 3M9
1-800-392-1207

Saskatchewan

Saskatchewan Ministry of Health
1-800-667-7766
info@health.gov.sk.ca

Alberta

Alberta Health
Attention: Alberta Health Care Insurance Plan
P.O.  Box 1360, Stn Main
Edmonton, AB
T5J 2N3
1-780-427-1432 (Edmonton)
1-310-0000 then 780-427-1432 (toll-free in Alberta)
780-422-0102 (fax)
health.ahcipmail@gov.ab.ca

British Columbia

Additional fees and charges

Yukon

Yukon Medical Council
1-867-667-3774
ymc@gov.yk.ca
Yukon Medical Council Complaint Process

Northwest Territories

Health Services Administration Office, Health and Social Services
Bag#9
Inuvik, NT
X0E OTO
1-800-661-0830
1-867-777-7400
1-867-777-3197 (fax)

Nunavut

Nunavut Health Insurance Programs Office
Department of Health
Box 889
Rankin Inlet, NU
X0C 0G0
1-800-661-0833 (toll free)
NHIP@gov.nu.ca

Footnotes

Footnote 1

https://www.health.gov.nl.ca/health/mcp/healthplancoverage.html

Return to footnote 1

Footnote 2

3(1)(b) surgical-dental treatment properly and adequately provided to a beneficiary and carried out in a hospital by a dentist if the treatment is of a type specified in the Schedule to the Medical Care Insurance Physicians and Fees Regulations ; https://www.assembly.nl.ca/Legislation/sr/Regulations/rc960021.htm#3_

Return to footnote 2

Footnote 3

https://www.health.gov.nl.ca/health/dentalservices/general_info.html#5

Return to footnote 3

Footnote 4

https://www.nlma.nl.ca/FileManager/Publications/Guides/nlma-physicians-guide-to-non-insured-service-june-2018.pdf

Return to footnote 4

Footnote 5

Services covered for recipients of last-resort financial assistance for 12 months or more.

Return to footnote 5

Footnote 6

On June 20, 2019, Ontario announced changes to its Cabinet that included the creation of the Ministry of Health and the Ministry of Long-Term Care. As such, the Ministry of Health and Long-Term Care will be referred to as the Ministry of Health (MOH) throughout this report.

Return to footnote 6

Footnote 7

BC Ministry of Health. (2020, March 17). Joint statement on Province of B.C.'s COVID-19 response, latest updates. Retrieved from https://news.gov.bc.ca/releases/2020HLTH0089-000505 .

Return to footnote 7

Footnote 8

BC Ministry of Health. (2020, March 18). Province declares state of emergency to support COVID-19 response. Retrieved from https://news.gov.bc.ca/releases/2020PSSG0017-000511 .

Return to footnote 8

Footnote 9

BC Ministry of Health. (2020, April 8). New measures support returning British Columbians, boost response to COVID-19. Retrieved from https://news.gov.bc.ca/releases/2020PREM0019-000657 .

Return to footnote 9

Footnote 10

BC Ministry of Health. (2020, July 21). BC's Restart Plan. Retrieved from https://www2.gov.bc.ca/gov/content/safety/emergency-preparedness-response-recovery/covid-19-provincial-support/bc-restart-plan

Return to footnote 10

Footnote 11

Ibid

Return to footnote 11

Footnote 12

BC Ministry of Health. (2020, August 21). Province introduces new measures to enforce COVID-19 public safety. Retrieved from https://news.gov.bc.ca/releases/2020PSSG0046-001568 .

Return to footnote 12

Footnote 13

BC Ministry of Health. (2020, September). Management of COVID-19: Health Sector Plan for Fall/Winter 2020/21. Retrieved from https://news.gov.bc.ca/files/COVID-19_fall-winter_preparation.pdf

Return to footnote 13

Footnote 14

A new Dentistry Master Agreement was executed in October 2020, that is, after the 2019-2020 Canada Health Act Annual Report reporting period.

Return to footnote 14

Footnote 15

https://www.hss.gov.nt.ca/sites/hss/files/resources/hss-annual-report-2019-20.pdf

Return to footnote 15

Footnote 16

https://www.hss.gov.nt.ca/en/services/d%C3%A9placement-pour-raisons-m%C3%A9dicales/medical-travel-policy

Return to footnote 16

Footnote 17

https://open.alberta.ca/dataset/schedule-of-dental-benefits.

Return to footnote 17

Footnote 18

Details on Medical Travel policy can be found here: https://www.hss.gov.nt.ca/en/services/d%C3%A9placement-pour-raisons-m%C3%A9dicales/medical-travel-policy

Return to footnote 18

Footnote 19

Nunavut Bureau of Statistics, Nunavut Population Estimates by Age Group, Region and Community, 2001 to 2019. Population estimates are based on the 2016 census counts adjusted for net census under coverage. Nunavut totals include unorganized areas and outpost camps.

Return to footnote 19

Footnote 20

Supplementary Appropriation (Operations and Maintenance), No. 3, 2019-2020, 2nd Session, 5th Assembly, Legislative Assembly of Nunavut.

Return to footnote 20

Footnote 21

2019–2020 Capital Estimates, Department of Finance, 2nd Session of the 5th Legislative Assembly.

Return to footnote 21

Footnote 22

Government of Nunavut, Public Accounts 2018-2019, Office of the Auditor General of Canada, Independent Auditor's Report to the Legislative Assembly of Canada 2018-19, page 37. https://gov.nu.ca/sites/default/files/2018-19_public_accounts_-_web_version.pdf

Return to footnote 22

Footnote 23

The amount of the administrative charge is $150.00 when the reimbursement is made under the CFMA, and $50 when the reimbursement is made under the IHFA.

Return to footnote 23

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Organization: Health Canada

Date published: 2021

Cat.: H1-4E / H1-4E-PDF

ISBN: 0842-3202 / 1497-9144 (PDF)

Pub.: 200432

Table of Contents

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:

We also greatly appreciate the extensive work effort that was put into this report by our production team, including desktop publishers, translators, editors and concordance experts, printers and staff of Health Canada.

Minister's Message

I am honoured to present to Parliament and to Canadians the Canada Health Act Annual Report 2019-2020. 

This past year can only be described as challenging on many fronts. The COVID-19 pandemic continues to have a substantial impact on our lives here in Canada and around the globe.  Although the timeframe for this report includes just the early days of the pandemic, those first few months saw Canadians having to make fundamental changes in our daily routines as we worked together to flatten the curve. As we all know, throughout the pandemic, many Canadians have experienced tragic consequences, including the loss of family members, dealing with financial uncertainty, and we have all been adjusting to reduced social interactions and periods of isolation. Yet despite the harsh realities of this past year, I continued to be inspired by the many ways in which Canadians have come together to support one another, and, importantly, to be kind to one another.

I feel strongly that one of the factors that positioned us well to respond to the pandemic is our universal health care system. In fact, a policy brief issued by the United Nations Secretary General, in October 2020, highlights the necessity of universal health coverage to both effectively address the COVID-19 pandemic, and to prepare for future crises. One of the strengths of our health care system is that all eligible residents are insured through their provincial or territorial health care plans. In a time when Canadians are worrying about many things, paying for needed medical care is not one of them. In the midst of this pandemic, it is clear how vitally important universal health care is, and why we must vigorously defend it.  

Upholding the Canada Health Act remains a central component of my mandate. The Act ensures all Canadians have equitable access to health care services based on their need, not on their ability, or willingness, to pay. When patients seek required care, they should not face the barrier of patient charges. It is for this reason that I authorized a deduction from New Brunswick's federal health transfer payments in March 2020. Legislation in the province prevents the coverage of abortion services received outside hospitals and this lack of coverage has directly resulted in patient charges. Additionally, Newfoundland and Labrador and British Columbia were also subject to deductions resulting from patient charges. While it is never my preference to take deductions from provinces or territories, when patients are charged for insured health services, I will take every measure available to me to see such charges come to an end. 

Under the Canada Health Act Reimbursement Policy, when provinces and territories have been subject to a deduction from federal health transfers due to patient charges, they are eligible to receive a reimbursement if they choose to work with Health Canada and take the necessary steps to put a stop to the charges. I am pleased that Newfoundland and Labrador and British Columbia both took action to eliminate the barriers to care that patient charges pose, and as such, qualified for reimbursements under this policy during the reporting period.

In British Columbia, patient charges have been the subject of a lengthy court challenge, Cambie Surgeries Corporation v. British Columbia (Attorney General), which culminated in a landmark judicial decision in September 2020 ruling in favour of the publicly funded health care system. The Court, in its 880 page ruling, affirmed the central principle of Canada's health care system – that care should be based on need, not the ability to pay. The Government of Canada will continue to support British Columbia in its defense of our universally accessible health care system as this case makes its way through the appeals process.

The values which underpin the Canada Health Act, those of equity, fairness, and solidarity, are the very values I think will help us come out of this pandemic collectively stronger as a nation. This past year, Canadians have demonstrated that we will be there for one another, we will protect our most vulnerable, and that we will stand together even when we have to stand apart.

Chapter 1 - Canada Health Act Overview

This section describes the evolution of Medicare in Canada; the Canada Health Act, its key definitions, requirements, regulations, and penalty provisions; and excluded persons and services. It also outlines interpretation letters from former federal Ministers of Health sent to their provincial and territorial counterparts, following months of consultation:

Additionally, in 2002 The Honourable A. Anne McLellan wrote to her provincial and territorial counterparts to outline the Canada Health Act Dispute Avoidance and Resolution process.

The Evolution of Medicare in Canada

Canada’s single-payor public health care insurance system, “Medicare”, is financed through a progressive tax system, which allows risks to be pooled and costs to be shared by all Canadians. Our health care insurance system evolved into its present form over more than six decades. Saskatchewan was the first province to establish universal, public hospital insurance in 1947 and, 10 years later, the Government of Canada passed the Hospital Insurance and Diagnostic Services Act (HIDSA), to encourage provinces and territories to provide universal coverage for these services by sharing in their costs. The unanimous adoption of HIDSA by the federal Parliament launched the largest single program ever undertaken in peace-time Canada, and by 1961, all the provinces and territories had public insurance plans that provided universal access to hospital services. Saskatchewan again pioneered by providing insurance for physician services, beginning in 1962. The Government of Canada enacted the Medical Care Act in 1966, to encourage provinces and territories to provide universal coverage for physician services by sharing in their costs. By 1972, all provincial and territorial plans had been extended to include physician services.

In 1979, at the request of the federal government, Justice Emmett Hall undertook a review of the state of health services in Canada. In his report, he affirmed that health care services in Canada ranked among the best in the world, but warned that extra-billing by doctors and user charges levied by hospitals were creating a two-tiered system that threatened the universal accessibility of care. This report, and the national debate it generated, led to the enactment of the Canada Health Act.

We, as a society, are aware that the pain of illness, the trauma of surgery, the slow decline to death, are burdens enough for the human being to bear without the added burden of medical or hospital bills penalizing the patient at the moment of vulnerability. The Canadian people determined that they should band together to pay medical bills when they were well and income earning. Health services were no longer to be bought off the shelf and paid for at the checkout stand. Nor was their price to be bargained for at the time they were sought. They were a fundamental need, like education, which Canadians could meet collectively and pay for through taxes.

Justice Emmett Hall, Royal Commission on Health Services, 1961

Adopted unanimously by Parliament in 1984, the Canada Health Act, Canada's federal health care insurance legislation, codified the national principles which underpin federal funding for hospital and physician services and added prohibitions on patient charges which threatened to undermine universal access to care.

In Canada, the roles and responsibilities for the health care system are shared between the federal, provincial and territorial governments. The provincial and territorial governments have primary jurisdiction in health care administration and delivery. This includes setting their own priorities, administering their health care budgets and managing their own resources. The federal government, under the Canada Health Act, defines the national principles that are to be reflected in provincial and territorial health care insurance plans.

What is the Canada Health Act?

The Canada Health Act sets out the primary objective of Canadian health care policy, which is “… to protect, promote and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to health services without financial or other barriers.”

The Act establishes criteria and conditions related to insured health services and extended health care services that the provinces and territories must fulfill to receive the full federal cash contribution under the Canada Health Transfer (CHT).  In fiscal year 2019-2020, the CHT was $40,373,000,000. Additional information on federal, provincial and territorial funding arrangements is available by visiting the Department of Finance’s website.

The aim of the Act is to ensure that all eligible residents of Canadian provinces and territories have reasonable access to medically necessary hospital, physician, and surgical-dental services that require a hospital setting on a prepaid basis, without charges related to the provision of insured health care services. A copy of the Act is provided in Annex A.

Key Definitions under the Canada Health Act

Insured health services are medically necessary hospital, physician, and surgical-dental services (performed by a dentist in a hospital, where a hospital is required for the proper performance of the procedures) provided to insured persons.

Extended health care services are certain aspects of long-term residential care (nursing home intermediate care and adult residential care services), and the health aspects of home care and ambulatory care services.

Insured persons are eligible residents of a province or territory. A resident of a province is defined in the Act as “… a person lawfully entitled to be or to remain in Canada who makes his home and is ordinarily present in the province, but does not include a tourist, a transient or a visitor to the province.”

Insured hospital services include medically necessary in- and out-patient services such as accommodation and meals at the standard or public ward level and preferred accommodation if medically required; nursing service; laboratory, radiological and other diagnostic procedures, together with the necessary interpretations; drugs, biologicals and related preparations when administered in the hospital; use of operating room, case room and anaesthetic facilities, including necessary equipment and supplies; medical and surgical equipment and supplies; use of radiotherapy facilities; use of physiotherapy facilities; and services provided by persons who receive remuneration therefore from the hospital.

Insured physician services are medically required services rendered by medical practitioners. Medically required physician services are generally determined by the provincial or territorial health care insurance plan, in consultation with the medical profession.

Insured surgical-dental services are services provided by a dentist in a hospital, where a hospital setting is required for the proper performance of the procedure.

“Thanks to medicare, no one need worry about any financial burden resulting from an unforeseen illness. Since health insurance is a collective program, all Canadians share the cost of medical care for which they could not pay individually. Their taxes provide anticipated payments towards the cost of the insured health services they will eventually need. This program is not only for the young, the wealthy and the healthy. It is designed also to help the poor, the old and the chronically ill. The latter group is the one most affected by the charging of direct fees.”

April 11, 1984 debate on the enactment of the Canada Health Act, statement by Senator Jacques Hébert

The Canada Health Act

Figure

Text description

If the provinces and territories fulfill the Canada Health Act's criteria and conditions:

Five Criteria:

  • Public Administration
  • Comprehensiveness
  • Universality
  • Portability
  • Accessibility

Two Conditions:

  • Information
  • Recognition

And ensure there is no extra-billing and user chargers for insured health services

They are entitled to their full Canada Health Transfer

Requirements of the Canada Health Act

The Canada Health Act contains nine requirements that the provinces and territories must fulfill in order to qualify for the full amount of their cash entitlement under the CHT.

They are:

The Criteria

1.0 Public Administration (section 8)

The public administration criterion of the Canada Health Act requires provincial and territorial health care insurance plans to be administered and operated on a non-profit basis by a public authority, which is accountable to the provincial or territorial government for decision-making on benefit levels and services, and whose records and accounts are publicly audited. However, the criterion does not prevent the public authority from contracting out the services necessary for the administration of the provincial and territorial health care insurance plans, such as the processing of payments to physicians for insured health care services.

The public administration criterion pertains only to the administration of provincial and territorial health care insurance plans and does not preclude private facilities or providers from supplying insured health care services as long as no insured person is charged in relation to these insured health services.

2.0 Comprehensiveness (section 9)

The comprehensiveness criterion requires that the health care insurance plan of a province or territory must cover all insured health care services provided by hospitals, physicians or dentists (i.e., surgical-dental services that require a hospital setting).

3.0 Universality (section 10)

Under the universality criterion, all insured residents of a province or territory must be entitled to the insured health care services provided by the provincial or territorial health care insurance plan on uniform terms and con­ditions. Provinces and territories generally require that residents register with the plan to establish entitlement.

4.0 Portability (section 11)

Residents moving from one province or territory to an­other must continue to be covered for health care services insured by the home jurisdiction during any waiting period imposed by the new province or territory of residence (up to three months), before coverage is established in the new jurisdiction. It is the responsibility of residents to inform their province or territory’s health care insurance plan that they are leaving and to register with the health care insurance plan of their new province or territory, in order to avoid any gaps in coverage.

Residents who are temporarily absent from their home province or territory, or from Canada, must continue to be covered for insured health care services by their home province or territory. If insured persons are temporarily absent in another prov­ince or territory, the portability criterion requires that insured services be paid at the host province’s rate. If insured persons are temporarily out of the country, insured services are to be paid at the home province’s rate.

The portability criterion does not entitle a person to seek services in another province, territory, or country, but is intended to permit a person to receive medically necessary services in relation to an urgent or emergent need when absent on a temporary basis, such as on business or vacation.

Prior approval by the health care insurance plan in a person’s home province or territory may be required before coverage is extended for elective (non-emergency) services to a resident while temporarily absent from their province or territory.

5.0 Accessibility (section 12)

The intent of the accessibility criterion is to ensure that insured persons in a province or territory have reasonable access to insured hospital, medical, and surgical-dental services that require a hospital setting, on uniform terms and conditions, unprecluded or unimpeded, either directly or indirectly, by charges (extra-billing or user charges) or other means (e.g., dis­crimination on the basis of age, health status, or financial circumstances).

Reasonable access in terms of physical availability of medically necessary services has been interpreted under the Canada Health Act using the “where and as available” principle. Thus, residents of a province or territory are entitled to have access on uniform terms and condi­tions to insured health care services at the setting “where” the services are provided and “as” the services are available in that setting. For example, if a hospital in one region of a province was providing highly specialised services, that would not mean that all hospitals in the province would be required to provide the same service. Rather, it means that all residents of the province should have access to the service wherever it is being offered, on the same basis.

In addition, the health care insurance plan of the province or territory must provide:

The Conditions

1.0 Information (section 13[a])

The provincial and territorial governments are required to provide information to the federal Minister of Health as prescribed by regulations under the Act.

2.0 Recognition (section 13[b])

The provincial and territorial governments are required to recognize the federal financial contributions toward both insured and extended health care services.

The Provisions - Extra-Billing  and User Charges

The provisions of the Canada Health Act pertaining to extra-billing and user charges for insured health care services in a province or territory are outlined in sections 18 to 21. If it can be confirmed that either extra-billing or user charges exist in a province or territory, a mandatory dollar‑for‑dollar deduction from the CHT payments to that province or territory is required under the Act.

Extra-Billing (Section 18)

Under the Act, extra-billing is defined as a charge by an enrolled physician or dentist (i.e., a dentist providing insured surgical-dental services in a hospital setting) to an insured person for an insured service in addition to the amount paid by the provincial or territorial health care insurance plan. For example, if an enrolled physician was to charge a patient any amount for an office visit that is insured by the provincial or territorial health care insurance plan, the amount charged would constitute extra-billing. Extra-billing is seen as a barrier or impediment for people seeking medical care, and is therefore also contrary to the accessibility criterion.

User Charges (Section 19)

A user charge is defined as any charge for an insured health care service, other than extra-billing. This includes any charge levied for insured hospital services, or any non-physician related services provided in conjunction with an insured physician service at a non-hospital facility (e.g., private clinic or private practice).  In other words, if patients were charged a fee as a condition of receiving insured health care services, that fee would be considered a user charge. User charges are not permit­ted under the Act because, as is the case with extra-billing, they constitute a barrier or impediment to access.

What is a patient charge?

Figure

Text description
  • If an enrolled physician or dentist…
  • Charges an insured resident…
  • For an insured service…
  • An amount in addition to the amount paid by the provincial or territorial health insurance plan that…
  • is extra-billing.
  • Other charges (e.g., for supplies) related to the provision of insured health services…
  • Are user charges.

Other Elements of the Act

Regulations (Section 22)

Section 22 of the Canada Health Act enables the federal government to make regulations for administering the Act in the following areas:

To date, the only regulations in force under the Act are the Extra-billing and User Charges Information Regulations. These Regulations require the provinces and territories to report annually to Health Canada on the amounts of extra-billing and user charges levied. A copy of these Regulations is provided in Annex A.

Penalty Provisions of the Canada Health Act

Mandatory Penalty Provisions

Under the Act, provinces and territories that allow extra-billing and user charges are subject to mandatory dollar-for-dollar deductions from the federal transfer payments under the CHT. For example, if it is determined that any amount of extra-billing by physicians has occurred in a province or territory, the federal cash contribution to that province or territory will be reduced by that same amount. Although deductions are usually based on informa­tion provided by the province or territory in accordance with the Extra-billing and User Charges Information Regulations, where information is not provided, or is incomplete, Health Canada will make an estimate of the amount of extra-billing and user charges. This process requires consultation with the province or territory concerned. Deductions based on estimates have been made on numerous occasions.

Provincial and territorial financial statements of extra-billing and user charges received during the reporting period are provided in Annex D.

Discretionary Penalty Provisions

Non-compliance with one of the five criteria or two conditions of the Act is subject to a discretionary penalty. The amount of any deduction from CHT payments is based on the magnitude of the non-compliance, and is approved by Cabinet.

The Canada Health Act sets out a consultation process that must be undertaken with the province or territory before discretionary penalties can be levied. To date, the discretion­ary penalty provisions of the Act have not been used.

Excluded Services and Persons

Although the Canada Health Act requires that insured health care services be provided to insured persons in a manner that is consistent with the criteria and conditions set out in the Act, not all health care services or Canadian residents fall under the scope of the Act.

Excluded Services

A number of services provided by hospitals and physi­cians are not considered medically necessary, and thus are not insured under provincial and territorial health care insurance legislation. Uninsured hospital services for which patients may be charged include preferred hos­pital accommodation (unless prescribed by a physician or when standard ward level accommodation is unavailable), private duty nursing services, and the provision of tele­phones and televisions. Uninsured physician services for which patients may be charged include telephone advice (unless it is insured by the provincial or territorial health insurance plan); the provision of medical certificates required for work, school, insurance purposes and most other purposes; the transfer of medical records; testimony in court; and cosmetic services. Amounts for these services are governed by provincial and territorial Colleges of Physicians, which generally require that charges be reasonable and reflect the cost of services provided.

The definition of insured health services exclude services to persons provided under any other Act of Parliament (e.g., certain services provided to veterans) or under the workers’ compensation legislation of a province or territory.

In addition to the medically necessary hospital and physician services covered by the Canada Health Act, provinces and territories also provide a wide range of other programs and services, such as prescription drug coverage, non-surgical dental care, ambulance services and optometric services, at their discretion and on their own terms and conditions. These services are often targeted to specific population groups (e.g., seniors, children, and those receiving social assistance), with levels of funding and scope of coverage varying from one province or territory to another.

Excluded Persons

The Canada Health Act definition of “insured person” excludes members of the Canadian Forces and persons serving a term of imprisonment within a federal penitentiary. The Government of Canada provides coverage to these groups through separate federal programs.

The exclusion of these persons from insured health care service coverage predates the adoption of the Act and is not intended to constitute differences in access to publicly insured health care.

Policy Interpretation Letters

There are three key policy statements that clarify the federal position on the Canada Health Act. These state­ments were made in the form of ministerial letters from former federal Ministers of Health to their provincial and territorial counterparts, following months of consultation. Copies of the letters are provided in Annex B of this report.

Epp Letter

In June 1985, approximately one year following the passage of the Canada Health Act in Parliament, federal Minister of Health and Welfare Jake Epp wrote to his provincial and territorial counterparts to set out and confirm the federal position on the interpretation and implementation of the Act. The letter sets forth statements of federal policy intent that clarify the Act’s criteria, conditions and regulatory provi­sions. The letter highlighted the fundamental change signified by the Canada Health Act, which was the prohibition of all patient charges for insured services provided to insured residents.  The Epp letter remains an important reference for assessing and interpreting compliance with the Act.

Marleau Letter - Federal Policy on Private Clinics

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

At the September 1994 federal, provincial and territorial meeting of Health Ministers in Halifax, all Ministers of Health present, with the exception of Alberta’s Health Minister, agreed to “…take whatever steps are required to regulate the development of private clinics in Canada”.

Diane Marleau, the federal Minister of Health at the time, wrote to all provincial and territorial Ministers of Health on January 6, 1995, to announce the new Federal Policy on Private Clinics. The Minister’s letter provided the federal interpretation of the Canada Health Act as it relates to the issue of facility fees charged directly to patients receiving medically necessary services at private clinics. The letter stated that the definition of hospital contained in the Act includes any public facility that pro­vides acute, rehabilitative, or chronic care. Thus, when a provincial or territorial health care insurance plan pays the physician fee for a medically necessary service delivered at a private clinic, it must also pay the facility fee or face a deduction from federal transfer payments.

Petitpas Taylor Letter

On August 8, 2018, the former federal Health Minister Ginette Petitpas Taylor wrote to her provincial and territorial counterparts formalizing three new Canada Health Act initiatives – the Diagnostic Services Policy, the Reimbursement Policy, and strengthened Canada Health Act reporting. These initiatives were the subject of discussion at the federal, provincial and territorial officials’ level and adjustments were made to the requirements of these initiatives based on feedback received from the provinces and territories.

Diagnostic Services Policy

The Diagnostic Services Policy came into effect on April 1, 2020. This policy is a formalization of the application of the Canada Health Act to diagnostic services. It confirms the longstanding federal position that medically necessary diagnostic services are insured services, regardless of the venue where the services are delivered. Under this policy, provinces and territories will be expected to report on patient charges for medically necessary diagnostic services in December 2022 (for any patient charges which occurred during 2020-2021).

DID YOU KNOW? As of April 1, 2020 any patient charges for medically necessary diagnostic imaging services, such as MRI or CT scans, regardless of where these services are provided, are contrary to the Canada Health Act.  If you believe you have been charged inappropriately, you may report these charges to your provincial or territorial health ministry, using the phone numbers provided inside the back cover of this report.  You may also contact the Canada Health Act Division of Health Canada at the following coordinates:

Canada Health Act Division
A.L. 0908C Brooke Claxton Building
Ottawa, Ontario K1A 0K9

medicare_hc@hc-sc.gc.ca
Reimbursement Policy

Should a province or territory be subject to a mandatory deduction, the federal Minister of Health has the discretion to provide a reimbursement if the province or territory eliminates the patient charges that led to the deductions within a specified timeframe. The first deductions eligible for reimbursement under the policy were those taken in March 2018.

Strengthened Canada Health Act Reporting

The aim of strengthened Canada Health Act reporting is to ensure Health Canada has the information required to accurately assess compliance with the Act, as well as to increase transparency for Parliament and Canadians on the administration of the Act, and the state of the publicly funded health care insurance system.

Dispute Avoidance and Resolution Process

In April 2002, former federal Minister of Health A. Anne McLellan outlined in a letter to her provincial and territorial counterparts a Canada Health Act Dispute Avoidance and Resolution process, which was agreed to by provinces and territories, except Quebec. The process meets federal, provincial and territorial interests of avoiding disputes related to the interpretation of the criteria of the Act and, when this is not possible, resolving disputes in a fair, transparent, and timely manner.

The process includes the dispute avoidance activities of government-to-government information exchange; dis­cussions and clarification of issues as they arise; active participation of governments in ad hoc federal, provincial and territorial committees on Act-related issues; and Canada Health Act advance assessments of proposed provincial and territorial policies, regulations and legislation, upon request.

Where dispute avoidance activities prove unsuccessful, dis­pute resolution activities may be initiated, beginning with government-to-government fact-finding and negotiations. If these are unsuccessful, either Minister of Health involved may refer the issues to a third-party panel to undertake fact-finding and provide advice and recommendations.

The federal Minister of Health has the final authority to interpret and enforce the Canada Health Act. In de­ciding whether to invoke the non-compliance provisions of the Act, the Minister will take the panel's report into consideration.

A copy of Minister McLellan's letter is provided in Annex C of this report.

Chapter 2 - Administration and Compliance

Administration

In administering the Canada Health Act, the federal Minister of Health (the Minister) is assisted by Health Canada staff and by the Department of Justice.

The Canada Health Act Division

The Canada Health Act Division of Health Canada is responsible for supporting the Minister in the administration of the Canada Health Act. Members of the Division fulfill the following ongoing functions:

Canada Health Act Compliance

The Canada Health Act Division monitors the operations of provincial and territorial health care insurance plans in order to provide advice to the Minister on possible non-compliance with the Canada Health Act. Sources for this information include: provincial and territorial government officials and publications; non‑governmental organizations; media reports; and correspondence received from the public.

Staff in the Canada Health Act Division assess issues of concern and complaints on a case-by-case basis. The assessment process involves compiling all facts and information related to the issue and taking appropriate action. Verifying the facts with provincial and territorial health officials sometimes reveals issues that are not directly related to the Act, while others may pertain to the Act but are a result of misunderstanding or miscommunication, such as eligibility for health care insurance coverage and portability of health services within and outside Canada. In these instances, matters are generally resolved quickly with provincial or territorial assistance.

In instances where a Canada Health Act issue has been identified and remains after initial enquiries, Division officials ask the jurisdiction in question to investigate the matter and report back. Division staff discuss the issue and its possible resolution with provincial or territorial officials. Only if the issue is not resolved to the satisfaction of the Division after following the aforementioned steps, is it brought to the attention of the federal Minister of Health.

Deductions and Reimbursements under the Act

For the most part, provincial and territorial health care insurance plans meet the criteria and conditions of the Canada Health Act. However, some issues and concerns remain. The most prominent of these relate to accessibility issues, and specifically patient charges for medically necessary health services at private clinics. There are also concerns under the portability criterion.

Newfoundland and Labrador

On the basis of its health ministry's initial report to Health Canada, a deduction in the amount of $70,819 was taken from the March 2020 Canada Health Transfer (CHT) payments to Newfoundland and Labrador in respect of user charges for insured health services provided by an enrolled physician at a private ophthalmological clinic in fiscal year 2017-2018. Because the province had already worked collaboratively with Health Canada to create a mutually agreed-upon Reimbursement Action Plan (RAP) to eliminate these patient charges, and had carried out the plan by eliminating those charges, it received a reimbursement of both its March 2019 and March 2020 deductions. A copy of Newfoundland and Labrador's RAP as well the January 2020 status update on its implementation are presented in Annex E of this report.

New Brunswick

In New Brunswick, surgical abortion services are insured under the provincial health insurance plan but are only covered if performed in hospital; procedures provided in the now-closed private clinic in Fredericton were not covered. Health Canada has raised this issue with New Brunswick at the officials' level and Ministerial levels. The Minister wrote to her New Brunswick counterpart to communicate her concerns about the lack of coverage for abortion services outside hospital, in February 2020.

Although the province's financial statement of extra-billing and user charges for 2018-2019 indicated a nil amount, Health Canada had received evidence of these charges from the Fredericton clinic. On that basis, Health Canada estimated patient charges for fiscal year 2018-2019 in the amount of $140,216, and a deduction in the same amount was taken from New Brunswick's March 2020 CHT payments.

British Columbia

British Columbia submitted a financial statement of extra-billing and user charges during fiscal year 2017-2018, in the amount of $16,753,833. The amount was based on patient complaints, an audit of select clinics (undertaken in 2017 and 2018) and publicly available evidence of $4.7 million of patient charges to insured residents by enrolled physicians at the Cambie Surgical Centre.  A deduction in the same amount was taken from British Columbia's March 2020 CHT payments. British Columbia had already begun to implement elements of its RAP, which it drafted in collaboration with Health Canada after its March 2018 CHT deduction. The elimination of patient charges was hindered by an injunction related to the Charter challenge, known as Cambie Surgeries Corporation v. British Columbia (Attorney General), in the British Columbia Supreme Court. In recognition of the elements of the plan which were successfully implemented during the reporting period, Health Canada authorized a reimbursement of $16,019,539 in March 2020. This represents a partial reimbursement of BC's March 2018 and March 2019 deductions. A copy of the RAP and subsequent status updates are presented in Annex E of this report.

Additional Compliance Issues

Health Canada continues to monitor provincial and territorial compliance with the Act. The following key developments occurred since the 2018-2019 Canada Health Act Annual Report was tabled in Parliament.

Abortion Services

Abortion services are insured in all provinces and territories; however, access to abortion services varies within and between jurisdictions across the country. In addition to the coverage issues in New Brunswick, described earlier in this section, media stories in Ontario have highlighted fees some individuals have been charged to access surgical abortion services in private clinics. Health Canada has learned that while the Ontario Health Insurance Plan provides coverage for physicians' fees related to abortion services in all private clinics, it only covers facility fees in the four private abortion clinics authorized under the province's Independent Health Facilities Act. Health Canada continues to consult with the Ontario health ministry to determine the extent of these patient charges.

Out-of-Country Portability

In April 2019, Ontario announced that it would end its program covering emergency hospital and physician services received by Ontario residents while outside Canada. The province officially eliminated this coverage on January 1, 2020. This was a direct contravention of the Canada Health Act's requirement that provincial and territorial health care insurance plans provide coverage to residents while outside the country. While Health Canada had long been concerned by the coverage levels in some provinces – only Prince Edward Island and the territories appear to be meeting this requirement – Ontario was the first province to eliminate coverage altogether. Its decision to terminate this coverage was overturned in September 2020, as a result of a legal challenge by the Canadian Snowbirds Association. In November 2020, the federal Minister of Health wrote to Ontario, which had initially indicated it planned to appeal this decision, to reiterate that the CHA requires provincial and territorial health insurance plans to provide coverage for Canadians when they are outside Canada.  On November 13, 2020, Ontario abandoned its appeal.

Patient Charges for Medically Necessary Diagnostic Services

As mentioned earlier in this report, in August 2018, the federal Minister of Health wrote to her provincial and territorial counterparts to announce the Diagnostic Services Policy, which formalized the longstanding federal position that medically necessary diagnostic services received in private clinics are considered insured health services. While Saskatchewan is the only province that expressly encourages this practice through legislation, there is evidence of residents paying out-of-pocket to secure faster access to diagnostic services in other provinces, including British Columbia, Alberta, Manitoba, Quebec, New Brunswick, and Nova Scotia. To give jurisdictions time to align their health care systems with the requirements of this policy, the effective date was set for April 1, 2020. Now that the policy is in effect, provinces and territories that permit patients to be charged for these services will be subject to deductions from federal transfers under the Canada Health Act. Provinces and territories will first report on these charges in December 2022. During the reporting period, Health Canada consulted with provinces and territories to offer assistance in preparation for the policy's implementation.

Patient Charges in Primary Health Care Co-Ops

In May 2019, a village in Nova Scotia announced its intent to open a health care co-operative, where patients would be required to purchase a membership and pay monthly dues to receive insured health services. Patient charges, as a condition of receiving insured health services, pose extra-billing and user charges concerns under the Canada Health Act. Health Canada communicated these concerns to the Nova Scotia health ministry, which then conducted an investigation. In follow-up, Nova Scotia reported to Health Canada that the village did not pursue its plans for this co-op. Health Canada considers this issue to be resolved.

During 2019-2020, Health Canada continued to monitor the following ongoing compliance and interpretation issue:

In-Country Portability

Physician services received by Quebec residents when out-of-province are not reimbursed at host province rates, which is a requirement of the portability criterion of the Act. Canadians from provinces and territories other than Quebec also report difficulties having their provincial or territorial health care insurance cards honoured while out-of-province, particularly by walk-in clinics, which runs counter to the spirit of the Act.

History of Deductions, Refunds and Reimbursements under the Canada Health Act

The Canada Health Act, which came into force April 17, 1984, reaffirmed the national commitment to the original principles of the Canadian health care system, as embodied in the previous legislation, the Medical Care Act and the Hospital Insurance and Diagnostic Services Act. By putting into place mandatory dollar-for-dollar penalties for extra-billing and user charges, the federal government took steps to eliminate the proliferation of direct charges for hospital and physician services, judged to be restricting the access of many Canadians to health care services due to financial considerations.

Canada Health Act Compliance from 1984-1987

During the period 1984 to 1987, subsection 20(5) of the Act provided for deductions in respect of these charges to be refunded to the province if the charges were eliminated before April 1, 1987. By March 31, 1987, it was determined that all provinces in which patients had been subject to extra-billing and user charges had taken appropriate steps to eliminate them. Accordingly, by June 1987, a total of $244,732,000 in deductions was refunded to New Brunswick, Quebec, Ontario, Manitoba, Saskatchewan, Alberta, and British Columbia.

Deductions and Subsequent Refunds for Extra-Billing and User Charges from 1984-1987
  1984-1985 1985-1986 1986-1987 Total
NB 3,078,000 3,306,000 502,000 6,886,000
QC 7,893,000 6,139,000 - 14,032,000
ON 39,996,000 53,328,000 13,332,000 106,656,000
MB 810,000 460,000 - 1,270,000
SK 1,451,000 656,000 - 2,107,000
AB 9,936,000 11,856,000 7,240,000 29,032,000
BC 22,797,000 30,620,000 31,332,000 84,749,000
TOTAL 85,961,000 106,365,000 52,406,000 244,732,000

In the first three years after the enactment of the Canada Health Act, almost $245 million in deductions were taken against federal health transfers to provinces, these deductions were refunded when the provinces effectively eliminated the patient charges that led to them.

Canada Health Act Compliance from 1987-2017

Following the Act's initial three-year transition period, during which refunds to provinces and territories for deductions were possible, penalties under the Act did not reoccur until fiscal year 1994-1995. See the chart later in this chapter for penalties occurring from fiscal year 1994-1995 to 2017.

In January 1995, federal Minister of Health, Diane Marleau, expressed concerns to her provincial and territorial colleagues about the development of two-tiered health care and the emergence of private clinics charging facility fees for medically necessary surgical services. As part of her communication with the provinces and territories, Minister Marleau announced that the provinces and territories would be given more than nine months to eliminate these user charges, but that any province that did not, would face financial penalties under the Act. Accordingly, beginning in November 1995, deductions were applied to the cash contributions to Alberta, Manitoba, Nova Scotia, and Newfoundland and Labrador for non-compliance with the Federal Policy on Private Clinics.

British Columbia

In the early 1990s, as a result of a dispute between the British Columbia Medical Association and the British Columbia government over compensation, several doctors opted out of the provincial health care insurance plan and began billing their patients directly. Some of these doctors billed their patients at a rate greater than the amount the patients could recover from the provincial health care insurance plan. This higher amount constituted extra-billing under the Act. Deductions began in May 1994, relating to fiscal year 1992-1993, and continued until extra-billing by physicians was banned when changes to British Columbia's Medicare Protection Act came into effect in September 1995. In total, $2,025,000 was deducted from British Columbia's cash contribution for extra-billing that occurred in the province between 1992-1993 and 1995-1996.

In January 2003, British Columbia provided a financial statement in accordance with the Canada Health Act Extra-billing and User Charges Information Regulations, indicating aggregate amounts actually charged with respect to extra-billing and user charges in private surgical clinics during fiscal year 2000 -2001, totaling $4,610. Accordingly, a deduction of $4,610 was made to the March 2003 Canada Health and Social Transfer (CHST) cash contribution.

In 2004, British Columbia did not report to Health Canada the amounts of extra-billing and user charges actually charged during fiscal year 2001-2002. As a result of reports that British Columbia was investigating 55 cases of user charges, a $126,775 deduction was taken from British Columbia's March 2004 CHST payment, based on the amount the federal Minister estimated to have been charged during fiscal year 2001-2002.

Between 2002-2003 and 2016-2017, deductions totaling $1,773,183 were taken from British Columbia's Canada Health Transfer payments in light of patient charges reported by the province to Health Canada.  The deduction taken to British Columbia's federal health transfers in 2012-2013, in respect of fiscal year 2010-2011, was estimated by the federal Minister of Health and represents the aggregate of the amounts reported to Health Canada by British Columbia and those reported publicly as the result of an audit performed by the Medical Services Commission of British Columbia. This methodology was used until fiscal year 2016-2017.

Alberta

Under the Federal Policy on Private Clinics, total deductions of $3,585,000 were made, from November 1995 until June 1996, to Alberta's cash contribution in respect of facility fees charged at clinics providing surgical, ophthalmological and abortion services. On October 1, 1996, Alberta prohibited private surgical clinics from charging patients a facility fee for medically necessary services for which the physician fee was billed to the provincial health care insurance plan.

Manitoba

From November 1995 to December 1998, deductions totaling $2,055,000 were taken from Manitoba's federal health transfer, under the Federal Policy on Private Clinics. These deductions ended with the confirmed elimination of user charges at surgical and ophthalmology clinics, effective January 1, 1999. However, during fiscal year 2001-2002, a monthly deduction (from October 2001 to March 2002 inclusive) in the amount of $50,034 was levied against Manitoba's CHST cash contribution on the basis of a financial statement provided by the province showing that actual amounts charged with respect to user charges for insured health services in fiscal years 1997-1998 and 1998-1999 were greater than the deductions levied on the basis of estimates. This brought total deductions levied against Manitoba to $2,355,201.

Quebec

In March 2017, on the basis of amounts of extra-billing and user charges reported by the Quebec Auditor General with respect to accessory fees charged in 2014-2015, the federal Minister estimated a deduction amount of $9,907,229. In light of corrective action the provincial government had already taken to eliminate accessory fees in January 2017, that amount was subsequently returned to Quebec by the Government of Canada.

Nova Scotia

With the closure of a private clinic in Halifax effective November 27, 2003, penalties to Nova Scotia for non-compliance with the Federal Policy on Private Clinics ceased. Before it closed, total deductions of $372,135 were made to Nova Scotia's CHST cash contribution for its failure to cover facility charges to patients, while paying the physician fee. A final deduction of $5,463 was taken from the March 2005 CHT payment to Nova Scotia as a reconciliation of deductions that had already been taken for 2002‑2003. A one-time positive adjustment in the amount of $8,121 was made to Nova Scotia's March 2006 CHT payment to reconcile amounts actually charged in respect of extra-billing and user charges with the penalties that had already been levied based on provincial estimates reported for fiscal 2003‑2004.

The March 2007 CHT payment to Nova Scotia was reduced by $9,460 in respect of extra-billing during fiscal year 2004‑2005. This amount was reported to Health Canada by the province based on the findings of an audit, concluded in 2006, of the billing practices of a Nova Scotia physician.

Newfoundland and Labrador

Pursuant to the Federal Policy on Private Clinics, a total of $280,430 was deducted from Newfoundland and Labrador's cash contribution due to facility fees in a private abortion clinic, before these fees were eliminated, effective January 1, 1998.

A deduction of $1,100 was taken from the March 2005 CHT payment to Newfoundland and Labrador as a result of patient charges for an MRI scan in a hospital which occurred during 2002-2003.

From March 2011 to March 2013, deductions totaling $102,249 were taken from CHT payments to Newfoundland and Labrador for extra-billing and user charges, based on charges reported by the province to Health Canada. These charges resulted from services provided by an opted-out dental surgeon who has since left the province and Health Canada considers this matter resolved.

Since the passage of the Act, from April 1984 to March 2020, deductions totaling $87,576,876 have been taken from transfer payments in respect of the extra-billing and user charges provisions of the Act. This amount excludes deductions totaling $244,732,000 that were made between 1984 and 1987, and subsequently refunded to the provinces when extra-billing and user charges were eliminated.

Deductions and Reconciliations to CHST/CHT Cash Contributions in Accordance with the Canada Health Act (in dollars) – 1994-1995 to 2016-2017
  NL PE NS NB QC ON MB SK AB BC YT NT NU Total
1994/95 - - - - - - - - - 1,982,000 - - - 1,982,000
1995/96 46,000 - 32,000 - - - 269,000 - 2,319,000 43,000 - - - 2,709,000
1996/97 96,000 - 72,000 - - - 588,000 - 1,266,000 - - - - 2,022,000
1997/98 128,000 - 57,000 - - - 586,000 - - - - - - 771,000
1998/99 53,000 - 38,950 - - - 612,000 - - - - - - 703,950
1999/00 (42,570) - 61,110 - - - - - - - - - - 18,540
2000/01 - - 57,804 - - - - - - - - - - 57,804
2001/02 - - 35,100 - - - 300,201 - - - - - - 335,301
2002/03 - - 11,052 - - - - - - 4,610 - - - 15,662
2003/04 - - 7,119 - - - - - - 126,775 - - - 133,894
2004/05 1,100 - 5,463 - - - - - - 72,464 - - - 79,027
2005/06 - - (8,121) - - - - - - 29,019 - - - 20,898
2006/07 - - 9,460 - - - - - - 114,850 - - - 124,310
2007/08 - - - - - - - - - 42,113 - - - 42,113
2008/09 - - - - - - - - - 66,195 - - - 66,195
2009/10 - - - - - - - - - 73,925 - - - 73,925
2010/11 3,577 - - - - - - - - 75,136 - - - 78,713
2011/12 58,679 - - - - - - - - 33,219 - - - 91,898
2012/13 50,758 - - - - - - - - 280,019 - - - 330,777
2013/14 (10,765) - - - - - - - - 224,568 - - - 213,803
2014/15 - - - - - - - - - 241,637 - - - 241,637
2015/16 - - - - - - - - - 204,145 - - - 204,145
2016/17 - - - - 9,907,229Table 2 Footnote a - - - - 184,508 - - - 10,091,737
Table 2 Footnote a

This amount was subsequently refunded to the province in light of corrective actions the provincial government had already taken to address the issue of accessory fees at the time of the deduction.

Table 2 Return to footnote a referrer

Understanding This Chart

Canada Health Act Compliance from 2018-Present

As described earlier, the Canada Health Act Reimbursement Policy came into effect in 2018, to provide a positive incentive for provinces and territories to come into compliance, should they be subject to mandatory penalties as a result of patient charges for insured health services. The federal Minister of Health now has the discretion to provide a reimbursement if the province or territory eliminates those charges within a specified timeframe. The first deductions eligible for reimbursement under the policy were those taken in March 2018.

British Columbia

Following collaborative work with Health Canada on an audit project to determine the extent and scope of patient charges in the province, a deduction of $15,861,818 was taken in March 2018 in respect of patient charges during fiscal year 2015-2016. This deduction reflected audit results, patient complaints, and publicly available evidence of $4.7 million of patient charges to insured residents by enrolled physicians at the Cambie Surgery Centre. A similar methodology was used to calculate the province's Canada Health Transfer deductions in March 2019 ($16,177,259) and March 2020 ($16,753,833). 

Following the implementation of the Canada Health Act Reimbursement Policy in 2018, British Columbia consulted with Health Canada on a Reimbursement Action Plan to eliminate patient charges. Because the province successfully carried out some elements of that plan, the province received a partial reimbursement of its March 2018 and March 2019 deductions, in the amount of $16,019,539, in March 2020.

Quebec

In March 2018, using the amount of extra-billing and user charges reported by the Quebec Auditor General with respect to accessory fees charged in 2014-2015 as a proxy, the federal Minister estimated a deduction amount of $9,907,229. In light of corrective action the provincial government had already taken to eliminate accessory fees in January 2017, this amount was subsequently returned to Quebec by the Government of Canada. This reimbursement pre-dated the Reimbursement Policy. Quebec's March 2017 and March 2018 deductions, which, due to Canada Health Act reporting timelines, were taken after patient charges had already been eliminated by the provincial government, served as the inspiration for the Reimbursement Policy.

A further deduction of $8,256,024 was taken to Quebec's March 2019 federal health transfer, reflecting patient charges which had occurred prior to the corrective action taken by Quebec and was immediately reimbursed. This reimbursement was the first made under the Reimbursement Policy.

New Brunswick

In March 2020, on the basis of evidence of patient charges during 2017-2018, a deduction of $140,216 was taken to New Brunswick's Canada Health Transfer payments.

Newfoundland and Labrador

In March 2019, a deduction of $1,349 was taken from CHT payments to Newfoundland and Labrador for extra‑billing and user charges, based on patient charges for insured health services at a private ophthalmological clinic that occurred in 2016-2017, reported by the province to Health Canada.  Similarly, a deduction of $70,819 was taken in March 2020 in respect of charges in this clinic during 2017-2018. 

After its March 2019 deduction, Newfoundland and Labrador consulted with Health Canada on a Reimbursement Action Plan to eliminate patient charges. Because the province successfully carried out that plan, and eliminated these patient charges, the province received a reimbursement of its March 2019 deduction, as well as an immediate reimbursement of its March 2020 deduction.

  2017-2018 2018-2019 2019-2020
Deduction Deduction Reimbursement Deduction Reimbursement
NL - 1,349 - 70,819 72,168
NB - - - 140,216 -
QC 9,907,229Table 3 Footnote a 8,256,024 8,256,024 - -
BC 15,861,818 16,177,259 - 16,753,833 16,019,539Table 3 Footnote b
Table 3 Footnote a

This amount was subsequently refunded to the province in light of corrective actions the provincial government had already taken to address the issue of accessory fees at the time of the deduction.

Table 3 Return to footnote a referrer

Table 3 Footnote b

This amount represents a partial reimbursement of British Columbia's March 2018 (50%) and March 2019 (50%) deductions and was issued based on the elements of the province's Reimbursement Action Plan that were successfully carried out.

Table 3 Return to footnote b referrer

Since the Canada Health Act Reimbursement Policy came into effect, $24,347,731 has been reimbursed to provinces, in recognition of their efforts to eliminate patient charges for insured health services.

Interprovincial Health Insurance Agreements Coordinating Committee

The Interprovincial Health Insurance Agreements Coordinating Committee (IHIACC) was formed in 1991 to address issues affecting the interprovincial billing of insured hospital and physician services. The Committee includes members from each province and territory and a non-voting chair from the Canada Health Act Division. The Canada Health Act Division also provides secretariat functions for IHIACC.

All provinces and territories participate in hospital reciprocal billing agreements, and all, with the exception of Quebec, participate in physician reciprocal billing agreements. These agreements generally ensure that a patient's health care insurance card will be accepted, in lieu of payment, when the patient receives insured hospital or physician services in another province or territory. The province or territory providing the service will then directly bill the patient's home province at agreed-upon rates. The intent of these agreements is to ensure that Canadian residents do not have to pay directly for medically necessary hospital and physician services when they travel within Canada. Of note, these agreements are interprovincial, not federal, and while they facilitate the portability criterion, they are not a requirement of the Act.

On April 1, 2019, IHIACC implemented a new Reciprocal Billing model that allows provinces and territories to more accurately recover the costs of high-cost organ transplant services provided to out-of-province/territory residents. During the early stages of the COVID-19 pandemic response, IHIACC suspended its normal work to serve as an information coordinating body for interprovincial and out-of-Canada health care coverage.  

The Interprovincial Health Insurance Agreements Coordinating Committee's Rate Review Working Group is responsible for determining reciprocal billing rates to ensure that the host province or territory providing the health service is compensated by the home province at a reasonable rate.

Issues related to registration and eligibility requirements are addressed through IHIACC's Eligibility and Portability Agreement Working Group, which is responsible for reviewing eligibility issues and identifying potential inter-jurisdictional gaps in health care coverage.

The Policy Research Working Group examines policy-related issues that impede coverage of insured health services with the aim of increasing the consistency and coordination of interprovincial health care coverage and billing practices.

Chapter 3 - Provincial and Territorial Health Care Insurance Plans In 2019–2020

The following chapter presents the 13 provincial and territorial health care insurance plans that make up the Canadian publicly funded health insurance system. The purpose of this chapter is to demonstrate clearly and consistently the extent to which provincial and territorial plans fulfilled the requirements of the Canada Health Act program criteria and conditions in 2019–2020.

Officials in the provincial, territorial and federal governments have collaborated to produce the detailed plan overviews contained in Chapter 3. The information that Health Canada requested from the provincial and territorial departments of health for the report consists of two components:

The narrative component is used to help with the monitoring and compliance of provincial and territorial health care insurance plans with respect to the requirements of the Act, while statistics help to identify current and future trends in the Canadian health care system. While all provinces and territories have submitted detailed descriptive information on their health care insurance plans, Quebec chose not to submit supplemental statistical information which is contained in the tables in this year's report.

To help provinces and territories prepare their submissions to the annual report, Health Canada provided them with the document; Canada Health Act Annual Report 2019–2020: A Guide for Updating Submissions (User's Guide). The User's Guide is designed to help provinces and territories meet Health Canada's reporting requirements. Annual revisions to the guide are based on Health Canada's analysis of health care insurance plan descriptions from previous annual reports and its assessment of emerging issues relating to insured health services.

The process for the Canada Health Act Annual Report 2019–2020 was launched summer 2020 with bilateral teleconferences. An updated User's Guide was also sent to the provinces and territories at that time.

Insurance Plan Descriptions

For the following chapter, provincial and territorial officials were asked to provide a narrative description of their health care insurance plan. The descriptions follow the program criteria areas of the Canada Health Act in order to illustrate how the plans satisfy these criteria. This narrative format also allows each jurisdiction to indicate how it met the Canada Health Act requirement for the recognition of federal contributions that support insured and extended health care services. This year, provinces and territories were invited to describe the efforts they undertook during the reporting period with respect to coverage and care during the COVID-19 pandemic, which routinely exceeded the requirements of the Canada Health Act.

Key Definitions Provided to Provinces and Territories to Guide their Submissions to this Report

Participating Physician or Dentist is a licensed physician or dentist who is enrolled in a provincial or territorial health care insurance plan.

Non-Participating Physician or Dentist practises completely outside a provincial or territorial health care insurance plan. Neither the physician or dentist nor the patient is eligible for any cost coverage for services rendered or received from the provincial or territorial health care insurance plans. A non-participating physician or dentist may therefore establish their own fees, which are paid directly by the patient.

Opted-out Physician or Dentist is a physician or dentist who is enrolled in the provincial or territorial health insurance plan but has voluntarily opted out of the plan and will therefore bill their patients directly. These charges can be up to, but not more than, the provincial or territorial amount allowed under the fee schedule agreement. The provincial or territorial plans reimburse patients of opted-out physicians or dentists for these charges.

Provincial and Territorial Health Care Insurance Plan Statistics

Over time, the section of the annual report containing the statistical information submitted from the provinces and territories has been simplified and streamlined based on feedback received from provincial and territorial officials, and based on reviews of data quality and availability. The supplemental statistical information tables can be found at the end of each provincial or territorial narrative, except for Quebec.

The purpose of the statistical tables is to place the administration and operation of the Canada Health Act in context and to provide a national perspective on trends in the delivery and funding of insured health services in Canada that are within the scope of the Act.

The statistical tables contain resource and cost data for insured hospital, physician and surgical-dental services by province and territory for five consecutive years ending on March 31, 2020. All information was provided by provincial and territorial officials.

Although efforts are made to capture data on a consistent basis, differences exist in the reporting on health care programs and services between provincial and territorial governments. Therefore, comparisons between jurisdictions are not made. Provincial and territorial governments are responsible for the quality and completeness of the data they provide.

Organization of the Information

Information in the statistical tables is grouped according to the nine subcategories described below.

Registered Persons: Registered persons are the number of residents registered with the health care insurance plans of each province or territory.

Insured Hospital Services within Own Province or Territory: Statistics in this sub-section relate to the provision of insured hospital services to residents in each province or territory, as well as to visitors from other regions of Canada.

Insured Hospital Services Provided to Residents in Another Province or Territory: This sub-section presents out-of-province or out-of-territory insured hospital services that are paid for by a person's home jurisdiction when they travel to other parts of Canada.

Insured Hospital Services Provided Outside Canada: This represents residents' hospital costs incurred while travelling outside of Canada that are paid for by their home province or territory.

Insured Physician Services within Own Province or Territory: Statistics in this sub-section relate to the provision of insured physician services to residents in each province or territory, as well as to visitors from other regions of Canada.

Insured Physician Services Provided to Residents in Another Province or Territory: This sub-section reports on physician services that are paid by a jurisdiction to other provinces or territories for their visiting residents.

Insured Physician Services Provided Outside Canada: This represents residents' medical costs incurred while travelling outside of Canada that are paid by their home province or territory.

Insured Surgical-Dental Services within Own Province or Territory: The information in this subsection describes insured surgical-dental services provided in each province or territory.

Newfoundland and Labrador

The Department of Health and Community Services (the department) is responsible for setting the overall strategic directions and priorities for the health and community services system throughout Newfoundland and Labrador.

The department works with stakeholders to develop and enhance policies, legislation, provincial standards and strategies to support individuals, families and communities to achieve optimal health and well-being. The department provides a lead role in policy, planning, program development, and support to the four Regional Health Authorities (RHAs). The department also works with stakeholders to ensure that high quality, cost effective and timely health services are available for all Newfoundlanders and Labradorians.

The department provides leadership, coordination, monitoring and support to the RHAs, which deliver the majority of publicly funded health services in the province, as well as to other entities that deliver programs and services. This ensures quality, efficiency, and effectiveness in areas such as the administration of health care facilities; access and clinical efficiency; programs for seniors, persons with disabilities and persons with mental health and addictions issues as well as long-term care and community support services; health professional education and training programs; the control, possession, handling, keeping and sale of food and drugs; the preservation and promotion of health; the prevention and control of disease; and public health and the enforcement of public health standards.

With an annual budget of approximately $3 billion, the department accounts for approximately 39 per cent of Newfoundland and Labrador’s total budget. In Budget 2019-2020, funding was provided for various programs and initiatives to make significant improvements to mental health and addictions, home and community care, and primary health care. Included in this was $8.9 million to start construction in spring 2019 on a new adult mental health and addictions facility and expand community-based supports province-wide. An overview of initiatives from the 2019-2020 Budget is available.

In Newfoundland and Labrador, health services are provided to more than 520,000 residents by approximately 32,400 people in the health and community services sector. Of this total, approximately 19,000 people are employed by the four RHAs and approximately 210 people are employed by the Department of Health and Community Services.

The purpose of this report is to clearly describe how Newfoundland and Labrador fulfilled the requirements of the Canada Health Act program criteria, conditions and provisions in 2019-2020.

COVID-19 Measures

Changes to the Medical Care Plan

In response to the COVID-19 pandemic, in March 2020, the department announced that the cost of screening and treatment of any COVID-19 related symptoms or conditions, including hospitalization, would be provided to individuals residing in the province who did not otherwise meet the criteria for Medical Care Plan (MCP) registration. Due to the possibility of delays in receiving documentation resulting from the pandemic, the department also extended MCP coverage for individuals whose cards would expire in the short term. An initial extension was made to June 30, 2020 for all beneficiaries whose cards expired as of March 1, 2020 and a further extension was made to September 30, 2020 for international students and workers who met established criteria.

Virtual Care

A Pandemic Virtual Care fee code for Fee for Service (FFS) physicians was introduced on March 25, 2020 to allow for appointments via virtual care methods (telephone or video conference). This expansion of virtual care services enabled greater access for patients while abiding by the social distancing advisory and provided for a safer workplace for staff and physicians in health care clinics. This service remains in effect. To account for loss of income due to restrictions on visits to medical offices, a Work Disruption policy was introduced for FFS physicians which guaranteed 80 per cent payment for physicians for a 111-day period from March 18 to July 6, 2020, based on their previous claims in the preceding 26-week period. Physicians who provided “additional services”, as defined in the policy, qualified for a 100 per cent top-up, for the duration of their “additional services”. As of June 11, 2020, the capability for virtual appointments with nurse practitioners for urgent, non-emergency health issues via telephone, text or video was implemented. A Virtual Care fee code was introduced for medical consultants as well, covering the period from July 7 to October 1, 2020, but it has since been extended and remains indefinite for the time being.

1.0 Public Administration

1.1 Health Care Insurance Plan and Public Authority

Health care insurance plans managed by the department include the Medical Care Plan (MCP) and the Hospital Insurance Plan (HIP). Both plans are non-profit and publicly administered.

The Medical Care and Hospital Insurance Act came into force on October 1, 2016, replacing both the Medical Care Insurance Act, 1999, and the Hospital Insurance Agreement Act. The Medical Care and Hospital Insurance Act (the Act) can be viewed on the Newfoundland and Labrador House of Assembly website.

As per section 5 of the Act, the Minister of Health and Community Services is required to administer a plan of medical care and hospital insurance for residents of the province. The Act provides authority to make regulations defining who is a resident, prescribing which services are insured services and under what circumstances insured services shall be paid by the minister.

The MCP facilitates the delivery of comprehensive medical care to all residents of the province by implementing policies, procedures and systems that permit appropriate compensation to providers for rendering insured professional services.

The HIP covers insured hospital services received within the province when recommended by a medical practitioner. Eligibility for coverage under the plan is linked with eligibility for the MCP. All beneficiaries of the MCP are automatically entitled to coverage under the HIP.

Both the HIP and the MCP operate in accordance with the provisions of the Medical Care and Hospital Insurance Act and related regulations, and in compliance with the Canada Health Act.

On November 4, 2019, an amendment was made to Section 4 of the Medical Care Insurance Insured Services Regulations which removed paragraph 4.(i)(v) “sex reassignment surgery, when not recommended by the Clarke Institute of Psychiatry” from the list of uninsured services. The effect of the amendment is to remove the requirement for an out-of-province assessment by the Clarke Institute of Psychiatry before proceeding with transition-related surgeries. As a result, assessments can now take place within the province.

1.2 Reporting Relationship

The department is mandated with administering the HIP and the MCP under section 5 of the Medical Care and Hospital Insurance Act. The department reports on these plans through the regular legislative processes, as well as through other public reporting mechanisms (e.g., Public Accounts and the Social Services Committee of the House of Assembly).

The Government of Newfoundland and Labrador has a provincial planning and reporting requirement for all government departments, including the Department of Health and Community Services. Under the Transparency and Accountability Act, the Department of Health and Community Services and the 10 other entities that report to the minister, including the RHAs, produce a strategic plan once every three years and report annually on their performance. Plans and reports are tabled in the House of Assembly and posted on the department’s website.

The 2019-2020 Department of Health and Community Services annual report has not yet been tabled in the House of Assembly.

1.3 Audit of Accounts

Each year, the province’s Auditor General independently examines provincial Public Accounts. MCP expenditures are considered a part of the Public Accounts. While respecting privacy and personal information, the Auditor General has full and unrestricted access to code-based records of the MCP. There were no Auditor General reviews of the department’s programs, services, or MCP expenditures in 2019–2020. The most recent comprehensive audit was a review of the Newfoundland and Labrador Prescription Drug Program (NLPDP) in June 2015.

Specific program reviews are executed in accordance with the Office of the Auditor General plan, which is largely driven by risk. In the planning stages of an audit, the department would be notified by receipt of an engagement letter from the Office of the Auditor General, advising that an audit is being planned and requesting any necessary arrangements to execute it. Therefore, it is not known whether an audit will occur in 2020-21.

The four RHAs are subject to financial statement audits, reviews and compliance audits. Financial statement audits are performed by independent auditing firms that are selected by each RHA. Review engagements are conducted using the Generally Accepted Auditing Standards of the Canadian Institute of Chartered Accountants. Various compliance and physician audits are carried out by personnel from the department under the authority of the Medical Care and Hospital Insurance Act.

Physician records and professional medical corporation records are reviewed to ensure that the records support the services billed and that the services are insured under the MCP. Beneficiary audits are performed by personnel from the department under the Medical Care and Hospital Insurance Act.

The Auditor General’s Report is submitted annually on or before January 31 and is found online.

2.0 Comprehensiveness

2.1 Insured Hospital Services

As of March 31, 2020, the Medical Care and Hospital Insurance Act and the Hospital Insurance Regulations provided for insured hospital services in Newfoundland and Labrador. No amendments were made to the Act during this current reporting period. All the hospital services as defined under the Canada Health Act are insured services in Newfoundland and Labrador.

Insured hospital services are provided for in-patients and out-patients in 15 hospitals, 23 community health centres and 65 community clinics throughout the province. This number remained constant in 2019-2020. As indicated in the statistics table, the change in the number of clinics in 2016-2017 reflects a change in how the department classifies public health facilities. Hospital insured services include:

There were no new services added to the schedule of insured hospital services during 2019-2020.

The coverage policy for insured hospital services is linked to the coverage policy for insured medical services. The department manages the process of adding or de-listing a hospital service from the list of insured services based on direction from the Lieutenant-Governor in Council. Public consultation is not a requirement for de-listing a service.

Currently, Newfoundland and Labrador does not have any private diagnostic clinics that charge patients for services that would be considered insured if provided in a hospital.

2.2 Insured Physician Services

As of March 31, 2020, the enabling legislation for insured physician services was the Medical Care and Hospital Insurance Act and the relevant regulations continued thereunder, which included the:

On November 4, 2019, an amendment was made to section 4 of the Medical Care Insurance Insured Services Regulations which removed paragraph 4.(i)(v) “sex reassignment surgery, when not recommended by the Clarke Institute of Psychiatry” from the list of uninsured services. Health care professionals in Newfoundland and Labrador meeting minimum credentials as established by the World Professional Association for Transgender Health (WPATH) Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People Version 7 (2012) can now perform surgical readiness assessments for transgender patients requiring transition-related surgery.

In 2019-2020 (as of March 31, 2020) there were 1,307 physicians (salaried and FFS) active in practice in the province.

For purposes of the Act, the following services are covered:

In 2019-2020, surgical readiness assessments performed by Newfoundland and Labrador physicians were added to the list of insured physician services. No further services were added.

The Medical Care Insurance Insured Services Regulations also lists specific services which are not insured under the MCP; these include:Footnote 1

Physicians can choose not to participate in the health care insurance plan as outlined in section 8 of the Medical Care and Hospital Insurance Act, namely:

As of March 31, 2020, no physicians had opted-out of the MCP.

Lieutenant-Governor in Council approval is required to add to or to de-insure a physician service from the list of insured services. This process is managed by the department in consultation with various stakeholders. Public consultation is not a specific requirement.

2.3 Insured Surgical-Dental Services

The provincial Surgical-Dental Program is a component of the MCP. Surgical-dental treatments provided to a beneficiary and carried out in a hospital by a licensed oral surgeon or dentist are covered by the MCP if the treatment is specified in the Surgical-Dental Services Schedule.

The Surgical Dental Program provides insured services under the Medical Care and Hospital Insurance Act. An insured service is defined as one that is:

  1. Listed in paragraph 3(1)(b)Footnote 2 of the Medical Care Insured Services Regulations
  2. Medically necessary. The clinical need of the provision and claim of an insured service may be evaluated by the Dental Monitoring Committee of MCP.

Policies on pre-existing conditions necessary to define 'medical necessity' must exist for the specific services to qualify as MCP insured services.Footnote 3

There were 17 dentists/oral surgeons providing insured services under the Surgical-Dental Program as of March 31, 2020.

Dentists/oral surgeons may opt out of the MCP as per section 8 of the Medical Care and Hospital Insurance Act referenced above. These dentists/oral surgeons must advise the patient of their opted-out status, state the fees expected and provide the patient with a written record of services and fees charged. As of March 31, 2020, there were no opted-out dentists. There was no extra-billing in 2019-2020.

Because the Surgical-Dental Program is a component of the MCP, management of the program is linked to the MCP process regarding changes to the list of insured services.

Any addition of a surgical-dental service to the list of insured services must be approved by the Minister of Health and Community Services. There were no new services added to the list/schedule of insured surgical-dental services in 2019-20.

2.4 Uninsured Hospital, Physician and Surgical-Dental Services

Hospital services not covered by the MCP include:

The use of the hospital setting for any services deemed uninsured by the MCP are also uninsured under the Hospital Insurance Plan.

For purposes of the Medical Care and Hospital Insurance Act, the following is a list of uninsured physician services:

The majority of diadependentgnostic services (e.g., laboratory services and x-ray) are performed within public facilities in the province. Hospital policy concerning access ensures that third parties are not given priority access.

Medical goods and services that are implanted and associated with an insured service are provided free of charge to the patient and are consistent with national standards of practice. Patients retain the right to financially upgrade standard medical goods or services. Standards for medical goods are developed by the hospitals providing those services in consultation with service providers.

The Act provides the Lieutenant-Governor in Council the authority to make regulations prescribing which services are or are not insured services for the purpose of the Act. This would involve consultation with the Newfoundland and Labrador Medical Association. There is no specified requirement for public consultation when delisting a service. No services were de-listed from the MCP during 2019–2020.

3.0 Universality

3.1 Eligibility

Residents of Newfoundland and Labrador are eligible for coverage under the Medical Care and Hospital Insurance Act. This Act defines a “resident” as a person who is lawfully entitled to be or to remain in Canada, makes his or her home in the province, and is ordinarily present in the province, but does not include a tourist, transient or visitor to the province.

The Medical Care Insurance Beneficiaries and Inquiries Regulations identify those residents eligible to receive coverage under the plans. There were no amendments to these Regulations during the reporting period. The MCP has established rules to ensure that the Regulations are applied consistently and fairly in processing applications for coverage. The MCP applies the standard that persons moving to Newfoundland and Labrador from another province become eligible on the first day of the third month following the month of their arrival. Under section 6 of the Act, every resident of the province is required to register for the MCP in accordance with the regulations. While there is no specified opt-out provision, a person may, in effect, do so by choosing not to register.

Persons not eligible for coverage under the MCP and HIP include:

If the status of these individuals change, they must meet the criteria as noted above in order to become eligible. Applicants wishing to appeal an eligibility issue may request a formal file review from the Minister of Health and Community Services.

There were approximately 526,151 people registered as active beneficiaries of the MCP as of March 31, 2020.

3.2 Other Categories of Individuals

Foreign workers, international students, foreign clergy and dependants of North Atlantic Treaty Organization (NATO) personnel and applicants for permanent residency are eligible for benefits. Returning Canadian citizens and their dependants born out-of-country, returning permanent residents who hold valid documentation, holders of minister’s permits, convention refugees, resettled refugees or “persons in need of protection” with valid immigration documents are also eligible, subject to MCP approval. Dependants of MCP beneficiaries may also be eligible for coverage.

4.0 Portability

4.1 Minimum Waiting Period

Persons who meet the eligibility criteria who are moving to Newfoundland and Labrador from other provinces or territories are entitled to coverage on the first day of the third month following the month of arrival.

Persons arriving from outside Canada to establish residence are entitled to coverage on the day of arrival. The same applies to discharged members of the Canadian Armed Forces, and individuals released from federal penitentiaries. For coverage to be effective, registration is required under the MCP. Immediate coverage is provided to persons from outside Canada authorized to work in the province for one year or more and their eligible dependants, and to international post-secondary students attending a recognized Newfoundland and Labrador educational institution who have a valid study permit entitling them to stay in Canada for more than 365 days and their eligible dependants. This requirement has been reduced to a six-month work permit for individuals entering the province under the Newfoundland and Labrador Provincial Nominee Program (NLPNP) and the Atlantic Immigration Pilot Program (AIPP). For international health care workers with employment authorizations, the period of employment may be for less than 365 days.

4.2 Coverage during Temporary Absences in Canada

Newfoundland and Labrador is a party to the Interprovincial Agreement on Eligibility and Portability regarding matters pertaining to portability of insured services in Canada.

Sections 12 and 13 of the Hospital Insurance Regulations denote portability of hospital coverage during absences both within and outside Canada. The eligibility policy for insured hospital services is linked to the eligibility policy for insured physician services. No amendments to the Regulations were made in 2019-2020.

Coverage is provided to residents during temporary absences within Canada. The Government of Newfoundland and Labrador has entered into formal agreements (e.g., the Hospital Reciprocal Billing Agreement) with other provinces and territories for the reciprocal billing of insured hospital services. In-patient costs are paid at standard rates approved by the host province or territory. In-patient, high-cost procedures and out-patient services are payable based on national rates agreed to by provincial and territorial health plans through the Interprovincial Health Insurance Agreements Coordinating Committee.

Medical services incurred in all provinces (except Quebec) or territories are paid through the Medical Reciprocal Billing Agreement at host province or territory rates. Claims for medical services received in Quebec are submitted by the patient to the MCP for payment at host province rates.

In order to qualify for out-of-province coverage, a beneficiary must comply with the legislation and the MCP rules regarding residency in Newfoundland and Labrador. Generally, a resident must reside in the province for at least four months in each 12-month period to qualify as a beneficiary. International workers and students may qualify for out-of-province coverage of up to 182 days in a 365 day period. The rules regarding medical and hospital care coverage during absences include the following:

Failure to request out-of-province coverage or failure to abide by the residency rules may result in the resident having to pay for medical or hospital costs incurred outside the province.

Insured residents moving permanently to other parts of Canada are covered up to, and including, the last day of the second month following the month of departure.

No changes to coverage during temporary absences in Canada were made in 2019-2020.

4.3 Coverage during Temporary Absences Outside Canada

Sections 12 and 13 of the Hospital Insurance Regulations denote portability of hospital coverage during absences both within and outside Canada. No amendments were made to the Regulations during the reporting period.

The province provides coverage to residents during temporary absences outside Canada. Out-of-country insured hospital in-patient and out-patient services are covered for emergencies, sudden illness and elective procedures at established rates listed below. Hospital services are considered under the plan when the insured services are provided by a recognized facility (licensed or approved by the appropriate authority within the state or country in which the facility is located) outside Canada. The maximum amount payable by the MCP for out-of-country in-patient hospital care is $350 per day, if the insured services are provided by a community or regional hospital. Where insured services are provided by a tertiary care hospital (a highly specialized facility), the approved rate is $465 per day. The approved rate for out-patient services is $62 per visit and haemodialysis is $220 per treatment. The approved rates are paid in Canadian funds.

Physician services are covered for emergencies or sudden illness, and are also insured for elective services not available in the province or within Canada. Emergency physician services are paid at the same rate as would be paid in Newfoundland and Labrador for the same service. If the elective services are not available in Newfoundland and Labrador, they are usually paid at Ontario rates, or at rates that apply in the province where they are available.

Coverage is immediately discontinued when residents move permanently to other countries.

In 2019-2020, the only change to coverage during temporary absences outside Canada related to workers employed with College of the North Atlantic’s campus in Qatar. For these beneficiaries, out-of-province coverage was extended from three to five years.

4.4 Prior Approval Requirement

Prior approval is not required for medically necessary insured services provided by accredited hospitals or licensed physicians in the other provinces and territories. However, physicians may seek advice on coverage from the MCP so that patients may be made aware of any financial implications.

Prior approval is mandatory in order to receive funding at host country rates if a resident of the province has to seek specialized hospital care outside the country because the insured service is not available in Canada. The referring physicians must contact the department for prior approval. If prior approval is granted, the provincial health care insurance plan will pay the costs of insured services necessary for the patient’s care. Prior approval is not granted for out-of-country treatment or elective services if the service is available in the province or elsewhere within Canada. If an individual opts to receive the service outside Canada it will be covered at the provincial rate if available in Newfoundland and Labrador. If the service is not available in Newfoundland and Labrador, it is usually paid at Ontario rates, or at rates that apply in the province where they are available. Applicants wishing to appeal out-of-province coverage may request a formal file review by the minister.

5.0 Accessibility

5.1 Access to Insured Health Services

Access to insured health services in Newfoundland and Labrador is provided on uniform terms and conditions. Co-insurance charges for insured hospital services and extra-billing by physicians is prohibited in the province.

Section 7 of the Medical Care and Hospital Insurance Act outlines that a practitioner who provides insured services, whether or not he or she has made an election to opt out of participation in the MCP, shall not charge or collect from a beneficiary a fee for those insured services in excess of the amount payable under the Act and regulations. A practitioner or other person who contravenes this is guilty of an offence and liable on summary conviction to a fine of up to but not more than $20,000 for each contravention. Cases of extra-billing and user charges may be identified through the audit process described under section 21 of the Act or may be reported from residents. These instances may be discovered when residents submit claims to the department for reimbursement.

Complaints from residents regarding charges for insured health services are managed by the department. Depending on the circumstance, the department may investigate or refer the matter to the College of Physicians and Surgeons of Newfoundland and Labrador, the regulatory body for physicians in the province, for potential disciplinary action. Residents may also contact the College directly if they feel that they have been subject to improper billing by their physician.

Regarding repayment, section 25 of the Act provides the minister with powers to recover overpayments and interest that were discovered via audit. The Minister of Health and Community Services may do this by entering into an agreement with the practitioner or their professional corporation or the minister may order the practitioner to pay to the minister the overpaid amount plus interest.

Residents wishing to file a complaint regarding medical care that they have received are encouraged to call or email the Complaints Coordinator at the College (1-709-726-8546 or complaints@cpsnl.ca) or call the MCP general inquiries line (Avalon area: 1-866-449-4459; all other regions:1-800-563-1557).

The department works closely with post-secondary educational institutions within the province to maintain an appropriate supply of health professionals. The province also works with external organizations for health professionals not trained in this province. Targeted recruitment incentives are in place to attract health professionals. Several programs have been established to provide targeted sign-on bonuses, bursaries, opportunities for upgrading, and other incentives for a wide variety of health occupations.

With respect to wait times to access insured health services, the department led a number of initiatives, including the Strategy to Reduce Hip and Knee Joint Replacement Surgery Wait Times, the Provincial Emergency Department Wait Time Strategy and the Provincial Endoscopy Wait Time Strategy. These strategies ended in 2017–2018. In 2019-2020, the department lead a provincial initiative to develop and implement a standardized provincial methodology for collecting surgical cancelations. This initiative aims to avoid increases in wait times associated with avoidable cancellations of elective surgeries. Prior to this undertaking, research determined that a national methodology for elective surgical cancellations does not exist, making NL one of a few provinces to put this data collection in place.

A Provincial Pain Advisory Committee (PPAC) has been established with the goals of developing and provincial model of care to standardize pain services in Newfoundland and Labrador and improve access to services for individuals with chronic pain.

5.2 Physician Compensation

Physicians in the province are paid via fee-for-service, salary, or alternate payment plan. As of March 31, 2020 the legislation governing payments to physicians and dentists for insured services continues to be the Medical Care and Hospital Insurance Act. There is no legislation that speaks to the ability of physicians or dentists to levy block fees. The Newfoundland and Labrador Medical Association (NLMA) has published the Physicians’ Guide to Non-Insured ServicesFootnote 4, which provides guidance on third party requested services, other non-insured services, suggested fees and relevant policies.

Compensation agreements are negotiated between the government and the NLMA, on behalf of physicians, and the Newfoundland and Labrador Dental Association (NLDA) on behalf of dentists. A Memorandum of Agreement was reached with the NLMA in December 2017, which increased overall physician compensation by approximately five per cent. The agreement expired on September 30, 2017, but remains in effect until such time as a new agreement is negotiated. The current agreement with the NLDA expires on March 31, 2022. The agreement was signed effective April 1, 2018, with no fee increases.

The Act authorizes the minister to appoint auditors to audit the accounts and claims for payment submitted by physicians and dentists. The Act prescribes the power and duties of auditors, sets out the remedies available and details the processes to be followed. The Act also details the review and appeal processes available to practitioners. Individual providers are randomly selected on a bi-weekly basis for audit.

5.3 Payments to Hospitals

The department is responsible for funding RHAs space for ongoing hospital operations and capital acquisitions. Payments are made in accordance with the Medical Care and Hospital Insurance Act, the Regional Health Authorities Act and the Financial Administration Act. As part of their accountability to the department, the RHAs are required to meet the department’s annual reporting requirements, which include submitting an annual budget, pursuant to section 21 of the Regional Health Authority Act, as well as audited financial statements and other financial and statistical information throughout the year as required.

6.0 Recognition Given to Federal Transfers

Funding provided by the federal government through the Canada Health Transfer and the Canada Social Transfer has been recognized and reported by the Government of Newfoundland and Labrador in the annual provincial budget, through press releases, government websites and various other documents. For fiscal year 2019–2020, these documents include the Public Accounts and Estimates 2019–2020. The Public Accounts and Estimates, tabled by the Government in the House of Assembly, are publicly available and are shared with Health Canada for information purposes.

Registered Persons
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
1. Number as of March 31st 532,415 530,144 526,692 526,278 526,151
Insured Hospital Services Within Own Province or Territory
Public Facilities 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
2. Number 51 103Newfoundland and Labrador table 2 Footnote 1 104 103 103
3. Payments for insured health services ($)           1,164,174,814 1,187,786,538 1,199,247,288 1,260,708,567 1,217,480,996
Private For-Profit Facilities 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
4. Number of private for-profit facilities providing insured health services 1 1 1 1 1
5. Payments to private for-profit facilities for insured health services ($) 899,538 899,418 939,422 1,023,737 954,483
Newfoundland and Labrador table 2 Footnote 1

Classification of public facilities changed in 2016–2017.

Newfoundland and Labrador table 2 Return to footnote 1 referrer
Insured Hospital Services Provided to Residents in Another Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
6. Total number of claims, in-patient 1,607 1,549 1,515 1,648 1,685
7. Total payments, in-patient ($) 21,928,705 25,223,361 22,013,818 26,701,044 24,194,946
8. Total number of claims,
out-patient		 23,105 21,915 24,093 22,701 25,216
9. Total payments, out-patient ($) 8,428,054 8,279,887 9,102,027 9,161,383 10,558,507
Insured Hospital Services Provided Outside CanadaNewfoundland and Labrador table 4 Footnote 1
Pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
10. Total number of claims, in-patient Not applicable Not applicable Not applicable 4 9
11. Total payments, in-patient ($) Not applicable Not applicable Not applicable 261,277 313,310
12. Total number of claims, out-patient Not applicable Not applicable Not applicable 17 65
13. Total payments, out-patient ($) Not applicable Not applicable Not applicable 69,682 455,264
Non pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
14. Total number of claims, non pre-approved in-patient Not applicable Not applicable Not applicable 85 126
15. Total payments, non pre-approved  in-patient ($) Not applicable Not applicable Not applicable 85,231 138,708
16. Total number of claims, non pre-approved out-patient Not applicable Not applicable Not applicable 309 335
17. Total payments, non pre-approved out-patient ($) Not applicable Not applicable Not applicable 31,343 20,837
Newfoundland and Labrador Table 4 Footnote 1

Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report, but did not require provinces or territories to report on previous years.

Newfoundland and Labrador Table 4 Return to footnote 1 referrer
Insured Physician Services Within Own Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
18. Number of participating physiciansNewfoundland and Labrador Table 5 Footnote 1 1,212 1,214 1,231 1,262 1,307
19. Number of opted-out physicians 0 0 0 0 0
20. Number of non-participating physicians 0 0 0 0 0
21. Total payments for services provided by physicians paid through all payment methods ($) Not available Not available Not available Not available Not available
22. Total payments for services provided by physicians paid through fee-for-service ($) 299,597,724 309,039,732 361,707,782 317,338,718 320,407,337
Newfoundland and Labrador Table 5 Footnote 1

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

Newfoundland and Labrador Table 5 Return to footnote 1 referrer
Insured Physician Services Provided to Residents in Another Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
23. Number of services 114,000 123,000 128,000 119,100 127,900
24. Total payments ($) 6,910,000Newfoundland and Labrador Table 6 Footnote 1 9,124,000Newfoundland and Labrador Table 6 Footnote 1 8,511,000Newfoundland and Labrador Table 6 Footnote 1 7,885,750 8,714,768
Newfoundland and Labrador Table 6 Footnote 1

Numbers are rounded to the nearest thousand.

Newfoundland and Labrador Table 6 Return to footnote 1 referrer
Insured Physician Services Provided Outside CanadaNewfoundland and Labrador Table 7 Footnote 1Newfoundland and Labrador Table 7 Footnote 2
Pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
25. Number of services (#) Not applicable Not applicable Not applicable 2,700 2,509
26. Total d payments ($) Not applicable Not applicable Not applicable 262,200 434,941
Non pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
27. Number of services (#) Not applicable Not applicable Not applicable Not available Not available
28. Total payments ($) Not applicable Not applicable Not applicable Not available Not available
Newfoundland and Labrador Table 7 Footnote 1

The claims in NL's data system cannot be separated into pre-approved or non pre-approved, therefore, the numbers reflect the total claims and payments as reported for previous years.

Newfoundland and Labrador Table 7 Return to footnote 1 referrer

Newfoundland and Labrador Table 7 Footnote 2

Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report,but did not require provinces or territories to report on previous years.

Newfoundland and Labrador Table 7 Return to footnote 2 referrer
Insured Surgical-Dental Services Within Own Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
29. Number of participating dentists 19 22 18 22 17
30. Number of opted-out dentistsNewfoundland and Labrador Table 8 Footnote 1 Not available Not available 0 0 0
31. Number of non-participating dentistsNewfoundland and Labrador Table 8 Footnote 1 Not available Not available 0 0 0
32. Number of services provided 3,397 4,843 4,924 5,638 4,097
33. Total payments ($) 592,660 885,610 927,020 1,231,180 713,570
Newfoundland and Labrador Table 8 Footnote 1

Health Canada requested this data as of the 2016-2017 report, but did not require provinces or territories to report data for 2015-2016.

Newfoundland and Labrador Table 8 Return to footnote 1 referrer

Prince Edward Island

In Prince Edward Island (PEI) the Department of Health and Wellness is responsible for providing policy, strategic, and fiscal leadership for the health care system.

The Health Services Act, R.S.P.E.I. 1988, Cap. H-1.6 provides the regulatory and administrative frameworks for improvements to the health care system in PEI by:

Within this governance structure Health PEI has the responsibility to:

In response to the COVID-19 global pandemic, The Department of Health and Wellness and Health PEI introduced several measures to help keep Islanders safe and stop the spread of COVID-19 in Island communities. Examples of these measures include:

1.0 Public Administration

1.1 Health Care Insurance Plan and Public Authority

The Hospital Services Insurance Plan, under the authority of the Minister of Health and Wellness (the Minister), is the vehicle for delivering hospital care insurance in Prince Edward Island (PEI). The enabling legislation is the Hospital and Diagnostic Services Insurance Act R.S.P.E.I. 1988, Cap. H-8. The Medical Services Insurance Plan provides for insured physician services under the authority of the Health Services Payment Act R.S.P.E.I. 1988, Cap. H-2. Together, the plans insure services as defined under section 2 of the Canada Health Act. The Department of Health and Wellness (the Department) is responsible for providing policy, strategic and fiscal leadership for the health care system, while Health PEI is responsible for service delivery and the operation of hospitals, health centres, manors and mental health facilities. Health PEI is responsible for the hiring of physicians, while the Public Service Commission of PEI hires nurse practitioners, nurses and all other health related workers.

1.2 Reporting Relationship

An annual report is submitted by the Department to the Minister who tables it in the Legislative Assembly. The report provides information about the operating principles of the Department and its legislative responsibilities, as well as an overview and description of the operations of the departmental divisions and statistical highlights for the year. The Health PEI annual report for 2019-2020 was published on October 28, 2020.

Health PEI prepares an annual business plan which functions as a formal agreement between Health PEI and the Minister responsible, and documents accomplishments to be achieved over the coming fiscal year.

1.3 Audit of Accounts

The provincial Auditor General conducts annual audits of the public accounts of PEI. The public accounts of the province include the financial activities, revenues and expenditures of the Department of Health and Wellness.

The provincial Auditor General, through the Audit Act, R.S.P.E.I. 1988, c A-24, has the discretion to conduct further audit reviews on a comprehensive or program specific basis.

2.0 Comprehensiveness

2.1 Insured Hospital Services

Insured hospital services are provided under the Hospital and Diagnostic Services Insurance Act. The accompanying Regulations define the insured in-patient and out-patient hospital services available at no charge to a person who is eligible. Insured hospital services include, but are not limited to:

The process to add a new hospital service to the list of insured services involves extensive consultation and negotiation between the Department of Health and Wellness (the Department), Health PEI and key stakeholders. The process involves the development of a business plan which, when approved by the Minister of Health and Wellness, would be taken to Treasury Board for funding approval. Executive Council (Cabinet) has the final authority in adding new services.

2.2 Insured Physician Services

The enabling legislation that provides for insured physician services is the Health Services Payment Act. Insured physician services are provided by medical practitioners licensed by the College of Physicians and Surgeons. The total number of practicing practitioners who billed the Medical Services Insurance Plan as of March 31, 2020, was 416. This includes all physicians (complement, locums, visiting specialists, and other non-complement physicians). Under section 10 of the Health Services Payment Act, a physician or practitioner who is not a participant in the Medical Services Insurance Plan is not eligible to bill the Plan for services rendered. When a non-participating physician provides a medically required service, section 10(2) requires that physicians advise patients that they are non-participating physicians or practitioners and provide the patient with sufficient information to enable recovery of the cost of services from the Department. Under section 10.1 of the Health Services Payment Act, a participating physician or practitioner may determine, subject to and in accordance with the Regulations and in respect of a particular patient or a particular basic health service, to collect fees outside the Plan or selectively opt out of the Plan. Before the service is rendered, patients must be informed that they will be billed directly for the service. Where practitioners have made that determination, they are required to inform the Minister thereof and the total charge is made to the patient for the service rendered.

As of March 31, 2020, no physicians had opted out of the Medical Services Insurance Plan.

All basic health services rendered by physicians that are medically required are covered by the Medical Services Insurance Plan. These include:

Services that are not covered as insured benefits include:

The process to add a physician service to the list of insured services involves negotiation between the Department, Health PEI and the Medical Society of Prince Edward Island (PEI). The process involves development of a business plan which, when approved by the Minister, would be taken to Treasury Board for funding approval. Insured physician services may also be added or deleted as part of the negotiation of a new Master Agreement with the Medical Society of PEI (Section 5.2). Cabinet has the final authority in adding new services.

2.3 Insured Surgical-Dental Services

Most dental services are not insured under the Medical Services Insurance Plan. Only oral maxillofacial surgeons are paid through the Plan. There are currently four surgeons in that category. Surgical-dental procedures included as basic health services in the Tariff of Fees are covered only when the patient's medical condition requires that they be done in hospital or in an office with prior approval, as confirmed by the attending physician.

Any new surgical-dental services added to the list of insured services covered by the Medical Services Insurance Plan is done through negotiations of the Dental Agreement between the Department, Health PEI and the Dental Association of PEI. In 2019–2020, no new services were added to the Dental Agreement.

2.4 Uninsured Hospital, Physician and Surgical-Dental Services

Services not covered by the Medical Services Insurance Plan include:

Hospital services not covered by the Hospital Services Insurance Plan include:

The process to de-insure services covered by the Medical Services Insurance Plan is done in collaboration with the Department, Health PEI and the Medical Society of PEI. No services were de-insured during the 2019–2020 fiscal year.

All Prince Edward Island residents have equal access to services. Third parties such as private insurers or the Workers' Compensation Board of PEI do not receive priority access to services through additional payment.

Prince Edward Island has no formal process to monitor compliance; however, feedback from physicians, hospital administrators, medical professionals and staff allows the Department and Health PEI to monitor usage and service concerns.

3.0 Universality

3.1 Eligibility

The Health Services Payment Act and the Hospital and Diagnostic Services Insurance Act, define eligibility for the Medical Services Insurance Plan and the Hospital Services Insurance Plan respectively. These plans are designed to provide coverage for eligible Prince Edward Island (PEI) residents. A resident is anyone legally entitled to remain in Canada and who makes his or her home and is ordinarily present on an annual basis for at least six months plus a day in PEI. While there is no formal appeal process, an individual can seek clarification regarding their eligibility determination.

All new residents must register with Health PEI in order to become eligible. Persons who establish permanent residence in PEI from elsewhere in Canada will become eligible for insured hospital and medical services on the first day of the third month following the month of arrival. PEI currently does not have a process where a resident can opt out of the health care insurance plan.

Residents who are ineligible for insured hospital and medical services coverage in PEI are those who are eligible for certain services under other federal or provincial government programs, such as members of the Canadian Forces, inmates of federal penitentiaries, and clients of Workers' Compensation or the Department of Veterans Affairs' programs.

Ineligible residents may become eligible in certain circumstances. For example, members of the Canadian Forces become eligible on discharge or completion of rehabilitative leave. Penitentiary inmates become eligible upon release. In such cases, the province where the individual in question was stationed at the time of discharge or release, or release from rehabilitative leave, would provide initial coverage during the customary waiting period of up to three months. Parolees from penitentiaries will be treated in the same manner as discharged prisoners.

New or returning residents must apply for health coverage by completing a registration application from Health PEI. The application is reviewed to ensure that all necessary information is provided. A health card is issued and sent to the resident within two weeks of becoming eligible. Renewal of coverage takes place every five years and residents are notified by mail six weeks before renewal.

The number of residents registered with the Medical Services Insurance Plan and the Health Services Insurance Plan in PEI as of March 31, 2020, was 154,728.

3.2 Other Categories of Individuals

Foreign students, tourists, transients or visitors to PEI do not qualify as residents of the province and are, therefore, not eligible for hospital and medical insurance benefits.

Temporary workers, refugees and Minister's Permit holders are not eligible for hospital and medical insurance benefits.

4.0 Portability

4.1 Minimum Waiting Period

Insured persons who move to Prince Edward Island (PEI) from another province or territory in Canada are eligible for health insurance on the first day of the third month following the month of arrival in the province.

4.2 Coverage during Temporary Absences in Canada

Residents absent each year for any reasons must reside in PEI for at least six months plus a day each year in order to be eligible for sudden illness and emergency services while absent from the province, as allowed under section 11 of the Health Services Payment Act Regulations. A person, including a student, who is temporarily absent from the province for up to 182 days in a 12 month period must notify Health PEI before leaving.

PEI participates in the Hospital Reciprocal Billing Agreements and the Medical Reciprocal Billing Agreements along with other jurisdictions across Canada.

4.3 Coverage during Temporary Absences outside Canada

The Health Services Payment Act is the enabling legislation that defines portability of health insurance during temporary absences outside of Canada, as allowed under section 11 of the regulations thereunder.

Persons must reside in PEI for at least six months plus a day each year in order to be eligible for sudden illness and emergency services while absent from the province, as allowed under section 11 of the Health Services Payment Act Regulations.

Insured residents may be temporarily out of the country for up to a 12 month period in some circumstances.

Students attending a recognized learning institution in another country must provide proof of enrollment from the educational institution on an annual basis. Students must notify Health PEI upon returning from outside the country.

For PEI residents leaving the country for work purposes for longer than one year, coverage ends the day the person leaves.

For PEI residents travelling outside Canada, coverage for emergency or sudden illness will be provided at PEI rates only, in Canadian currency. Residents are responsible for paying the difference between the full amount charged and the amount paid by Health PEI.

4.4 Prior Approval Requirement

Prior approval is required from Health PEI before receiving non-emergency, out-of-province medical or hospital services. Island residents seeking such required services may apply for prior approval through a PEI physician. If approval is not granted, a letter can be submitted to Health PEI to appeal a medical insurance decision. Full coverage may be provided for (PEI insured) non-emergency or elective services, provided the physician completes an application to Health PEI. Prior approval is required from the Medical Director of Health PEI to receive out-of-country hospital or medical services not available in Canada.

5.0 Accessibility

5.1 Access to Insured Health Services

Both of Prince Edward Island's (PEI) Hospital Services Insurance Plan and the Medical Services Insurance Plan provide services on uniform terms and conditions on a basis that does not impede or preclude reasonable access to those services by insured persons. While there is no formal complaints process for inappropriate charges, an individual can seek clarification on the appropriateness of any charges through the Department of Health and Wellness (the Department). The Department can be contacted at:

Prince Edward Island Department of Health and Wellness
P.O. Box 2000
Charlottetown, PE
C1A 7N8
(902) 368-6414

PEI has a publicly administered and funded health system that guarantees universal access to medically necessary hospital and physician services as required by the Canada Health Act.

The Government of PEI recognizes that the health system must constantly adapt and expand to meet the needs of residents.

Several examples of initiatives from the 2019–2020 fiscal year include:

5.2 Physician Compensation

A collective bargaining process is used to negotiate physician compensation. Bargaining teams are appointed by both physicians and the government to represent their interests in the process. The last five-year Master Agreement between the Medical Society of PEI, the Department and Health PEI covered the period of April 1, 2019, to March 31, 2024.

Many physicians continue to work on a fee-for-service basis; however, alternate payment plans have been developed and some physicians receive salary, contract and sessional payments. Alternate payment modalities are expanding and seem to be the preference for new graduates. Currently, 67 per cent of PEI's physicians (excluding locums and visiting specialists) are compensated under an alternate payment method (non-fee-for-service) as their primary means of remuneration.

The legislation governing payments to physicians and dentists for insured services is the Health Services Payment Act. Health PEI is responsible for auditing physician claims for compliance with legislative requirements and the Master Agreement tariff, as permitted under the Health Services Payment Act and delegated by the Minister. The Health Services Payment Act allows for audits of physician payments to assist in efficient and effective use of resources. Health PEI's audit rights are affirmed in the Master Agreement with the Medical Society of PEI. Health PEI approved its Practitioner Claims Monitoring, Compliance, and Recovery Policy on December 22, 2015, and continues to conduct physician payment audits on a go-forward basis. The policy information was communicated to physicians in January 2016.

Physicians submit bills for services provided to insured residents to Health PEI's Claims Payment System (CPS). The CPS contains billing rules aligned with the Master Agreement which help to ensure billings which do not meet Master Agreement criteria are rejected or flagged for review. As part of Health PEI's monitoring process, physicians are randomly selected and requested to provide Health PEI with documentation to support sample billings. Overall physician billings are periodically reviewed to identify unusual billing profiles when compared to peers, significant increases in fee code billings and irregularities in the use of new fee codes. Any irregularities discovered may trigger an audit.

The audits include specific steps for:

The Health Services Payment Act allows for recovery of overpayments and provides for appeal of adjustments to claims. The initial stage for appeal is a discussion with the Executive Director, Medical Affairs or designate. If no agreement can be reached, the matter is appealed to the Health Services Payment Advisory Committee which will provide a recommendation to the Minister.

5.3 Payments to Hospitals

Payments (advances) to provincial hospitals and community hospitals for hospital services are approved for disbursement by the Department in line with cash requirements and are subject to approved budget levels.

The usual funding method includes using a global budget adjusted annually to take into consideration increased costs related to such items as labour agreements, drugs, medical supplies and facility operations.

6.0 Recognition Given To Federal Transfers

The Government of Prince Edward Island (PEI) strives to recognize the federal contributions provided through the Canada Health Transfer whenever appropriate. Over the past year, this has included reference in public documents such as the Province of PEI 2019–2020 Annual Budget and in the 2019–2020 Public Accounts, both of which were tabled in the Legislative Assembly and are publicly available to Prince Edward Island residents.

It is also the intent of the Department of Health and Wellness to recognize this important contribution in the 2019–2020 Annual Report.

Registered Persons
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
1. Number as of March 31st 146,930 150,194 150,990 153,861 154,728
Insured Hospital Services Within Own Province or Territory
Public Facilities 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
2. Number 7 7 7 7 7
3. Payments for insured health services ($)           210,797,200 218,043,400 222,523,865 227,859,554 235,449,936
Private For-Profit Facilities 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
4. Number of private for-profit facilities providing insured health services 0 0 0 0 0
5. Payments to private for-profit facilities for insured health services ($) 0 0 0 0 0
Insured Hospital Services Provided to Residents in Another Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
6. Total number of claims, in-patient 2,616 2,612 2,683 2,736 2,853
7. Total payments, in-patient ($) 28,867,047 28,644,094 27,621,152 27,458,162 30,439,891
8. Total number of claims, out-patient 20,397 19,166 20,008 19,522 19,373
9. Total payments, out-patient ($) 7,930,682 8,234,123 8,866,851 8,667,961 8,670,798
Insured Hospital Services Provided Outside CanadaPEI Table 4 Footnote 1
Pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
10. Total number of claims, in-patient (#) Not applicable Not applicable Not applicable 0 3
11. Total payments, in-patient ($) Not applicable Not applicable Not applicable 0 34,465
12. Total number of claims, out-patient (#) Not applicable Not applicable Not applicable 0 6
13. Total payments, out-patient ($) Not applicable Not applicable Not applicable 0 642
Non pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
14. Total number of claims, in-patient (#) Not applicable Not applicable Not applicable 22 30
15. Total payments, in-patient ($) Not applicable Not applicable Not applicable 121,344 110,913
16. Total number of claims, out-patient (#) Not applicable Not applicable Not applicable 100 95
17. Total payments, out-patient ($) Not applicable Not applicable Not applicable 36,992 50,255
PEI Table 4 Footnote 1

Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report, but did not require provinces or territories to report on previous years.

PEI Table 4 Return to footnote 1 referrer
Insured Physician Services Within Own Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
18. Number of participating physicians 357 367 382 412 416
19. Number of opted-out physicians 0 0 0 0 0
20. Number of non-participating physicians 0 0 0 0 0
21. Total payments for services provided by physicians paid through all payment methods ($) 98,070,004 102,691,590 104,240,026 107,814,785 85,915,289
22. Total payments for services provided by physicians paid through fee-for-service ($) 64,477,376 65,226,925 69,491,809 72,228,583 73,456,751
Insured Physician Services Provided to Residents in Another Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
23. Number of services 107,666 113,338 111,377 115,918 124,520
24. Total payments ($) 11,973,879 11,782,835 11,366,710 11,498,714 12,740,969
Insured Physician Services Provided Outside CanadaPEI Table 7 Footnote 1
Pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
25. Number of services Not applicable Not applicable Not applicable 11 10
26. Total payments ($) Not applicable Not applicable Not applicable 2,584 1,641
 Non pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
27. Number of non pre-approved services Not applicable Not applicable Not applicable 441 262
28. Total payments ($) Not applicable Not applicable Not applicable 26,316 59,715
PEI Table 7 Footnote 1

Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report,but did not require provinces or territories to report on previous years.

PEI Table 7 Return to footnote 1 referrer
Insured Surgical-Dental Services Within Own Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
29. Number of participating dentists 2 2 3 4 4
30. Number of opted-out dentistsPEI Table 8 Footnote 1 - 0 0 0 0
31. Number of non-participating dentistsPEI Table 8 Footnote 1 - 0 0 0 0
32. Number of services provided 373 365 481 401 401
33. Total payments ($) 129,361 127,385 171,255 145,910 164,239
PEI Table 8 Footnote 1

Health Canada requested this data as of the 2016-2017 report, but did not require provinces or territories to report data for 2015-16.

Return to footnote 1 referrer

Nova Scotia

The Nova Scotia Department of Health and Wellness' (the Department) vision and mission are:

The health and wellness system includes the delivery of health care as well as the prevention of disease and injury and the promotion of health and healthy living. The Health Authorities Act establishes roles and responsibilities of the Department, the Nova Scotia Health Authority and the IWK Health Centre.

The Department is responsible for providing leadership and ensuring accountability for funding for the health system.

The Nova Scotia Health Authority and the IWK Health Centre are responsible for governing, managing and providing health services in the province and engaging with the communities they serve.

Insured services in Nova Scotia cover hospital services and physician services. Services such as home care, long-term care, and pharmaceuticals are also provided.

Nova Scotia continues to be committed to the delivery of hospital services and medically required services consistent with the principles of the Canada Health Act.

Additional information related to health care in Nova Scotia may be obtained from the Department of Health and Wellness website.

Covid-19 Measures

Due to the Covid-19 pandemic, the Nova Scotia government put several measures into place in the health care system in 2019-20. These include:

Measures to assist with expanding Health Human Resources:

Measures to increase or expand services for Nova Scotians:

Measures to increase patient safety:

Measures to support vulnerable populations:

1.0 Public Administration

1.1 Health Care Insurance Plan and Public Authority

Two plans cover insured health services in Nova Scotia: The Hospital Insurance and the Medical Services Insurance (MSI) Plans, which both operate under the Health Services and Insurance Act.

The Nova Scotia Department of Health and Wellness (the Department) administers the Hospital Insurance Plan and the MSI Plan is administered and operated by Medavie Blue Cross (MBC) on behalf of the Minister.

Section 8 of the Health Services and Insurance Act gives the Nova Scotia Minister of Health and Wellness (the Minister), with approval of the Governor in Council, the power to enter into agreements and vary, amend or terminate the same agreements with such person or persons as the Minister deems necessary to establish, implement and carry out the MSI Plan.

The Department and MBC entered into a service level agreement, effective August 1, 2005. Under the agreement, MBC is responsible for operating and administering programs contained under MSI, Pharmacare Programs and Health Card Registration Services.

In 2019-2020, no amendments were made to either the Health Services Insurance Act or the Medical Services Insurance Regulations.

1.2 Reporting Relationship

A. Hospital Insurance

Section 17(1)(i) of the Health Services and Insurance Act, and sections 11(1) and 12(1) of the Hospital Insurance Regulations, under this Act, set out the terms for reporting by hospitals and hospital boards to the Minister of Health and Wellness.

B. Medical Insurance

In the service level agreement between MBC and the Department, MBC is obliged to provide reports to the Department under various Statements of Requirements as listed in the contract. MBC is audited every year on various areas of reporting. MBC provides audited financial statements for the fiscal year ending March 31st and the statements are provided within 4 months of the fiscal year end.

1.3 Audit of Accounts

The Auditor General audits all expenditures of the Department. Under its service level agreement with the Department, MBC provides audited financial statements of MSI costs to the Department. The Auditor General and the Department have the right to perform audits of the administration of the agreement with MBC.

Within the Physician Services program there are various programs that are audited by third parties and that submit financial statements to the Department. This includes financial statements from the Dalhousie Family Medicine training sites and the Practice Ready Assessment program. Additionally, MBC conducts audits of the Academic Funding Plans (AFP).

On behalf of the Minister, the service provider that operates Nova Scotia’s out-of-hospital emergency medical services (Emergency Health Services (EHS) 911 Ground Ambulance, EHS Critical Care Transport, and non-emergent EHS Mobile Integrated Health Services) and 811 Telehealth services is required to submit audited financial statements each year and they are due 90 days after year-end of March 31st. The Department also receives audited financial statements from various other service providers including Nova Scotia Hearing and Speech Centres, Canadian Blood Services, Society of Deaf and Hard of Hearing Nova Scotia but there is no set deadline for these statements.

Under section 36(4) of the Health Authorities Act, a health authority is required to submit to the Minister, no later than June 30 each year, an audited financial statement for the preceding fiscal year.

In addition to the annual audit of the Provincial Financial Statements, the Auditor General conducts performance audits on a variety of programs. The most recent Auditor General audits on the Department of Health and Wellness were follow-up reports, specifically:

For further details please visit the Auditor General’s website.

1.4 Designated Agency

MBC administers monies to pay physician accounts as per the service agreement with the Department of Health and Wellness. Physician rates of pay are set based on the Master Agreement negotiated with Doctors Nova Scotia (the sole negotiating body for physicians in Nova Scotia) and the Clinical Academic Funding Plan, which is negotiated with Doctors Nova Scotia, Dalhousie University, the Nova Scotia Health Authority and the IWK Health Centre.

MSI is the provincial plan of insured medical services. It is designed to pay for a wide range of medically necessary physicians’ services, as well as certain dental and optometric services.

The Department and the Office of the Auditor General, have the right, under the terms of the service level agreement, to audit all MSI and Pharmacare transactions.

Green Shield Canada administers and has the authority to receive monies to pay dentists under a service level agreement with the Department. The tariff of dental fees is negotiated between the Nova Scotia Dental Association and the Department.

As part of an agreement with the Department, Green Shield Canada also provides monthly, quarterly and annual reports with regard to dental programs in Nova Scotia. This includes hospital dental services when the hospital setting is required for the safe performance of the procedure. These reports address provider claims and payment, program utilization, and audit. A complete list of reports can be obtained from the Department.

Green Shield is required to submit their audited financial statements annually.

MBC is responsible for providing a number of regular and ad hoc reports to the Department pertaining to health card administration, physician claims activity, financial monitoring, provider management, audit activities and program utilization. These reports are submitted on a monthly, quarterly, or annual basis. A complete list of reports can be obtained from the Department.

2.0 Comprehensiveness

2.1 Insured Hospital Services

The enabling legislation that provides for insured hospital services in Nova Scotia is the Health Services and Insurance Act (HSIA). Hospital Insurance Regulations were made pursuant to the Act. No amendments were made to this legislation in fiscal year 2019-2020.

Under the Hospital Services Insurance Plan, in-patient services include:

Out-patient services include:

Each year, the Nova Scotia Health Authority and the IWK Health Centre submit business plans outlining budgets and priorities for the coming year to ensure safe and high-quality access to care. Under the Health Authorities Act, business plans are to be submitted on November 1 every year and will be approved by the Minister of Health and Wellness.

The Department is aware of the operation of a private MRI clinic that is operating outside of HSIA and the Hospital Insurance Plan Regulations. The Department is currently reviewing options for how to address the situation.

2.2 Insured Physician Services

The legislation covering the provision of insured physician services in Nova Scotia is the Health Services and Insurance Act, sections 3(2), 5, 8, 13, 13A, 17(2), 22, 27–31, 35, and the Medical Services Insurance Regulations. No amendments were made to this legislation in 2019-2020.

As of March 31, 2020, 2,801 physicians were paid through the MSI Plan.

Physicians retain the ability to opt in or out of the MSI Plan. To opt out, a physician notifies MSI and relinquishes their billing number. MSI reimburses patients who pay the physician directly due to opting out. As of March 31, 2020, no physicians had opted-out of the MSI plan to pursue this method of remuneration.

Insured services include those that are medically necessary. Payment is provided for the following physicians’ services, when medically necessary:

If, in the opinion of the physician, a patient requires the services of a specialist for either consultation or care, a referral to the specialist is made. Payment at the specialist tariff is based on a valid referral by the attending physician.

Additional services were added to the list of insured physician services in 2019–2020, including Body Mass Index surgical premium, Mohs Micrographic Surgery, Head and Neck Surgery, Endobronchial Ultrasound, and Autistic Diagnostic Assessment.

The Fee Committee is outlined in Article 4.1(c) of the 2019 Master Agreement. The Fee Committee is a collaborative structure made up of the Department, Nova Scotia Health Authority, and Doctors Nova Scotia. The Committee reviews requests for new fees, amendments to current fees, and for additions, revision, or clarification of the Preamble to the MSI Physician manual. The Fee Committee provides advice and recommendations to the Master Agreement Management Group on all matters pertaining to the fee schedule, based on consensus and available budget. If the fee is approved, Medavie Blue Cross is directed to add the new fee to the schedule of insured services payable by the MSI Plan.

Public consultations are not generally undertaken when listing or delisting insured medical services.

2.3 Insured Surgical-Dental Services

To provide insured surgical-dental services under the Health Services and Insurance Act, dentists must be registered members of the Nova Scotia Dental Association, must be certified competent in the practice of dental surgery, and must also have privileges from the health authorities to deliver services at specific hospitals. The Health Services and Insurance Act is written so that a dentist may choose not to participate in the MSI Plan. To participate, a dentist must register with MSI. A participating dentist who chooses not to participate must advise MSI in writing and is then no longer eligible to submit claims to MSI. In 2019 –2020, 18 dentists were paid through the MSI Plan for providing insured surgical-dental services.

Insured surgical-dental services must be provided in a public health care facility. Insured surgical-dental services are detailed in the Department’s Dentists Guide and are reviewed annually. Services under this program are insured when the condition of the patient is such that it is medically necessary for the procedure to be done in a public hospital and the procedure is of a surgical nature.

Generally included as insured surgical-dental services are extractions and oral and maxillofacial surgery. Requests for an addition to the list of surgical-dental services are accomplished through the Nova Scotia Dental Association which submits a proposal to the Department. Then, in consultation with experts in the field, the Department renders a decision on the addition of the procedure as an insured service. Public consultations are not undertaken during the consideration of additions to the list of insured services.

Insured services in the “Other extraction services” (routine extractions) category are approved for the following groups of patients: cardiac patients, transplant patients, immunocompromised patients, and radiation patients. This is the case only when patients are undergoing active treatment in a hospital setting and the medical procedure must require the removal of teeth in a manner that would otherwise be considered routine extractions.

Currently, there are no opted-out dentists and no non-participating dentists providing insured surgical-dental services.

2.4 Uninsured Hospital, Physician and Surgical-Dental Services

Uninsured hospital services include:

Uninsured Physician Services include:

Major third-party agencies currently purchasing medically required health services in Nova Scotia include Workers’ Compensation Board and the Department of National Defence.

All residents of the province are entitled to services covered under the Health Services and Insurance Act. If enhanced goods and services, such as fibreglass casts, are offered as an alternative, the specialist or physician is responsible to ensure that the patient is aware of their responsibility for the cost. Patients are not denied service based on their inability to pay. The province provides alternatives to any of the enhanced goods and services.

The Department carefully reviews all patient complaints or public concerns that may indicate that the general principles of insured services are not being followed.

If a service or procedure is deemed by the Department not to be medically required, it is removed from the physician fee schedule and will no longer be reimbursed to physicians as an insured service. Once a service has been de-insured, all procedures and testing relating to the provision of that service also become de-insured. The same also applies to dental services and hospital services. Public consultations are not undertaken during the determination of medical necessity and de-listing of insured services. Consultation with the Nova Scotia Dental Association has preceded past de-listing of dental services. The last time there was any significant de-insurance of services was in 1997.

3.0 Universality

3.1 Eligibility

Eligibility for insured health care services in Nova Scotia is outlined under section 2 of the Hospital Insurance Regulations made pursuant to section 17 of the Health Services and Insurance Act. All residents of Nova Scotia are eligible. A resident is defined as anyone who is legally entitled to stay in Canada and who makes their home and is ordinarily present in Nova Scotia. Registration for the hospital and medical insurance plans is voluntary and residents may choose not to register.

In 2019-2020, a person was considered to be "ordinarily present" in Nova Scotia if the person:

Children born out-of-country to Nova Scotia residents are eligible for coverage provided their parents meet the Nova Scotia residency requirements.

Persons moving to Nova Scotia from another Canadian province will normally be eligible for Medical Services Insurance on the first day of the third month following the month of their arrival. Persons moving permanently to Nova Scotia from another country are eligible on the date of their arrival in the province, provided they are Canadian citizens or hold "Permanent Resident" status as defined by IRCC.

Individuals insured under the Workers’ Compensation Act or any other act in the Legislature or of the Parliament of Canada or under any statute or law of any other jurisdiction either within or outside of Canada are not eligible for MSI Coverage (such as members of the Canadian Forces, federal inmates and some classes of refugees). Once individuals are no longer covered under any of the acts, statutes or laws noted above, they are then eligible to apply for and receive Nova Scotia health insurance coverage, provided that they are either a Canadian Citizen, a permanent resident as defined by IRCC or meet the Nova Scotia residency requirements. An administrative review may be requested for individuals who are deemed ineligible.

In 2019-2020, the total number of residents registered with the health insurance plan was 1,043,849.

No amendments were made to the Nova Scotia Health Insurance Policy in 2019-2020.

3.2 Other Categories of Individuals

Other individuals may be eligible for insured health care services in Nova Scotia if they meet specific eligibility criteria listed below:

Immigrants: Persons moving from another country to live permanently in Nova Scotia are eligible for health care on the date of arrival if they arrive as a permanent resident, as determined by Immigration, Refugees and Citizenship Canada.

Non-Canadians married to Canadian Citizens or Permanent Residents (copy of marriage certificate required), who possess the required documentation from IRCC indicating they have applied for permanent residency, will be eligible for coverage on the date of arrival in Nova Scotia (if applied prior to their arrival to Nova Scotia), or the date of application for permanent residency (if applied after their arrival in Nova Scotia).

Convention refugees or persons in need of protection who possess the required documentation from IRCC indicating they have applied for permanent residency will be eligible for coverage on the date of application for permanent residency.

In 2019-2020, there were 57,575 permanent residents registered with the health care insurance plan.

Refugees: Refugees are eligible for MSI once they have been granted permanent residency status by IRCC, or if they possess either a work permit or study permit.

Work Permits: Persons moving to Nova Scotia from outside the country who possess a work permit can apply for coverage on the date of arrival in Nova Scotia, provided they will be remaining in Nova Scotia for at least one full year. A declaration must be signed to confirm that the worker will not be outside Nova Scotia for more than 31 consecutive days, unless required in the course of employment. MSI coverage is extended for a maximum of 12 months at a time. Each year, a copy of their renewed immigration document must be presented, and a declaration signed. Dependants of such persons, who are legally entitled to remain in Canada, are granted coverage on the same basis. Seasonal Workers are eligible for the same coverage as those with work permits.

Once coverage has terminated, the person is to be treated as never having qualified for health services coverage as herein provided and must comply with the above requirements before coverage will be extended to them or their dependants.

In 2019-2020, there were 7,694 individuals with work permits covered under the health care insurance plan.

Study Permits: Persons moving to Nova Scotia from another country and who possess a study permit (Student Authorization) will be eligible for MSI on the first day of the thirteenth month following the month of their arrival, provided they have not been absent from Nova Scotia for more than 31 consecutive days, unless required in the course of their studies. MSI coverage is extended for a maximum of 12 months at a time and only for services received within Nova Scotia. Each year, a copy of their renewed immigration document must be presented, and a declaration signed. Dependants of such persons, who are legally entitled to remain in Canada, will be granted coverage on the same basis once the student has gained entitlement.

In 2019-2020, there were 1,985 individuals with study permits covered under the health care insurance plan.

4.0 Portability

4.1 Minimum Waiting Period

Persons moving to Nova Scotia from another Canadian province or territory will normally be eligible for Medical Services Insurance on the first day of the third month following the month of their arrival.

4.2 Coverage during Temporary Absences in Canada

The Interprovincial Agreement on Eligibility and Portability is followed in all matters pertaining to the portability of insured services.

Generally, the Nova Scotia Medical Services Insurance (MSI) Plan provides coverage for residents of Nova Scotia who move to other provinces or territories for a period of three months, per the Eligibility and Portability Agreement. Students and their dependants, who are temporarily absent from Nova Scotia and in full-time studies at an educational institution may remain eligible for MSI on a yearly basis. To qualify for MSI, the student must provide to MSI a letter directly from the educational institution which states that they are registered as a full-time student. MSI coverage will be extended on a yearly basis pending receipt of this letter.

Workers who leave Nova Scotia to seek employment elsewhere will still be covered by MSI for up to 12 months, provided they do not establish residence in another province or territory. Services provided to Nova Scotia residents in other provinces or territories are covered by reciprocal agreements. Nova Scotia participates in the Hospital Reciprocal Billing Agreement and the Medical Reciprocal Billing Agreement. Quebec is the only province that does not participate in the Medical Reciprocal Billing Agreement. Nova Scotia pays for services provided by Quebec physicians to Nova Scotia residents at Quebec rates if the services are insured in Nova Scotia. The majority of such claims are received directly from Quebec physicians. In-patient hospital services are paid through the interprovincial reciprocal billing arrangement at the standard ward rate of the hospital providing the service. Nova Scotia pays the host province rates for insured services in all reciprocal billing situations.

The total amount paid by the plan in 2019-2020 for in-patient and out-patient hospital services received in other provinces and territories was $37,085,112.

Nova Scotia residents remain eligible to receive MSI during vacation outside of the province for up to seven months in each calendar year and will continue to be deemed a resident if the following conditions are met:

No amendments were made to the Nova Scotia Health Insurance Policy in 2019-2020.

4.3 Coverage during Temporary Absences Outside Canada

Nova Scotia adheres to the Agreement on Eligibility and Portability for dealing with insured services for residents temporarily outside Canada. Provided a Nova Scotia resident meets eligibility requirements, out-of-country services will be paid, at a minimum, on the basis of the amount that would have been paid by Nova Scotia for similar services rendered in this province. In order to be covered, procedures of a non-emergency nature must have prior approval before they will be covered by MSI.

Residents receiving haemodialysis outside Canada are eligible for reimbursement to a maximum of $496 per day, provided they submit the original service invoice.

Nova Scotia residents remain eligible to receive MSI during vacation out-of-country for up to seven months in each calendar year and continue to be deemed a resident if the above stated conditions are met.

Students and their dependants who are temporarily absent from Nova Scotia and in attendance at an educational institution outside Canada may remain eligible for MSI on a yearly basis. To qualify for MSI, the student must provide to MSI a letter obtained from the educational institution that verifies the student's attendance there in each year for which MSI coverage is requested.

Persons who engage in employment (including volunteering, missionary work or research) outside Canada, which does not exceed 24 months, are still covered by MSI, providing the person has already met the residency requirements.

The total amount spent in 2019-2020 for insured in-patient services provided outside of Canada was $7,327,272. Nova Scotia does not cover out-patient services out-of-country.

In 2019-2020, the total number of residents registered with the health insurance plan was 1,043,849.

No amendments were made to the Nova Scotia Health Insurance Policy in 2019-2020.

4.4 Prior Approval Requirement

Prior approval must be obtained, if residents wish to be reimbursed for elective services outside the country. Application for prior approval is made to the medical consultant of the MSI Plan by a specialist in Nova Scotia on behalf of an insured resident. The medical consultant reviews the terms and conditions and determines whether or not the service is available in the province, or if it can be provided in another province or only out-of-country. The decision of the medical consultant is relayed to the patient's referring specialist. If approval is given to obtain service outside the country, the full cost of that service will be covered under MSI. An administrative review may be requested for individuals who are deemed ineligible.

5.0 Accessibility

5.1 Access to Insured Health Services

Section 3 of the Health Services and Insurance Act states that “subject to this Act and the regulations, all residents of the Province are entitled to receive insured hospital services from hospitals upon uniform terms and conditions.” As well, all residents of the province are insured on uniform terms and conditions in respect of the payment of insured professional services to the extent of the established tariff. There are no user charges or extra charges allowed under the plan. In Nova Scotia, there is not a dedicated number or website to report cases of patient charges.

Complaints generally come directly to the Department of Health and Wellness via telephone or e-mail; are received by Medavie Blue Cross and then directed to the Department; or are directed to the College of Physicians and Surgeons of Nova Scotia (CPSNS). Complaints are investigated and addressed.

The Department of Health and Wellness General Inquiry contact information is as follows:

By phone: 902-424-5818
1-800-387-6665 (toll-free in Nova Scotia)
1-800-670-8888 (TTY/TDD)

By mail: Department of Health and Wellness
PO Box 488
Halifax, Nova Scotia B3J 2R8

E-mail questions or feedback on-line.

Nova Scotia continually monitors and reviews situations around access to insured health services across Canada to ensure equity of access.  

5.2 Physician Compensation

The Health Services and Insurance Act, RS Chapter 197 governs payment to physicians and dentists for insured services. Physician payments are made in accordance with a negotiated agreement between Doctors Nova Scotia (the sole bargaining agent for physicians) and the Province of Nova Scotia, as represented by the Minister.

Fee-for-service is the most prevalent method of payment for physician services; however, there is growth in the share of total physician payments made through alternative payment arrangements. Alternative payment arrangements facilitate the delivery of medical care that may not be compatible with the fee-for-service funding model and are often used to support physician recruitment and retention, and the funding of group-based care in rural areas where service volumes are expected to be less. Additionally, within the academic funding context, payments may include compensation for non-medical activities such as teaching, research, and administration.

The 2019 Master Agreement committed the province to developing a blended capitation model; this work is underway. Other funding programs such as emergency agreements, sessional funding, and locum funding are also utilized by the province.

In Nova Scotia, payment and payment monitoring are part of Medical Services Insurance’s (MSI) deliverables. Section 9 of the 2019 Master Agreement lays out the Department’s right to conduct audits of Physicians with respect to insured medical service being claimed. Schedule E of the Master Agreement outlines billing audit processes including an Audit Committee of the Master Agreement Management Group to review the audit process and make recommendations. Annually, MSI develops an audit plan and conducts monitoring of claims to determine whether:

Payment rates for dental services in the province are negotiated between the Department and the Nova Scotia Dental Association following a process similar to physician negotiations. Dentists are generally paid on a fee-for-service basis. Pediatric dentists at the IWK Health Centre receive remuneration through an Academic Funding Plan.

5.3 Payments to Hospitals

The Department establishes budget targets for health care services. It does this by receiving business plans from the Nova Scotia Health Authority and the IWK Health Centre and other non-district health authority organizations. Approved provincial estimates form the basis on which payments are made to these organizations for service delivery.

The Health Authorities Act establishes the Nova Scotia Health Authority and the IWK Health Centre as the bodies responsible for overseeing the delivery of health services in the province of Nova Scotia and requires them to work collaboratively to do so.

Section 10 of the Health Services and Insurance Act and sections 9 through 13 of the Hospital Insurance Regulations define the terms for payments by the Minister of Health and Wellness to hospitals for insured hospital services.
In 2019-2020 there were 2,828 hospital beds in Nova Scotia (2.9 beds per 1,000 population). Department direct expenditures for insured hospital services operating costs were $2,033,885,945.

6.0 Recognition Given to Federal Transfers

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

The Government of Nova Scotia also recognized the federal contribution under the Canada Health Transfer in various published documents, including the following documents:

Registered Persons
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
1. Number as of March 31st 1,008,726 1,012,642 1,020,007 1,034,476 1,043,849
Insured Hospital Services Within Own Province or Territory
Public Facilities 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
2. Number 35 35 35 35 35
3. Payments for insured health services ($)Nova Scotia Table 2 Footnote 1 1,720,856,746 1,790,425,313 1,862,969,024 1,917,181,492 2,033,885,945
Private For-Profit Facilities 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
4. Number of private for-profit facilities providing insured health servicesNova Scotia Table 2 Footnote 2 0 0 0 0 0
5. Payments to private for-profit facilities for insured health services ($) Not applicable Not applicable Not applicable Not applicable Not applicable
Nova Scotia table 2 Footnote 1

Reflects payments made to the public facilities noted for indicator 2.

Nova Scotia table 2 Return to footnote 1 referrer

Nova Scotia table 2 Footnote 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.

Nova Scotia table 2 Return to footnote 2 referrer
Insured Hospital Services Provided to Residents in Another Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
6. Total number of claims, in-patient 2,019 1,882 2,995 2,934 1,986
7. Total payments, in-patient ($) 19,022,461 19,801,011 19,474,523 19,879,822 21,568,883
8. Total number of claims, out-patient 40,344 37,910 39,706 40,361 38,929
9. Total payments, out-patient ($) 14,174,680 14,428,730 15,209,411 15,715,186 15,516,229
Insured Hospital Services Provided Outside CanadaNova Scotia Table 4 Footnote 1
Pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
10. Total number of claims, in-patient Not applicable Not applicable Not applicable Not Available Not Available
11. Total payments, in-patient ($) Not applicable Not applicable Not applicable 2,386,348 7,327,272
12. Total number of claims, out-patient Not applicable Not applicable Not applicable Not Available Not Available
13. Total payments, out-patient ($) Not applicable Not applicable Not applicable Not Available Not Available
Non pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
14. Total number of claims, in-patient Not applicable Not applicable Not applicable Not Available Not Available
15. Total payments, in-patient ($) Not applicable Not applicable Not applicable 331,879 352,994
16. Total number of claims, out-patient Not applicable Not applicable Not applicable Not Available Not Available
17. Total payments, out-patient ($) Not applicable Not applicable Not applicable Not Available Not Available
Nova Scotia Table 4 Footnote 1

Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report, but did not require provinces or territories to report on previous years.

Nova Scotia Table 4 Return to footnote 1 referrer
Insured Physician Services Within Own Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
20. Number of non-participating physicians Not applicable Not applicable Not applicable Not applicable Not applicable
21. Total payments for services provided by physicians paid through all payment methods ($) 740,465,887 735,418,537 769,657,951 800,367,900 834,933,109
22. Total payments for services provided by physicians paid through fee-for-service ($) 378,290,569 377,118,049 352,410,103 357,558,840 352,279,973
Insured Physician Services Provided to Residents in Another Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
23. Number of services 222,026 220,932 215,616 221,096 226,834
24. Total payments ($) 9,304,321 9,167,527 9,023,845 9,292,479 9,522,757
Insured Physician Services Provided Outside CanadaNova Scotia Table 7 Footnote 1
Pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
25. Number of services Not applicable Not applicable Not applicable 38 47
26. Total payments ($) Not applicable Not applicable Not applicable 119,968 110,315
Non pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
27. Number of services Not applicable Not applicable Not applicable 1,971 1,391
28. Total payments ($) Not applicable Not applicable Not applicable 121,608 91,170
Nova Scotia Table 7 Footnote 1

Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report,but did not require provinces or territories to report on previous years.

Nova Scotia Table 7 Return to footnote 1 referrer
Insured Surgical-Dental Services Within Own Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
29. Number of participating dentists 28 26 19 18 18
30. Number of opted-out dentistsNova Scotia Table 8 Footnote 1 Not applicable 0 0 1 0
31. Number of non-participating dentistsNova Scotia Table 8 Footnote 1 Not applicable 0 0 0 0
32. Number of services providedNova Scotia Table 8 Footnote 2 8,591 8,518 8,123 6,642 6,381
33. Total payments ($)Nova Scotia Table 8 Footnote 3 1,401,379 1,470,674 1,422,086 1,427,177 1,460,699
Nova Scotia Table 8 Footnote 1

Health Canada requested this data as of the 2016-2017 report, but did not require provinces or territories to report data for 2015-16.

Nova Scotia Table 8 Return to footnote 1 referrer

Nova Scotia Table 8 Footnote 2

Total services includes block funded dentists. This also inclued maxillofacial and cleft palate surgeries.

Nova Scotia Table 8 Return to footnote 2 referrer

Nova Scotia Table 8 Footnote 3

Total payments does not include block funded dentists.

Nova Scotia Table 8 Return to footnote 3 referrer

New Brunswick

As with the rest of Canada, in March 2020, New Brunswick was faced with the unique challenges posed by the COVID-19 virus. Taking immediate steps, such as expanding the virtual provision of care at a time when physical contact put both patients and providers at risk, New Brunswick initiated actions to continue to ensure that citizens receive the care that they need, while preserving capacity to fight the pandemic.

We are proud of the way care New Brunswick’s health providers and citizens, and civil servants from all Orders of Government have risen to this challenge, showing an admirable combination of competence, courage, determination, and compassion.

1.0 Public Administration

1.1 Health Care Insurance Plan and Public Authority

In New Brunswick, the formal name for Medicare is the Medical Services Plan. The Minister of Health (Minister) has the mandate and responsibility for operating and administering the plan by virtue of the Medical Services Payment Act and its Regulations. The Act and Regulations set out who is eligible for Medicare coverage, the rights of the patient, and the responsibilities of the Department of Health (the Department). This law establishes a Medicare plan, and defines which Medicare services are covered and which are excluded. It also stipulates the type of agreements the Department may enter into. As well, it specifies the rights of a medical practitioner; how the amounts to be paid for medical services will be determined; how assessment of accounts for medical services may be made; and confidentiality and privacy issues as they relate to the administration of the Act.

1.2 Reporting Relationship

The Medicare and Physician Services Branch of the Department are mandated to administer the Medical Services Plan. The Minister reports to the Legislative Assembly through the Department’s annual report and through regular legislative processes.

The Regional Health Authorities Act establishes the regional health authorities (RHA) and sets forth the powers, duties, and responsibilities of the same. The Minister is responsible for the administration of the Act, provides direction to each RHA, and may delegate additional powers, duties or functions to the RHA.

The Department of Health prepares and submits an Annual Report to the Legislature, and also provides information to the Office of the Comptroller for inclusion in their Public Accounts documents. The Minister and Department of Health executive team are accountable to answer questions of members of the Legislature pursuant to those Public Accounts documents. The most current Department of Health Annual Report can be found here.

1.3 Audit of Accounts

Three groups have a mandate to audit the Medical Services Plan.

The Office of the Auditor General: In accordance with the Auditor General Act, the Office of the Auditor General conducts the external audit of the accounts of the province of New Brunswick, which includes the financial records of the Department. The Auditor General also conducts management reviews on programs as they see fit. Chapter 2 of the Auditor General’s June 2019 report reviewed the way in which Medicare Cards are renewed. The report’s key findings and the Department’s responses can be found here.

The Office of the Comptroller: The Comptroller is the chief internal auditor for the province of New Brunswick and provides accounting, audit and consulting services in accordance with responsibilities and authority set out in the Financial Administration Act. Annual financial statements and supplementary information submitted to the Legislature by the Office of the Comptroller for all publicly funded purposes including those associated with insured services under the Canada Health Act) can be found here. 

Monitoring and Compliance Team: This team is tasked with managing compliance with the Medical Services Payment Act and Regulations, as well as the Negotiated Fee Schedule.

2.0 Comprehensiveness

2.1 Insured Hospital Services

Legislation providing for insured hospital services as described in the Canada Health Act includes the Hospital Services Act, section 9 of Regulation 84–167, and the Hospital Act. Under Regulation 84–167 of the Hospital Services Act, New Brunswick residents are entitled to the following insured hospital services.

Insured in-patient services include:

Insured out-patient services include:

In 2019-2020 no amendments were made to the Acts or Regulations noted above, nor were any insured services added or deleted.

The publicly funded New Brunswick health system is rich in medical imaging resources, and imaging deemed by a referring physician to be medically necessary is conducted swiftly, without patient comments or concerns respecting accessibility. There is no evidence in New Brunswick of unmet patient need for timely access to CHA insurable imaging services.

Accordingly, New Brunswick finds no present need to legislate or regulate such private businesses. While in 2019-2020 there was one clinic in New Brunswick soliciting private clients for diagnostic imaging, the Department has no relationship with the organization, and does not foresee entering into one.

2.2 Insured Physician Services

The Medical Services Payment Act and corresponding regulations provide for insured physician services. As of March 31, 2020, there were 1,748 participating physicians in New Brunswick. While any practitioner licensed in New Brunswick who has not affirmatively “opted-in” is deemed to have “opted out” (and no further action is required to have opted-out status), no physicians rendering health care services in this fiscal year so chose. Opted-out practitioners are not paid directly by Medicare for the services which they render, must bill their patients in all cases, and the patients are not entitled to a reimbursement from Medicare. Further, practitioners can elect to opt-out for any given patient only for the total management of the patient’s condition under care, including any complications which may develop within a reasonable length of time, and they must advise the patient in advance of rendering service that they are opting-out for those services.

The services which residents are entitled to under Medicare include:

A physician or the Department of Health may request the addition of a new service. All requests are considered by the New Service Items Committee, which is jointly managed by the New Brunswick Medical Society and the Department. The decision to add a new service is based on conformity to the definition of “medically necessary” and whether the service is considered generally acceptable practice (not experimental) within New Brunswick and/or Canada. Considerations under the term “medically necessary” include services required for maintaining health, preventing disease and/or diagnosing or treating an injury, illness or disability. No public consultation process is used.

In May 2019, Regulation 2019-9 added audiologists to the lists in Section 11(2.1) and 11(2.2) of those who may refer to a medical practitioner or oral and maxillofacial surgeon. Apart from this, there were no changes to the Medical Services Payment Act or Regulation during the period of this report.

2.3 Insured Surgical-Dental Services

Schedule 4 of Regulation 84–20 under the Medical Services Payment Act identifies the insured surgical- dental services that can be provided by a qualified dental practitioner in a hospital, providing the condition of the patient requires services to be rendered in a hospital.

In addition, a general dental practitioner may be paid to assist another dentist for medically required services under some conditions. In addition to Schedule 4 of Regulation 84–20, oral maxillofacial surgeons (OMS) have added access to approximately 300 service codes in the Physician Manual and can admit or discharge patients and perform physical examinations, including those performed in an out-patient setting. OMS may also see patients for consultation in their office.

As of March 31, 2020, there were 11 dentists and oral maxillofacial surgeons who provided services insured under the Medical Services Plan.

There is not a formally defined process through which new dental services may be added to the list of insured services; however, oral maxillofacial surgeons may approach government with such a request if they deem it appropriate. In 2019-2020 there were no such additions.

2.4 Uninsured Hospital, Physician and Surgical-Dental Services

Uninsured hospital services include:

The services listed in Schedule 2 of New Brunswick Regulation 84–20 under the Medical Services Payment Act are specifically excluded from the range of entitled medical services under Medicare. They are as follows:

Dental services not specifically listed in Schedule 4 of the Dental Schedule are not covered by the Plan. Those listed in Schedule 2 are considered the only non-insured medical services.

There are no specific policies or guidelines, other than the Act and Regulations, to ensure that charges for uninsured medical goods and services (e.g., fibreglass casts), provided in conjunction with an insured health service, do not compromise reasonable access to insured services.

The decision to de-insure physician or surgical-dental services is based on the conformity of the service to the definition of “medically necessary,” a review of medical service plans across the country, and the previous use of the particular service. Once a decision to de-insure is reached, the Medical Services Payment Act dictates that the government may not make any changes to the Regulation until the advice and recommendations of the New Brunswick Medical Society are received or until the period within which the Society was requested by the Minister to furnish advice and make recommendations has expired. Subsequent to receiving their input and resolution of any issues, a regulatory change is completed. Physicians are informed in writing following notification of approval. The public is usually informed through a media release. No public consultation process is used.

In 2019–2020, no services were removed from the insured services list.

3.0 Universality

3.1 Eligibility

Sections 3 and 4 of the Medical Services Payment Act and Regulation 84–20 define eligibility for the health care insurance plan in New Brunswick. Residents are required to complete a Medicare application and provide proof of identity, proof of residency, and proof of Canadian citizenship or a valid Canadian immigration document. A resident is defined as a person lawfully entitled to be, or to remain, in Canada, who makes their home and is ordinarily present in New Brunswick, but does not include a tourist, transient, or visitor to the province.

As of March 31, 2020, there were 782,398 persons registered in New Brunswick.

All persons entering or returning to New Brunswick (excluding children adopted from outside Canada) have a waiting period before becoming eligible for Medicare coverage. Coverage commences on the first day of the third month following the month of arrival.

Exceptions are as follows:

Residents who were not eligible for Medicare coverage during this reporting period included:

Persons who are discharged or released in New Brunswick from the Canadian Armed Forces, or a federal penitentiary, become eligible for coverage on the date of their discharge or release. An application must be completed and signed, and the applicant must provide proof of Canadian citizenship, proof of residency and the official date of release.

3.2 Other Categories of Individuals

Non-Canadian new hires coming to Canada under a work permit must have a permit valid for a minimum of one year (or two six-month permits within a few months of each other). The Department of Health also requires a copy of their passport (including a copy of the last entry date stamp), and proof of residency in New Brunswick.

Children born out-of-country to Canadian citizens will take the eligibility status of the parent upon return to the province.

Should an individual disagree with a decision of the Department of Health, including a decision respecting eligibility to receive services, they may petition the Insured Services Appeal Committee, which shall provide advice to the Minister.

There were no amendments made to eligibility provisions in 2019-2020.

4.0 Portability

4.1 Minimum Waiting Period

A person is eligible for New Brunswick Medicare coverage on the first day of the third month following the month permanent residency has been established. The three month waiting period is legislated under New Brunswick’s Medical Services Payment Act. Refer to section 3.1 of this submission for exceptions; there were no amendments made to this section of the Act in 2019-2020.

4.2 Coverage during Temporary Absences in Canada

The legislation that defines portability of health insurance during temporary absences in Canada is the Medical Services Payment Act, Regulation 84–20, sub-sections 3(4) and 3(5). This portion of the Act was not amended in 2019-2020.

Medicare coverage may be extended upon request in the case of temporary absences to:

Students: Those in full-time attendance at a university or other approved educational institution, who leave the province to further their education in another province, will be granted coverage for a 12 month period that is renewable, provided the following terms are met:

Residents: Residents temporarily employed in another province or territory are granted coverage for up to 12 months, provided the following terms are met:

New Brunswick has formal agreements for reciprocal billing arrangements of insured hospital services with all provinces and territories. In addition, New Brunswick has reciprocal agreements with all provinces, except Quebec, for the provision of insured physician services. Services provided by Quebec physicians to New Brunswick residents are paid at Quebec rates provided the service delivered is insured in New Brunswick. The majority of such claims are received directly from Quebec physicians. Any claims submitted directly by a patient are reimbursed to the patient.

4.3 Coverage during Temporary Absences Outside Canada

The legislation that defines portability of health insurance during temporary absences outside Canada is the Medical Services Payment Act, Regulation 84–20, subsections 3(4) and 3(5).

Eligibility for New Brunswick residents temporarily absent outside of Canada is determined in accordance with the Medical Services Payment Act.

Residents temporarily employed outside Canada are granted coverage for 182 days. This may be extended up to 12 months within a three year period upon approval from the Director of Medicare Eligibility and Claims. Exceptions to this are mobile and contract workers.

Coverage for any absence over 212 days for vacation purposes requires approval from the Director of Medicare Eligibility and Claims. This approval can only be for up to 12 months in duration and will only be granted once every three years.

New Brunswick residents exceeding the 12 month extension have to reapply for New Brunswick Medicare upon their return to the province. In this instance, cases are reviewed on a case by case basis. Depending on the circumstances, some cases may be eligible for first day coverage while others who have been away from the province slightly beyond the 12 month period may be given a grace period.

Insured residents who receive insured emergency services out-of-country are eligible to be reimbursed $100 per day for in-patient stays and $50 per out-patient visit. The insured resident is reimbursed for physician services associated with the emergency treatment at New Brunswick rates. The difference in rates is the patient’s responsibility.

Mobile Workers: Mobile Workers are residents whose employment requires them to travel outside the province (e.g., pilots). The following guidelines must be met to receive Mobile Worker designation.

Mobile Worker status is assigned for a maximum of two years, after which the resident must reapply and submit documentation to confirm a continuation of Mobile Worker status.

Contract Workers: Any New Brunswick resident accepting a contract out-of-country must supply the following information and documentation:

Contract Worker status is assigned up to a maximum of two years. Any further requests for contract worker status must be forwarded to the Director of Medicare Eligibility and Claims for approval on an individual basis.

Students: Those in full-time attendance at a university or other approved educational institution in another country will be granted coverage for a 12 month period that is renewable, provided they comply with the following:

4.4 Prior Approval Requirement

Medicare may cover out-of-country services that are not available in Canada on a pre-approval basis only. Residents may opt to seek non-emergency out-of-country services; however, they are responsible for assuming the total cost.

New Brunswick residents may be eligible for reimbursement if they receive elective medical services outside the country, provided the following requirements are met:

If the above requirements are met, it is mandatory to request prior approval from Medicare in order to receive coverage. A physician, patient or family member may request prior approval to receive these services outside the country, accompanied by supporting documentation from a Canadian specialist or specialists.

A beneficiary who disagrees with a decision made by Medicare regarding their case or the case of an immediate family member can appeal to the Insured Services Appeal Committee. Beneficiary appeals can include decisions about eligibility, refusal of a claim payment for entitled services or the amount paid on a claim. The Committee includes members from the general public. It meets three to four times a year based on the number of cases. It reviews each case and presents recommendations to the Minister of Health who makes the final decision regarding an appeal.

Out-of-country insured services that are not available in Canada, are non-experimental, and receive prior approval are paid in full. Often the amount payable is negotiated with the provider by Global Medical Management on the province’s behalf.

Haemodialysis is exempt from the out-of-country coverage policy. Patients are required to obtain prior approval and Medicare will reimburse the resident at a rate equivalent to the current inter-provincial rate per session.

A New Brunswick patient may choose to receive an insured service paid by Medicare in any public hospital in Canada, without prior approval. Most of these services are covered by Interprovincial Reciprocal Billing Agreements, although some may be billed directly to the host province. Some procedures require prior Medicare approval before a patient will be accepted for treatment in another province (e.g. high cost procedures, residential addictions/mental health services, some plastic procedures etc.). Should such prior approval be required, the attending physician would write to the medical consultant with Medicare, providing pertinent documentation and the reason for the out-of-province referral. Travel is not covered by Medicare, but lodging may be considered if the patient meets Medicare’s Hostel Policy criteria.

5.0 Accessibility

5.1 Access to Insured Health Services

New Brunswick’s health care system delivers equitable, quality care to the public it serves. As indicated in section 13.1 of Medical Services Payment Act Regulation 84–20, New Brunswick does not permit user fees for insured health services as defined by the Canada Health Act. New Brunswick uses a robust “comment based” approach to identifying individual citizens’ concerns on a wide range of health issues. In a typical month in the 2019–2020 fiscal year, the Department of Health received, logged, and responded to 100–150 concerns from individual New Brunswickers on issues including access to primary or specialized care, pharmaceutical approvals, access to services in a citizen’s language of choice, wait times for specific services, the structure of specific programs, etc. The Department’s web page provides several mechanisms to make such comments, including mailing addresses, e-mail addresses, telephone numbers, and a web-based message service. One contact respecting a privately provided imaging service was received in the 2019–2020 fiscal year. Specifically prohibited for reimbursement by the Medical Services Payment Act when provided privately, review indicated that the patient experienced no access barrier – neither respecting geography, nor the scheduled date of the service.

Access in a resident’s official language of choice is not a limiting factor, regardless of where a resident receives services in the province.

Improving access to primary care and acute care is an ongoing focus within New Brunswick’s health system. To support this focus, Government announced a number of investments in 2019–2020 that will further improve access to health services. They include:

5.2 Physician Compensation

Payments to physicians and dentists are governed under the Medical Services Payment Act, Regulations 84–20, 93–143 and 2002–53.

The methods used to compensate physicians for providing insured health services in New Brunswick are fee-for-service, salary and sessional, alternate payment mechanisms or Family Medicine New Brunswick that may include a blended system.

5.3 Payments to Hospitals

The legislative authorities governing payments to hospital facilities in New Brunswick are the Hospital Act, which governs the administration of hospitals, and the Hospital Service Act, which governs the financing of hospitals. The Regional Health Authorities Act provides for the delivery and administration of health services in defined geographic areas within the province.

The Department mainly distributes available funding to New Brunswick’s regional health authorities (RHA) through a Current Service Level approach. The funding base of the RHA from the previous year is the starting point, to which approved salary increases and a global inflator for non-wage items are added. This applies to all clinical services provided by hospital facilities, as well as support services (e.g., administration, food services, etc.).

Funding for Service New Brunswick, a shared services agency that manages the information technology, materials management, laundry and clinical engineering components of the hospital facilities in New Brunswick, is also based on the Current Service Level approach.

Any requests for funding for new programs or services are submitted to the Deputy Minister of Health for approval. Funding for approved new programs or services is based on requirements identified through discussions between Department of Health and RHA staff. These amounts are added to the RHA funding base once there is agreement on the funding requirements.

6.0 Recognition given to Federal Transfers

New Brunswick recognizes the federal role regarding its contributions under the Canada Health Transfer in public documentation presented through legislative and administrative processes. Federal transfers are identified in the Main Estimates document and in the Public Accounts of New Brunswick. Both documents are published annually by the New Brunswick government.

Registered Persons
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
1. Number as of March 31st 754,522 761,157 767,562 775,093 782,398
Insured Hospital Services Within Own Province or Territory
Public Facilities 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
2. Number 62 62 62 64 64
3. Payments for insured health services ($) 1,666,482,214 1,704,602,299 1,778,140,499 1,933,194,385 1,942,617,634
Private For-Profit FacilitiesNew Brunswick Table 2 Footnote 1 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
4. Number of private for-profit facilities providing insured health services 0 0 0 0 0
5. Payments to private for-profit facilities for insured health services ($) 0 0 0 0 0
New Brunswick Table 2 Footnote 1

There are no private for-profit facilities providing health insured services operating in New Brunswick.

New Brunswick Table 2 Return to footnote 1 referrer
Insured Hospital Services Provided to Residents in Another Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
6. Total number of claims, in-patient 4,972 4,552 4,524 4,517 4,506
7. Total payments, in-patient ($) 52,181,789 46,528,311 50,506,502 47,646,790 48,739,305
8. Total number of claims, out-patient 53,344 50,434 49,939 50,858 51,004
9. Total payments, out-patient ($) 20,046,048 20,857,748 21,199,404 21,711,066 22,677,309
Insured Hospital Services Provided Outside CanadaNew Brunswick Table 4 Footnote 1
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
10. Total number of claims, pre-approved in-patient Not applicable Not applicable Not applicable 5 4
11. Total payments, pre-approved in-patient ($) Not applicable Not applicable Not applicable 12,555 273,499
12. Total number of claims, pre-approved out-patient Not applicable Not applicable Not applicable 16 78
13. Total payments, pre-approved out-patient ($) Not applicable Not applicable Not applicable 37,319 1,126,040
Non pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
14. Total number of claims, non pre-approved in-patient Not applicable Not applicable Not applicable 101 74
15. Total payments, non pre-approved in-patient ($) Not applicable Not applicable Not applicable 68,869 535,056
16. Total number of claims, non pre-approved out-patient Not applicable Not applicable Not applicable 624 524
17. Total payments, non pre-approved out-patient ($) Not applicable Not applicable Not applicable 245,165 972,707
News Brunswick Table 4 Footnote 1

Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report, but did not require provinces or territories to report on previous years.

New Brunswick Table 4 Return to footnote 1 referrer
Insured Physician Services Within Own Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
18. Number of participating physiciansNew Brunswick Table 5 Footnote 1 1,652 1,666 1,742 1,734 1,748
19. Number of opted-out physicians 0 0 0 0 0
20. Number of non-participating physicians 0 0 0 0 0
21. Total payments for services provided by physicians paid through all payment methods ($)New Brunswick Table 5 Footnote 2 589,156,558 598,757,372 616,104,222 637,821,346 631,179,766
22. Total payments for services provided by physicians paid through fee-for-service ($) 362,601,062 373,715,908 381,321,118 393,236,955 405,341,277
New Brunswick Table 5 Footnote 1

These are the number of physicians with an active physician status on March 31st of each year.

New Brunswick Table 5 Return to footnote 1 referrer

New Brunswick Table 5 Footnote 2

The total payment for all payment methods.

New Brunswick Table 5 Return to footnote 2 referrer
Insured Physician Services Provided to Residents in Another Province or TerritoryNew Brunswick Table 6 Footnote 1
Private For-Profit Facilities 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
23. Number of services 247,273 226,812 225,177 218,578 212,579
24. Total payments ($) 24,675,343 23,067,671 22,061,956 22,167,200 21,681,383
New Brunswick Table 6 Footnote 1

These are all physician services provided to residents and dispensed in another province.

New Brunswick Table 6 Return to footnote 1 referrer
Insured Physician Services Provided Outside CanadaNew Brunswick Table 7 Footnote 1
Pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
25. Number of pre-approved services Not applicable Not applicable Not applicable 547 622
26. Total pre-approved payments ($) Not applicable Not applicable Not applicable 25,142 103,403
Non pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
27. Number of non pre-approved services Not applicable Not applicable Not applicable 2,955 1,933
28. Total non pre-approved payments ($) Not applicable Not applicable Not applicable 296,008 175,131
New Brunswick Table 7 Footnote 1

Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report,but did not require provinces or territories to report on previous years.

New Brunswick Table 7 Return to footnote 1 referrer
Insured Surgical-Dental Services Within Own Province
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
29. Number of participating dentistsNew Brunswick Table 8 Footnote 1 9 11 13 10 11
30. Number of opted-out dentistsNew Brunswick Table 8 Footnote 2 Not applicable Not applicable Not applicable Not applicable Not applicable
31. Number of non-participating dentistsNew Brunswick Table 8 Footnote 2 Not applicable Not applicable Not applicable Not applicable Not applicable
32. Number of services provided 1,607 1,623 1,788 1,601 1,747
33. Total payments ($) 273,686 343,764 379,857 314,903 331,722
New Brunswick Table 8 Footnote 1

These are the number of dentists and oral maxillofacial surgeons (OMS) participating in New Brunswick's Medical Services Plan during a fiscal year. Routine dental services are not covered by New Brunswick Medicare therefore few dentists and OMSs are registered - only some emergency dental services done in hospital are covered by the Medical Services Plan.

New Brunswick Table 8 Return to footnote 1 referrer

New Brunswick Table 8 Footnote 2

Health Canada requested this data as of the 2016-2017 report, but did not require provinces or territories to report data for 2015-16. In general, NB Medicare does not keep track of dentists in the province.

New Brunswick Table 8 Return to footnote 2 referrer

Quebec

COVID-19

COVID-19 testing is covered for all persons in Quebec, whether or not they have a health insurance card.

Health care coverage by client category, as of March 30, 2020
Client category COVID-19 test Health care (professional and hospital services) for Covid-19 Health care (professional and hospital services) unrelated to COVID-19

Person with an expired card

Covered

Covered (easing – expired card honoured)

Covered under the usual terms of the plan, expired card honoured

Person repatriated by the Government of Canada during the pandemic

Covered

Covered

Covered under the usual terms of the plan, but without a waiting period

Person temporarily residing outside Quebec returning to Quebec after more than 183 days abroad

Covered

Covered

Covered under the usual terms of the plan,
but Presence in Québec rule of 183 days is suspended

Homeless person

Covered

Covered (easing – authentification and photo card are not required)

Covered under the usual terms of the plan

Person temporarily residing outside of Quebec, currently in Canada

Not applicable

Covered under the usual terms of the legal and regulatory framework

Covered under the usual terms of the legal and regulatory framework

Person temporarily residing outside of Quebec, currently outside of Canada

Not applicable

Covered under the usual terms of the legal and regulatory framework

Covered under the usual terms of the legal and regulatory framework

Person with refugee status

Covered

Covered

Covered under the usual terms of the plan

Newcomer (person who has recently settled in Quebec on a permanent basis)

Covered

Covered
Pursuant to memo 2014-030 (01.01.10.03) of the Quebec department of health and social services– services required for health problems of an infectious nature affecting public health – these services are covered during the waiting period

Covered under the usual terms of the plan, with a 3‑month waiting period

Foreign worker or student from a country that is signatory to a social security agreement with Quebec (person who has recently arrived in Quebec as a temporary resident to work or study, with a valid residency permit)
The signatory countries are: Belgium, Denmark, Finland, France, Greece, Luxembourg, Norway, Portugal, Romania, Sweden

Covered

Covered (without waiting period)

Covered under the usual terms of the plan (without waiting period)

Foreign worker (person who has recently arrived in Quebec as a temporary resident to work, with a valid residency permit)

Covered

Covered
Pursuant to memo 2014-030 (01.01.10.03) of the Quebec department of health and social services– services required for health problems of an infectious nature affecting public health – these services are covered during the waiting period

Covered under the usual terms of the plan, with a 3‑month waiting period

Foreign worker or student (person who is a temporary resident in Quebec, to work or study, with an expired residency permit)

Covered

Covered if there is no coverage provided by the person's country of origin, a federal program, or an insurance policy

Not covered

Refugee protection claimant (including persons crossing the Canada – United States border irregularly)

Covered

Covered under the Interim Federal Health Program (IFHP)

Covered under the Interim Federal Health Program (IFHP)

Person without status or undocumented person

Covered

Covered if there is no coverage provided by the person's country of origin, a federal program, or an insurance policy

Not covered

Traveller, tourist and any other category of persons who are not eligible to obtain a health insurance card (includes students who are not from a country that is signatory to a social security agreement with Quebec)

Covered

Covered if there is no coverage provided by the person's country of origin, a federal program, or an insurance policy

Not covered

1.0 Public Administration

1.1 Health Insurance Plan and Public Authority

Quebec’s hospital insurance plan, the Régime d’assurance hospitalisation du Québec, is administered by the Ministère de la Santé et des Services sociaux (MSSS) [the Quebec Department of Health and Social Services].

Quebec’s health and drug insurance plans are administered by the Régie de l’assurance maladie du Québec (the Régie), a public body established by the provincial government which reports to the Minister of Health and Social Services.

RAMQ is responsible for the sound management of the Québec Health Insurance Plan and of the Public Prescription Drug Insurance Plan. As part of its mission, it manages the eligibility of persons for the plans, monitors the remuneration of health professionals and facilitates access to health care. Find out more about RAMQ through its mission, services, values, services and publications.

1.2 Reporting Relationships

The Public Administration Act (R.S.Q., c. A-6.01) sets forth government criteria for preparing reports on the planning and performance of public authorities, including the MSSS and the Régie.

The Board must, not later than 15 October each year, produce a report showing the sums it has paid out to physicians in the course of the preceding fiscal year under the Health Insurance Act (chapter A-29). The report must indicate, on the one hand, the proportion of budget variance between expenditures and estimates and on the other, the reasons for such variance.

Not later than 31 July each year, the Board shall submit to the Minister of Health and Social Services a report of its activities for its previous fiscal year; such report shall also contain all the information which the Minister of Health and Social Services may prescribe.

In a separate section of the report, the Board shall state, in particular, the number of inspections and investigations conducted and, as regards the latter, their class and the number of them having lasted more than one year, as well as the sums recovered following those inspections and investigations.

Such report shall be laid before the National Assembly if it is in session or, if it is not, within thirty days of the opening of the next session.

The Board shall give the Minister of Health and Social Services any information he may require respecting its operations.

1.3 Audit of Accounts

The Quebec Hospital Insurance Plan and the Quebec Health and Drug Insurance Plans are administered by the public authorities on a non-profit basis. All books and accounts are audited by the auditor general of the province.

The books and accounts of the Board shall be audited by the Auditor General each year and also whenever so ordered by the Government; his reports shall accompany the annual report of the Board.

The QC Ombudsperson released their 2019-2020 annual report in September 2020, which includes commentary on RAMQ, and can be accessed at the following site: https://publications.virtualpaper.com/protecteur-citoyen/annual_report_2020/#2/

2.0 Comprehensiveness

2.1 Insured Hospital Services

Insured in-patient services include the following:

Out-patient services include the following:

Other insured services are:

The Ministère de la Santé et des Services sociaux (MSSS) administers a free ambulance transportation program for persons aged 65 and older, in accordance with the parameters described in the Quebec policy on user transportation. It should be noted that this policy will be revised in the coming year.

In addition to basic insured health services, the Régie de l’assurance maladie du Québec (the Régie) also covers:

It also covers, for Quebec residents within the meaning of the Health Insurance Act (R.S.Q. c. A-29) who meet the eligibility criteria for each program:

This coverage applies only to aids and appliances covered in the Regulations. Financial aid is granted for external breast prostheses, ocular prostheses, devices provided to ostomies, and compression clothing for people with lymphedema.

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 otherwise would not have access to a private drug insurance plan. In 2019-2020, the public drug insurance plan covered 4.1 million insured persons.

2.2 Insured Physician Services

Services insured under this plan include medical and surgical services that are provided by physicians participating in the plan and are medically necessary.

Also included are:

2.3 Insured Surgical-Dental Services

Services insured under this plan include surgery performed by dental surgeons and specialists in oral and maxillofacial surgery, in a prescribed hospital centre or university institution.

2.4 Uninsured Hospital, Physician and Surgical-Dental Services

Uninsured hospital services include:

The following services are not insured:

3.0 Universality

3.1 Eligibility

Registration with the Hospital Insurance Plan is not required. Registration with the Régie de l’assurance maladie du Québec (RAMQ) is sufficient to establish an individual’s eligibility. Any individual residing or staying in Quebec as defined in the Health Insurance Act must be registered with RAMQ to be eligible for hospital services.

A person whose eligibility has been denied or who is dissatisfied with a decision of the RAMQ may request a review of the decision. The request for a review must be submitted to the RAMQ in a written notice setting out the reasons for the request. The request must be submitted within the six-month period following the date when the requester was informed of the decision.

As a last resort, within 60 days of being notified of the decision, a person may contest before the Tribunal administrative du Québec the decision for which the person has requested a review.

No relevant amendments to eligibility were made in 2019-2020.

3.2 Other Categories of Individuals

Inmates in federal penitentiaries are not covered by the Quebec Health Insurance Plan.

Certain categories of residents, notably permanent residents under the Immigration Act and persons returning to live in Canada, become eligible under the plan following a waiting period of up to three months. Persons from another country receiving last-resort financial assistance benefits are eligible upon registration. 

Canadian Forces personnel and their family members posted to Quebec from another Canadian province or territory who have status permitting them to settle there are eligible on the date of their arrival. Those who have not acquired Quebec resident status, and inmates of federal penitentiaries, become insured the day they are discharged or released.

Immediate coverage is provided for certain seasonal workers, repatriated Canadians, persons from outside Canada who are living in Quebec under an official bursary or internship program of the Ministère de l’Éducation [the Quebec Department of Education], persons from outside Canada who are eligible under an agreement or accord reached with a country or an international organization, and refugees. 

Persons from outside Canada who have work permits and are living in Quebec for the purpose of holding an office or employment for a period of more than six months may be eligible for the plan following a waiting period of up to three months.

4.0 Portability

4.1 Minimum Waiting Period

Persons settling in Quebec after moving from another province of Canada are entitled to coverage under the Quebec Health Insurance Plan when they cease to be entitled to benefits from their province of origin, provided they register with the Régie and meet certain conditions.

4.2 Coverage during Temporary Absences from Quebec

If living outside Quebec in another province or territory for 183 days or more and provided they so notify the Régie, students and full-time unpaid trainees may retain their status as residents of Quebec:

This is also the case for persons living outside Quebec who are temporarily employed or working on contract there. Their resident status can be maintained for no more than two consecutive calendar years. 

Persons who are directly employed or working on contract outside Quebec for a company or corporate body with its headquarters or a place of business in Quebec to which they report directly, or who are employed by the federal government and posted outside Quebec, also retain their status as a resident of the province. The same is true of persons who remain outside the province for 183 days or more, but less than 12 months within a calendar year, provided such absence occurs only once every seven years.

Insured persons who leave Quebec to live in another province or territory in Canada remain eligible for health insurance for up to three months after their departure, but their eligibility for the Quebec drug plan ends on the day of their departure.

However, coverage for insured persons who leave Quebec to permanently move abroad terminates the day of their departure.

4.3 Reimbursement of Professional Services Received Outside Quebec

The costs of insured services provided by health professionals to an insured person in another province or territory of Canada are reimbursed for the amount actually paid or at the rate that would have been paid by the Régie for such services in Quebec, whichever is lower. Exceptionally, for the Outaouais region, Quebec has negotiated a permanent arrangement with Ontario to pay Ottawa medical specialists at the Ontario fee rate for specialized services that are not available in the Outaouais region. This agreement came into effect on November 1, 1989. The Régie covers the amount it would have paid for the same services in Quebec. The Centre intégré de services de santé et de services sociaux de l’Outaouais [Outaouais integrated health and social services centre] pays the difference between the cost invoiced by Ontario and the amount initially reimbursed by the Régie. A similar agreement was signed in December 1991 between the Centre de santé Témiscaming [Témiscaming Health Centre] and the North Bay Regional Health Centre.

The service provided must be an insured service within the meaning of the Act. Services that are experimental in nature are not reimbursed.

4.4 Reimbursement of Hospital Services Received in Canada

Costs for hospital services provided to an insured person in another province or territory of Canada are paid in accordance with the terms and conditions of the Hospital Reciprocal Billing Agreement regarding hospital insurance agreed to by the provinces and territories of Canada. These costs are paid either at the established per diem for hospitalization in a standard ward or in intensive care proposed by the host province and approved by all the provinces and territories or, in cases of out-patient services or expensive procedures, at the approved interprovincial rates. Services that are excluded from interprovincial agreements but covered under the provincial program are reimbursed at the rate in force. 

4.5 Reimbursement of Hospital Services Outside Canada

During a temporary stay outside Canada, the Régie reimburses the full cost of emergency hospital services and 75 per cent of the cost in other cases to students, unpaid trainees, Quebec government employees posted abroad and employees of non-profit organizations working in international aid or co-operation programs recognized by the Minister of Health and Social Services (the Minister). However, when such persons go on holiday outside their place of study, training or work, this coverage is no longer in force, and regular coverage for hospital services applies.

Residents of Quebec who are working or studying abroad are covered by the plan in effect in that country when the stay falls under a social security agreement reached between the Minister and the country in question. 

For residents who are not in one of the above situations and receive insured services in a hospital outside Canada, the Régie reimburses the cost of such services, when they become necessary due to an emergency or sudden illness, to a maximum of: $100 CAD per day if the patient was hospitalized, including for day surgery, or to a maximum of $50 CAD per day for out-patient services. However, haemodialysis treatments are covered to a maximum of $220 CAD per treatment. The services must be rendered in a hospital or hospital centre recognized and accredited by the appropriate authorities. No reimbursements are made for nursing homes, spas or similar establishments.

4.6 Prior Approval Requirement

To receive full reimbursement for professional and hospital services elsewhere in Canada or in another country not covered under an agreement, a written request signed by two physicians with expertise in the field of the pathology of the person on whose behalf the request is made must first be sent to the Régie. The request must be accompanied by a summary of the insured person’s medical file, describe the specialized services required by the insured person, attest to the unavailability of the said services in Quebec or Canada, and contain information about the treating physician and the name and address of the hospital where the services are to be provided. Following an evaluation of the request by the Régie, authorization to receive the services is either given or denied. No authorization will be given if the service is available in Quebec or if it is an experimental service.

A person whose request has been denied or who is dissatisfied with a decision of the Régie de l’assurance maladie du Québec (RAMQ) may request a review of the decision. The request for a review must be submitted to the RAMQ in a written notice setting out the reasons for the request. The request must be submitted within the six-month period following the date when the requester was informed of the decision.

As a last resort, within 60 days of being notified of the decision, a person may contest before the Tribunal administrative du Québec the decision for which the person has requested a review.

5.0 Accessibility

5.1 Access to Insured Health Services

Everyone has the right to receive adequate health care services without any kind of discrimination. In Quebec, the Health Insurance Act does not allow user fees to be imposed. It also prohibits any person from demanding or receiving any payment from a person for incidental fees related to an insured service, except in cases prescribed by regulation and the conditions mentioned therein. If anyone thinks that the person has been incorrectly billed fees, the person may request reimbursement from the Régie de l’assurance maladie du Québec (the Régie), which will determine whether any amounts have been unjustifiably paid. If appropriate, the Régie will reimburse the insured person and will recover the amount reimbursed from the health-care professional or the clinic involved. It is also possible to reimburse insured persons who have not made reimbursement requests if the Régie finds that fees have been charged to them illegally.

A situation that appears to be illegal with respect to fees charged to an insured person may also be reported to the Régie which, after verification, will follow up appropriately. These follow-ups may include an inspection or an investigation of the clinics or the professionals involved. Residents who have reason to believe that they have been subject to patient charges can contact the Régie.

Improving access to health and social services for the population is a government priority. In order to achieve this objective, Quebec undertook a transformation of the Health and Social Services Network (the network) and its governance in 2015.

For most health and social services regions, this transformation has established an integrated health and social services centre or an integrated university health and social services centre which generally encompasses all of the health missions.

In more detail, as of March 31, 2020, the health and social services network had 141 institutions: 51 public and 90 private. These institutions administer 1,624 facilities or physical spaces providing health and social services to the Quebec population. 

The 51 public institutions are administered by 34 president-CEOs or CEOs. They include Integrated Health and Social Services Centres (CISSS) and Integrated University Health and Social Services Centres (CIUSSS), hereafter referred to as integrated centres, as well as grouped institutions and other institutions that have been neither grouped nor merged. 

As of April 1, 2015, each of the 22 integrated centres is the result of the merger of all or some of the public institutions in a given health and social services region, as the case may be, with the health and social services agency. Nine of the 22 integrated centres call themselves “centre intégré universitaire de santé et de services sociaux” because they are located in a health and social services region in which a university offers a complete predoctoral program of study in medicine or because they operate a centre designated as a university institute in the field of social services.

For their part, the 29 remaining public institutions are distributed as follows:

In addition, as of March 31, 2020, Quebec had 42 public and five private facilities under agreement with a hospital centre (CH) mission providing diagnostic services and general and specialized medical care in the physical health (CHSGS) and mental health (CHPSY) sectors. As of that date, there were 20,983 beds with a CH mission, i.e., 19,854 general and specialized care beds and 1,129 psychiatric care beds. According to the most recent available data:

In conclusion, Quebec also has four integrated university health networks (réseaux universitaires intégrés de santé or RUISS) which promote co-operation, complementarity and integration of the care, teaching and research missions of the health facilities and universities with which they are affiliated. In addition to the services provided by public facilities, the population also has access to the services of private facilities which offer accommodation, long-term care and other services.

Since 2002, Family Medicine Groups (GMF) have served as flagships for the organization of front-line health care and services in Quebec. GMF promote teamwork, collaboration among professions, institutional responsibility to the population, and the development of trust and close collaboration between patients and clinicians. Review of the GMF management framework led to the creation of the Programme ministériel de financement et de soutien professionnel [departmental funding and professional support program] (The program). The Program came into force on November 16, 2015. It offers financial and professional support tailored to the realities of clinicians and the needs of patients. It has introduced equitable, patient-centred funding, additional professional support (in addition to nursing personnel, social workers, pharmacists and other health professionals), a more balanced service offer, less burdensome administrative procedures, and mandatory use of electronic health records. These features have the voluntary support of physicians and the benefit of a team funding structure.

The core of the model continues to be the registration of patients with a group physician and a service offering that allows registered patients to take advantage of accessible services. The elementary structure of the GMF ensures that registered patients have reasonable and timely access, as is demonstrated by the addition of a measurement of patients’ attendance at the GMF in which they are registered. The Program updates terms of funding and resource allocation, and is designed to be more flexible to implement. It relies on the professional commitment of clinical communities to provide accessible, continuous and quality services.

As of March 31, 2020, Quebec had 358 accredited GMF in the province. As of the same date, there were 52 GMF networks (of which 35 were former network clinics).

5.2 Physician Compensation

Physicians are remunerated in accordance with the negotiated fee schedule. The Minister may enter into an agreement with the organizations representing any class of health professional.
The Health Insurance Act (A-29) governs the compensation of health professionals (physicians, dentists, optometrists and pharmacists). While the majority of physicians practise within the provincial plan, Quebec allows two other options:

To become a non-participant, a health professional must notify the Régie by registered or certified mail. The non-participation takes effect the thirtieth (30th) day from the date of mailing, and re-enrollment takes effect the eighth (8th) day following the date of mailing of the notice (Regulation respecting the application of the Health Insurance Act, s. 29).

There are various modes of remuneration:

According to the most recent data available, in 2019-2020 the Régie paid an estimated $7.8 billion for professional services provided to Quebec residents. Professional services (including reimbursements to insured persons and payments to professionals) received outside Quebec were estimated at $44.7 million.

The Régie is responsible for enforcing health-care professional compensation agreements and for controlling compensation paid to health-care professionals. It has established a framework that enables it to enhance its controls on the basis of the risks identified, in order to ensure that the compensation paid to health-care professionals complies with the terms and conditions in the agreements negotiated. The Régie has various control measures as follows:

Awareness-Raising Mechanisms

The Régie issues notifications to the Quebec Department of Health and Social Services with respect to issues and risks associated with controlling the payment of health-care professionals on the basis of the agreements negotiated. Thus, based on its analyses, the Régie’s findings may result in the issuance of notifications on different issues even if they apply more to medical practice or the organization of services.

Systematic Controls

These measures are aimed at the overall billing of health-care professionals or agreement situations. The controls are carried out manually, by computer, by taking samples, or by monitoring. Systematic controls may be followed by specific controls if the Régie deems it necessary to do an in-depth analysis of a situation with a professional or a limited group of professionals.

Specific Controls (inspections, investigations, service audits performed)

These measures are aimed at the billings of a professional or a limited group of professionals for whom practices have been identified as at risk of being non-compliant or potentially abusive or fraudulent. A specific audit may also be initiated following a complaint or a tip.

The Régie recovers the amounts that have been inappropriately paid by means of a compensation or recovery mechanism.

The Régie has a monitoring mechanism to ensure that professionals with non‑compliant, abusive or fraudulent billings are subject to monitoring.

5.3 Payments to Hospitals

The Minister of Health and Social Services funds hospitals through payments directly related to the cost of insured services provided.

Ontario

Ontario has one of the largest and most complex publicly funded health care systems in the world. Administered by the province's Ministry of Health (MOH)Footnote 6, Ontario's health care system was supported by over $63.7 billion (including capital) in spending during 2019–2020.

COVID-19 Measures

In response to the COVID-19 outbreak, Ontario implemented the following temporary funding changes related to its health insurance program:

The emergence of COVID-19 and resulting constrained global supply chain impeded Health Service Provider (HSP) access to Personal Protective Equipment (PPE) and other critical supplies. HSPs that typically procured supplies independently via public funding were unable to effectively procure critical inventory required for the provision of key health services. In response to these challenges, the Ministry of Health began supplementing regular funding mechanisms with the direct, centralized procurement and distribution of PPE and other critical supplies to HSPs.

1.0 Public Administration

1.1 Health Care Insurance Plan and Public Authority

Ontario Health Care and Health Care Planning

The Ontario Health Insurance Plan (OHIP) is administered on a non-profit basis by the MOH. OHIP was established in 1972 and is continued under the Health Insurance Act (HIA), Revised Statutes of Ontario, 1990, c. H-6, to provide insurance in respect of the cost of insured services provided to Ontario residents (as defined in the HIA) in hospitals and health facilities, and by physicians and other health care practitioners.

The MOH provides services to the public through programs such as health insurance, drug benefits, assistive devices, forensic mental health and supportive housing, home care, community and public health, and health promotion and disease prevention. It also regulates hospitals and nursing homes, medical laboratories and specimen collection centres, and coordinates emergency health services.

Local Health Integration Networks (LHIN) were established under the Local Health System Integration Act, 2006 (LHSIA). Since April 1, 2007, Ontario's fourteen (14) LHINs have served as Ontario's regional health authorities and have had responsibility for funding, planning and integrating health care services at the local level. This included services delivered by hospitals, community care access centres, community health centres, community support service agencies, and mental health and addictions agencies.

In 2017, the LHINs' role was expanded to include the management and delivery of home and community care services. To support their expanded mandate, the roles and responsibilities of the former 14 community care access centres were transferred to the LHINs.

On February 26, 2019, Ontario announced its long-term plan to build a modern and sustainable health care system that starts and ends with the patient. Ontario is creating an integrated public health care system by coordinating the work of existing provincial health agencies and programs. Ontario will have one single health agency—Ontario Health (OH), a Crown agency, has the mandate to oversee health care delivery, improve clinical guidance and provide support for providers to ensure better quality care for patients. OH will also support or provide value-oriented supply chain management services to health service providers, and work together with patients, providers and the health sector to build an integrated, patient-focused supply chain for health care products and services.

On December 2, 2019, as part of the first phase of transitions, the following five health agencies were transferred into OH:

The 14 LHINs were clustered into five interim geographical regions, and five Transitional Regional Leads were appointed. The Transitional Regional Leads are responsible for the ongoing management of the LHIN operations in their regions and also report to the President and CEO of OH to support planning for the eventual transition of LHIN functions and oversight responsibilities into OH. The government also transferred non-home and community care executives of the LHINs into OH.

On March 31, 2020, the five health agencies transferred into OH, existing then only as corporate shells, were dissolved by Minister's order. By April 1, 2020 the second phase of transitions were in effect including the transfer of the Ontario Telemedicine Network to OH and its formal dissolution, and the assignment of oversight of two digital health transfer payment agreements (Electronic Child Health Network and OntarioMD) to OH.

As the COVID-19 pandemic continued to evolve rapidly in Ontario in Spring 2020, and recognizing the critical role of OH and the Local Health Integration Networks in the health system response, the Ministry decided to delay the transfer of select LHIN non-patient care functions into OH until a later date.

As the COVID-19 response begins to stabilize and plans are underway to reopen the economy, the Ministry has resumed planning for the next phase of OH transfers and transformation work without negatively impacting the COVID-19 efforts and compromising patient care. The transformation will take place over a number of years. It will continue to roll out in carefully planned phases to ensure patient care is not interrupted.

1.2 Reporting Relationship

Section 2 of the HIA stipulates that the Minister of Health is responsible for the administration and operation of OHIP, and is Ontario's public authority for the purposes of the Canada Health Act.

Annually, the MOH reports on its plans, results and outcomes via a published plan and annual report. The MOH's published plan and annual report are tabled in the legislature and published on the MOH's website.

1.3 Audit of Accounts

Every year the Auditor General of Ontario reports on the results of their examination of government resources and administration. The Auditor General's report is tabled by the Speaker of the Legislative Assembly, usually in the fall, at which time it becomes available to the public. Audit reports on select areas of the MOH chosen for review by the Auditor General are included within this annual report, the last of which was released on December 4, 2019.

The MOH's accounts are published annually in the Public Accounts of Ontario. The 2019-2020 Public Accounts of Ontario were tabled and released on September 23rd, 2020.

2.0 Comprehensiveness

2.1 Insured Hospital Services

Insured in-patient and out-patient hospital services in Ontario are prescribed in sections 7 and 8 of Regulation 552 under the Health Insurance Act (HIA).

In keeping with the provisions of the Canada Health Act, Ontario insures all medically necessary hospital services. Hospital services are all services that are medically required to be performed in hospital. These are described in the regulations as follows:

Insured in-patient hospital services include medically required:

Insured out-patient services include medically required:

Each individual hospital service is not specifically listed in Regulation 552 ; rather, the Regulation lists the above broad categories of services so that new medical and technological advances are automatically included as they become accepted standards of practice.

Regulatory changes are approved by Cabinet and generally there is a public consultation process by way of Ontario's Regulatory Registry.

No regulation changes to insured hospital services were completed in fiscal year 2019-2020.

2.2 Insured Physician Services

Insured physician services are prescribed in Regulation 552 under the HIA.

Under Regulation 552 of the HIA, a service provided by a physician in Ontario is an insured service if it:

Physicians provide medical, surgical and diagnostic services, including primary health care services. Services are provided in a variety of settings, including: physician offices, community health centres, hospitals, mental health facilities, licensed independent health facilities, and long-term care homes.

In general terms, insured physician services include:

Physicians must be registered to practice medicine in Ontario by the College of Physicians and Surgeons of Ontario, and be located in Ontario when rendering the service in order for their services to be covered under OHIP.

During 2019–2020, most physicians submitted claims for all insured services rendered to insured persons directly to OHIP, and a small number of physicians billed the insured person. Physicians who do not bill OHIP directly are commonly referred to as having opted-out of the Plan. When a physician has opted-out of the Plan the physician bills the patient an amount not exceeding the amount payable for the service under the Schedule of Benefits—Physician Services (this was permitted on a 'grandparented' basis following proclamation of the Commitment to the Future of Medicare Act [CFMA] in 2004). The patient then recoups that amount from the Plan.

There were approximately 33,245 physicians who submitted claims to OHIP in 2019–2020. This figure includes physicians submitting both fee-for-service claims and physicians included in an alternative payment plan who submitted tracking or shadow-billed claims. In 2019–2020, there were 15 opted-out physicians in Ontario.

The Schedule of Benefits — Physician Services is regularly reviewed and revised to reflect current medical practice and new technologies. In 2019-2020, numerous changes were made that included new services added, existing services revised, or obsolete services removed through regulatory amendment. This process involved consultation with the Ontario Medical Association (OMA) and negotiation of payments with the OMA under the Binding Arbitration Framework.

Additional changes were also made in March 2020 by way of Ministerial Order, to address the provision of physician services during the COVID-19 pandemic. This included temporarily listing as insured services new fee codes for the provision of assessments of, or counselling to, insured persons by telephone or video, or advice and information to patient representatives by telephone or video, and certain services provided within eligible assessment centres that would differentiate physician payment for services provided after-hours, weekend hours and holidays in these centres.

2.3 Insured Surgical-Dental Services

In accordance with the Canada Health Act, certain surgical-dental services are prescribed as insured services under Regulation 552 in the HIA and listed in the Schedule of Benefits— Dental Services. The Act authorizes OHIP to pay for a limited number of procedures when r the procedure is i performed in a public hospital graded under the Public Hospitals Act as Group A, B, C or D, by a dental surgeon who has been appointed to the dental staff of the public hospital.

Generally, insured dental services include:

With respect to insured surgical-dental services, the MOH consults with the Ontario Dental Association in making changes to the Schedule of Benefits - Dental Services.

Regulatory changes are approved by Cabinet and generally there is a public consultation process by way of Ontario's Regulatory Registry.

In Ontario, in the fiscal year 2019–2020, 880 dentists had active billing numbers and 276 dentists billed OHIP. There were 599 dentists who had active billing numbers but did not bill OHIP. Following proclamation of the CFMA in 2004, dentists are required to submit claims for all insured surgical-dental services to OHIP, i.e. are prohibited from charging the patient for insured services. No dentists are 'opted-out' or exempt under 'grandparented' provisions.

2.4 Uninsured Hospital, Physician and Surgical-Dental Services

Uninsured hospital services include but are not limited to:

Section 24 of Regulation 552 details some specified physician and supporting services that are not insured services.

Uninsured physician services may include:

Under section 24, treatment for a medical condition that is generally accepted within Ontario as experimental is also not insured.

Additionally, “add ons” to insured services that are considered non-medically necessary and optional upgrades to a basic insured service (e.g. upgraded cataract lenses, specialized testing for cataract surgery, fibreglass casts, etc.) are uninsured services for which a patient may be charged.

Dental services provided in dentists’ offices are not insured and payment is the responsibility of the individual patient. Dental services not specifically listed in the Dental Schedule are also not insured including such services as prosthetic restorations (fixed bridges and dentures) for the replacement of teeth, orthodontic treatment, fillings and crowns.

In an effort to uphold requirements under the Canada Health Act to prohibit extra-billing and user charges (EBUC) for insured health care services, Ontario’s CFMA provides authority to investigate and take action related to allegations of EBUC. Specifically with respect to EBUC the CFMA makes it illegal:

For more fulsome information on the CFMA, please refer to section 5.1.

Under the Independent Health Facilities Act (IHFA), the MOH provides facility fee funding to cover overhead costs associated with the provision of insured services rendered in non-hospital facilities. Under this Act, facility fees are payable only by the Minister of Health, Cancer Care Ontario or a Local Health Integration Network and only to a licensed independent health facility, and charges to or receipt of a facility fee payment from a patient is an illegal facility fee.

The MOH reviews all possible violations of the CFMA and IHFA that come to its attention. Possible violations come to the MOH’s attention from various sources such as patient complaints, the media, advertisements, health care providers and their staff and Members of Provincial Parliament. In some cases, the MOH may also review possible violations of the CFMA and IHFA on a proactive basis (i.e., without receiving a complaint tied to a specific patient). If it is found that a patient has paid an unauthorized payment, the MOH ensures that patients are reimbursed in accordance with provisions of the CFMA.

Providers and facilities are legally permitted to charge patients for uninsured services, either on a fee-for-service basis, or through a block or annual fee, which covers a group of uninsured services rendered by a physician, practitioner or hospital over a specified time period.

The MOH does not regulate charges by physicians for uninsured services, or for services rendered to uninsured persons nor does the MOH set prices for uninsured services.

The College of Physicians and Surgeons of Ontario (CPSO), the body governing the practice of medicine in Ontario, is responsible for regulating charges by physicians for uninsured services, including block fees. The MOH’s interest in block fees is to ensure that they do not create a barrier to accessing insured services, do not include charges for insured services, do not confer preferential access to insured services, or constitute illegal facility fees contrary to Ontario law. However, the ministry does not regulate the amount charged for block fees or the types of uninsured services that may or may not be included in block fees.

The CPSO has established guidelines with respect to charging patients for uninsured services, and is responsible for investigating complaints against physicians, such as for excessive fees. It is professional misconduct under the Medicine Act for physicians to charge a fee that is excessive in relation to the services performed. The MOH directs patients who have complaints regarding charges for uninsured services to the CPSO.

A regulatory amendment is required for changes to OHIP insured services, including potential public consultation via the Regulatory Registry.

3.0 Universality

3.1 Eligibility

Section 11 of the Health Insurance Act (HIA) specifies that every person who is a resident of Ontario is entitled to become an insured person under the OHIP upon application. In order to be considered an Ontario resident, Regulation 552 under the HIA, with a few exceptions that are noted in the Regulation, requires that a person must:

Individuals who are not eligible for OHIP coverage are those who do not meet the definition of a resident, such as tourists, visitors to the province and those who do not hold an immigration or other similar status as defined in the Regulation. Services that a person is entitled to receive under federal legislation are not insured services, for example, those provided to federal penitentiary inmates and Canadian Forces members. Services that a person is entitled to receive under the Workplace Safety and Insurance Act are also not insured services in Ontario.

When it is determined that a person is not eligible, or is no longer eligible, for OHIP coverage, a request may be made by the person to the MOH to review the decision. Anyone may request that the MOH review the denial of their OHIP eligibility by making a request in writing to the OHIP Eligibility Review Committee (OERC). Those who are not satisfied with the OERC’s decision regarding their OHIP eligibility may request an appeal of their case by the Health Services Appeal and Review Board.

The MOH is the sole payor for OHIP insured physician, hospital and hospital surgical-dental services. An eligible Ontario resident may not obtain any benefits from another insurance plan for the cost of any insured service that is covered by OHIP (with the exception of during the OHIP waiting period).

Persons who were previously ineligible for OHIP coverage but whose status and/or residency situation has changed may be eligible upon application, subject to the requirements of Regulation 552. There were 14,295,514 valid and active health card users in Ontario as of March 31, 2020.

3.2 Other Categories of Individuals

The MOH provides health insurance coverage to a limited number of specified categories of residents of Ontario, other than Canadian citizens and permanent residents or landed immigrants.

These residents are required to provide acceptable original documentation to support their residence in Ontario and their identity in the same manner as Canadian citizens and permanent resident or landed immigrant applicants.

The individuals listed below who are residents in Ontario may be eligible for OHIP coverage in accordance with Regulation 552 of the HIA. Individuals are required to apply in person to ServiceOntario, which has the government-wide mandate for the delivery of front-facing services to the residents of Ontario, including the issuance of the Ontario Photo Health Card.

As of March 19, 2020, the province has removed the three-month waiting period requirement for OHIP coverage.

Applicants for Permanent Residence: These are persons who have submitted an application for Permanent Resident status to Immigration, Refugees and Citizenship Canada (IRCC), and IRCC has confirmed that the person meets the eligibility requirements to apply for permanent residence in Canada and that the application has not yet been denied.

Protected Persons/Convention Refugees: These are persons who are determined to be Protected Persons/Convention Refugees under the terms of the federal Immigration and Refugee Protection Act. Members of this group are provided with immediate OHIP coverage.

Holders of Temporary Resident Permits: A Temporary Resident Permit is issued to an individual by IRCC when there are compelling reasons to admit an individual into Canada who would otherwise be inadmissible under the federal Immigration and Refugee Protection Act. Each Temporary Resident Permit has a case type or numerical designation on the permit that indicates the circumstances allowing the individual entry into Canada. Individuals who hold a permit with a case type of 86, 87, 88, 89, 90, 91, 92, 93, 94, 95 or 80 (if for adoption) are eligible for OHIP coverage.

Foreign Clergy, Foreign Workers and their Accompanying Family Members: An eligible foreign clergy is a person who is sponsored by a religious organization or denomination if the member has finalized an agreement to minister to a religious congregation or group in Ontario for at least six months, as long as the member is legally entitled to stay in Canada.

A foreign worker is eligible for OHIP if the individual has been issued a Work Permit or other document by IRCC that permits the person to work in Canada, and if the person also has a formal agreement in place to work full-time for an employer in Ontario. The work permit or other document issued by IRCC, or a letter provided by the employer, must set out the employer's name, state the person's occupation with the employer, and state that the person will be working for the employer for no less than six consecutive months.

A spouse and/or dependent (under 22 years of age; or 22 years of age or older if dependent due to a mental or physical disability) of an eligible foreign clergy or an eligible foreign worker is also eligible for OHIP coverage as long as the spouse or dependent is legally entitled to stay in Canada.

Applicants for Canadian Citizenship: These individuals are eligible for OHIP coverage if they have submitted an application for Canadian citizenship under section 5.1 of the federal Citizenship Act, even if the application has not yet been approved, provided that IRCC has confirmed that the person meets the eligibility requirements to apply for citizenship under that section and the application has not yet been denied.

Children Born Out-of-Country: A child born to an OHIP-eligible woman who was transferred from Ontario to receive insured health services that were pre-approved for payment by OHIP is eligible for immediate OHIP coverage provided that the mother was pregnant at the time of departure from Ontario.

Seasonal Agricultural Farm Workers: are persons who have a Work Permit issued under the Seasonal Agricultural Worker Program administered by the Government of Canada. Due to the special nature of their employment, migrant farm workers do not have to meet any other residency requirement and are provided with immediate OHIP coverage.

3.3 Premiums

No premiums are required to obtain OHIP coverage. There is an Ontario Health Premium that is collected through the provincial income tax system but it is not connected to OHIP registration or eligibility in any way. Responsibility for the administration of the Ontario Health Premium lies with the Ontario Ministry of Finance.

4.0 Portability

4.1 Minimum Waiting Period

Prior to March 19, 2020, in accordance with section 5 of Regulation 552 under the Health Insurance Act (HIA), individuals who moved to Ontario were typically entitled to Ontario Health Insurance Plan (OHIP) coverage three months after establishing residency in the province unless listed as an exception in sections 6, 6.1, 6.2, or 6.3 of Regulation 552, or subsection 11(2.1) of the HIA.

Assessment of whether or not an individual was subject to the waiting period occurred at the time of their application for OHIP coverage. Examples of those who are exempt from the three- month waiting period included newborn babies, eligible military family members, and insured residents from another province or territory who move to Ontario and immediately become residents of an approved long-term care home in Ontario.

In accordance with Regulation 552 under the HIA and as provided for in the Interprovincial Agreement on Eligibility and Portability, persons who permanently moved to Ontario from another Canadian province or territory where they are insured were typically be eligible for OHIP coverage after the last day of the second full month following the date residency is established, in other words, an interprovincial waiting period.

Effective March 19, 2020, in response to the COVID 19 pandemic, Regulation 552 under the HIA was amended to remove the waiting period for OHIP for all new and returning residents of Ontario. Currently no waiting period for OHIP coverage exists.

4.2 Coverage during Temporary Absences in Canada

Ontario adheres to the terms of the Interprovincial Agreement on Eligibility and Portability (EPA), as per section 1.6 of Regulation 552, and in accordance with the EPA, an insured person who leaves Ontario temporarily to travel within Canada, without establishing residency in another province or territory, may continue to be covered by OHIP for a period of up to 12 months.

An insured person who temporarily seeks or accepts employment in another province or territory may continue to be covered by OHIP for a period of up to 12 months. If the individual plans to remain outside Ontario beyond the 12-month maximum, he or she should apply for coverage in the province or territory where that person has been working or seeking work.

As per section 1.8 of Regulation 552, and in accordance with the EPA, insured students who are temporarily absent from Ontario, but remain within Canada, may be eligible for continuous health insurance coverage for the duration of their full-time studies, provided they do not establish permanent residency elsewhere during this period. To ensure that they maintain continuous OHIP eligibility, a student should provide the MOH with documentation or information from their educational institution confirming registration as a full-time student. Insured family members (spouses and dependents) of students who are studying in another province or territory are also eligible for continuous OHIP eligibility while accompanying students for the duration of their studies.

Also, in accordance with section 1.6 and 1.8 of Regulation 552 of the HIA, most insured residents who want to travel, work or study outside Ontario, but within Canada, and maintain OHIP coverage, must have resided in Ontario for at least 153 days in the last 12 month period immediately prior to departure from Ontario.

Payments for insured out-of-province services are prescribed under sections 28, 28.0.1, 28.0.2, and 29 of Regulation 552 of the HIA. Insured residents who are temporarily outside of Ontario can use their valid Ontario health card to obtain insured physician (except in Quebec) and hospital services generally at no direct cost.

Ontario participates in Reciprocal Hospital Billing Agreements with all other provinces and territories for payment of insured in-patient and out-patient hospital services. For the 2019-2020 fiscal year, rates were set and approved by the Interprovincial Health Insurance Agreements Coordinating Committee. Payment for in-patient services depends on the hospital's approved in-patient per diem rate. Payment for out-patient services is at the standard approved out-patient rate.

Ontario is also party to the Reciprocal Medical Billing Agreements with all other provinces and territories, except Quebec (which does not participate in reciprocal medical billing). Ontario residents who have been directly billed for insured physician or hospital services in another province or territory can submit their receipts to MOH for reimbursement. Reimbursement of insured physician services is at the rates payable in the Ontario Schedule of Benefits for Physician Services or the amount billed, whichever is less. Reimbursement of insured hospital services is at the established rates or the amount billed, whichever is less.

Out-of-Province (Within Canada)

Out-of-province (but within Canada) authorized laboratory tests performed outside of a publicly funded hospital require prior approval of funding in accordance with Section 28.0.2 of Regulation 552. In addition, certain medical services that require prior approval of funding in Ontario (as prescribed in the Schedule of Benefits for Physician Services for services including breast reduction and panniculectomy) must be prior approved if the service is sought in another province or territory.

4.3 Coverage during Temporary Absences outside Canada

Residents may be temporarily outside of Canada for a total of 212 days in any 12 month period and still maintain OHIP coverage as long as their primary place of residence remains Ontario.

Extended Absences:

Health insurance coverage for insured Ontario residents during extended absences (longer than 212 days) outside Canada is governed by Regulation 552 of the HIA.

The MOH requests that residents apply to MOH to confirm this coverage before their departure and provide documents explaining the reason for their absence.

In accordance with regulations and MOH policy, most applicants must also have been residents in Ontario for at least 153 days in each of the two consecutive 12 month periods before their expected date of departure.

The length of time that a person can receive continuous Ontario health insurance coverage during an extended absence outside Canada varies depending on the reason for the absence as follows:

Reasons and lengths of time a person can receive continuous Ontario Health Insurance coverage during an extended absence
Reason OHIP coverage
Study Duration of full-time academic studies (unlimited)
Work Five-year terms (specific residency requirements must be met for two years between absences)
Charitable Worker Five-year terms (specific residency requirements must be met for two years between absences)
Vacation/Other Two-year terms (specific residency requirements must be met for five years between absences)

Spouses and dependents may also qualify for continuous OHIP coverage while accompanying the primary applicant on an extended absence outside Canada.

Out-of-Country Coverage for Ontario Residents who are Temporarily Absent

Until December 31, 2019, Regulation 552 under the HIA set out eligibility criteria and payment authority for funding emergency health care costs incurred by eligible Ontarians who were temporarily absent from Canada, such as for travel, work, and studying.

The provisions under this program provided reimbursement at very limited rates for medical treatment required to treat illnesses, diseases, conditions or injuries that were acute, unexpected, arose outside of Canada and required immediate treatment.

OHIP reimbursed patients at the following rates:

These provisions were intended and designed to provide a very limited amount of funding for the medical treatment of insured residents of Ontario if they incurred an unexpected illness, disease, condition or injury while they are outside of Canada and not if the illness, disease, condition or injury arose before the patient left Canada, or if it was not acute or unexpected, no payment could be made.

Effective January 1, 2020 OHIP no longer provided coverage for emergency health care costs incurred by eligible Ontarians while temporarily absent from Canada, such as for travelling, working and studying. On September 23, 2020, pursuant to a challenge by the Canadian Snowbirds Association, the Ontario Superior Court of Justice (Divisional Court) quashed the regulation that ended this program. As a result, the Ministry intends that the OOC emergency Travellers program will be re-established retro active to January 1, 2020.

4.4 Prior Approval Requirement

As set out in Regulation 552 under the HIA, payment for non-emergency health services provided outside of Canada requires written prior approval from the General Manager of OHIP before the services are rendered.

With written prior approval, full funding for out-of-country medical services is paid directly to out-of-country hospitals, health facilities and physicians as well as laboratories for medically necessary insured services that are not performed in Ontario or, with the exception of laboratory services, for services that cannot be obtained in Ontario without medically significant delay.

In accordance with the requirements of Regulation 552 under the HIA, the requested out-of- country medical services are eligible for funding as insured services only if they are:

Requests for prior approval of funding require written confirmation from a physician who is a specialist in the type of services for which prior approval has been requested to confirm that the regulatory criteria for the funding of out-of-country medical services are met. This requirement does not apply to emergency services or services that are within a general practitioner’s scope of practice.

There are also other specified requirements in section 28.4 of Regulation 552 depending on the nature of the service for which funding is requested.

Funding requirements for non-emergency authorized laboratory tests performed outside Canada are described in section 28.5 of Regulation 552 of the HIA.

In the case of a denial of funding, the referring Ontario physician and the patient are advised that the decision may be reviewed if new medical information is submitted for consideration. Internal reviews may be requested as often as needed, provided new additional supporting medical documentation is submitted. In addition, the patient may appeal an out-of-country funding decision to the Health Services Appeal and Review Board.

5.0 Accessibility

5.1 Access to Insured Health Services

Funding for all insured hospital, physician, and designated practitioner services provided to insured Ontario residents is in accordance with the HIA and Regulations. Access to insured services without charges is protected under Part II of the Commitment to the Future of Medicare Act (CFMA), “Health Services Accessibility.” The CFMA prohibits extra-billing by including a provision that prohibits any physician or designated practitioner from charging or accepting payment or other benefit for rendering an insured service to an insured person for more than the amount that is paid by OHIP. The CFMA also prohibits a physician or designated practitioner from accepting payment or benefit for an insured service rendered to an insured person except from OHIP (subject to a few specified exceptions) and generally prohibits any person or entity from charging or accepting payment or other benefit for an insured service rendered to an insured person except as outlined above or as specified in the regulations.

The CFMA further prohibits queue-jumping through a provision that prohibits any person or entity from paying, charging, or accepting payment or other benefit in exchange for conferring upon an insured person a preference in obtaining access to an insured service. In addition, the CFMA prohibits physicians, practitioners and hospitals from refusing to provide an insured service if an insured person chooses not to pay a “block” or “annual” fee for uninsured services.

The CFMA contains provincial offence provisions, where individuals and corporations in violation of the Act may be subject to fines under the Provincial Offence Act (POA).

The MOH reviews all possible contraventions of the CFMA that come to its attention. For situations in which it is determined that an unauthorized payment has occurred, the MOH takes steps to ensure that the amount is repaid to the payee. When a CFMA review identifies possible inappropriate OHIP billing or fraud, the matter is subsequently referred to either the ministry’s Payment Accountability Unit or to the Ontario Provincial Police fraud investigation unit for more serious cases.

For complaints regarding charges for insured services, the CFMA program of the ministry can be reached at 1-888-662-6613 or by email at: protectpublichealthcare@ontario.ca.

Health Card Validation (HCV) assists health care providers with access to information requested for claims payment. HCV allows the provider to determine the point-in-time status of a patient’s Ontario health number (and version code) indicating eligibility or ineligibility for provincially funded health care services, thereby reducing claim rejects. A health care provider may subscribe for validation services if they have a valid and active billing number as assigned by the MOH. If patients require access to insured services and do not have a valid health card in their possession, upon obtaining patient consent, the provider may obtain the necessary information by utilizing the accelerated health number release service provided by ServiceOntario’s Health Number Look Up service which is offered 24 hours a day, 365 days per year to physicians or hospitals registered for this service.

Acute care priority services are designated, highly specialized, hospital-based services that deal with life-threatening conditions such as organ transplants, cancer surgery and treatments, and neuro services. These services are often high-cost and are rapidly growing, which has made access a concern. Generally, these services are managed provincially, on an ongoing basis by continually monitoring demand and adjusting funding as needed.

Acute care priority services include:

Primary Health Care: The various primary health care physician compensation models encourage access to comprehensive primary health care services for Ontario as a whole, as well as for targeted population groups and remote underserviced communities.

Interprofessional Care Models:

Family Health Teams (FHT) are independent, non-profit organizations that provide interdisciplinary team-based primary health care; they are staffed by providers such as nurse practitioners, nurses, social workers and dieticians. Physician groups that can affiliate with and participate in FHTs are funded by one of three compensation options: Blended Capitation (such as FHN or FHO), Complement Based Models (RNPGA or other specialized agreements) and BSM (for community sponsored FHTs). FHT are located across Ontario, in both urban and rural settings, ranging in size, structure, scope and governance.

Nurse Practitioner-Led Clinics (NPLCs) have been created throughout Ontario to provide comprehensive, accessible and coordinated family health care services by targeting Ontarians who have difficulty accessing primary care. NPLCs are contributing to a number of local and provincial health care priorities by providing faster access to care through same day and next day appointments and collaborating with other community partners to improve quality and better coordinate care for their patients.

Community Health Centres (CHCs) are models of primary health care delivery that play a key role delivering primary health care services to priority populations across Ontario and support the province’s overarching efforts to transform primary care. CHCs are not-for-profit community governed organizations with a primary focus to improve the health and well-being of populations who have traditionally faced barriers accessing health services, including those who are low income, new immigrants, those with complex mental health issues and individuals who do not have health insurance. CHCs are mandated to deliver comprehensive primary health care services, health promotion, and disease prevention services to individuals and families. CHCs develop partnerships that focus on broader health and social issues, such as inadequate housing, literacy, pollution and other social determinants of health.

Aboriginal Health Access Centres (AHACs) are Aboriginal-led, primary health care organizations that provide a combination of traditional healing, primary care, cultural programs, health promotion programs, community development initiatives, and social support services to First Nations, Métis and Inuit Communities. AHACs are closely modelled after Ontario’s Community Health Centres and provide the mechanisms to improve the health and well-being of communities in Ontario facing various barriers in accessing health care. AHACs serve as a key contributor to Ontario’s commitment to improve and expand access to comprehensive primary care by providing clinical care services, integrated chronic disease prevention and management, family focused maternal/child health care and addictions counselling and mental health care.

Health Care Connect (HCC): refers Ontarians who are seeking a primary health care provider (family doctor or nurse practitioner) to a provider who is accepting new patients in their community. Insured persons without a primary health care provider who register with HCC may be referred to a family doctor or a nurse practitioner if there is a participating provider who is accepting new patients in their community. HCC is voluntary for both patients and providers and there is no guarantee that a referral will be made for each program registrant.

During 2019-2020, MOH continued to administer various initiatives to improve access to health care services across the province. Ontario's physician supply has stabilized due to past medical school expansion and ongoing evidence-informed planning, and the province is working to enhance the retention and distribution of physicians through measures, such as:

There are a number of existing initiatives to improve access across Ontario, including but not limited to the Northern and Rural Recruitment and Retention Initiative, the Northern Physician Retention Initiative, and the Northern Health Travel Grant Program.

Northern and Rural Recruitment and Retention Initiative (NRRRI): The NRRRI supports the recruitment and retention of physicians in rural and northern communities. The NRRRI provides financial recruitment incentives to physicians who establish a fulltime practice in an eligible community. Community eligibility for the NRRRI is based on a Rurality Index for Ontario score of 40 or more. Also eligible are the five Northern Ontario Census Urban Referral Centre census metropolitan areas (Thunder Bay, Sudbury, North Bay, Sault Ste. Marie and Timmins).

Northern Physician Retention Initiative (NPRI): The NPRI provides physicians who have completed a minimum of four years of continuous full-time practice in Northern Ontario with a retention incentive paid at the end of each fiscal year in which they continue to practise full-time in Northern Ontario. NPRI supports retention of physicians in Northern Ontario and encourages them to maintain active hospital privileges. Northern Ontario is defined as the districts of Algoma, Cochrane, Kenora, Manitoulin, Nipissing, Parry Sound, Muskoka, Rainy River, Sudbury, Thunder Bay and Timiskaming.

Northern Health Travel Grant (NHTG) Program: The NHTG Program helps defray travel-related costs for residents of Northern Ontario who must travel long distances to access insured medical specialist services, or designated health care facility-based procedures that are not locally available, within a radius of 100 kilometres. In addition to travel grants based on kilometric rate, the program provides an accommodation allowance of $100-$550 (dependent on the number of lodging nights) per eligible treatment trip to patients whose one-way road distance to a specialist is at least 200 kilometers. In 2017–2018, a $9.9 million enhancement was introduced to move from a $100 flat rate accommodation allowance to a maximum of $550, dependent on the number of medically necessary lodging nights. The NHTG Program also promotes using specialist services located in Northern Ontario, which encourages more specialists to practice and remain in the north.

5.2 Physician Compensation

Physicians are paid for the services they provide through a number of mechanisms. Many physician payments are provided through fee-for-service arrangements. Fee-for-service remuneration is based on the Schedule of Benefits - Physician Services under the HIA. Other physician payment models include Primary Health Care Models (such as blended capitation models), Alternate Payment Plans, and funding arrangements for physicians in Academic Health Science Centres.

Physicians that belong to these other payment models may also bill fee-for-service when providing services that are outside of the scope of these models.

The MOH undertakes payment accountability activities to ensure physicians receive the payment to which they are entitled. Pre-payment activities include monitoring and system controls, such as automated payment rules in the OHIP fee-for-service claims payment system.

Post-payment activities may include claims reviews, audits, and educating and assisting physicians in meeting OHIP billing requirements. If payments for inappropriate claims are identified, the MOH attempts to work with the physician to resolve the issue. The MOH may also use remedies outlined in the HIA or IHFA. Post-payment reviews are identified through monitoring such as data analytics, as a result of concerns reported to the MOH, such as through the fraud hotline or other mechanisms.

In 2018-2019, 95 per cent of General Practitioners received fee-for-service payments from OHIP, but fewer than 30 per cent of them were paid solely on a fee-for-service basis. The majority (65 per cent) of primary care physicians in Ontario received funding through one of the primary health models: Comprehensive Care (CCM), Family Health Group (FHG), Family Health Network (FHN), Family Health Organization (FHO), Community Health Centres (CHC), Rural and Northern Physician Group Agreement (RNPGA), Group Health Centre (GHC), Blended Salary Model (BSM) and specialized agreements.

The MOH negotiates physician compensation with the Ontario Medical Association (OMA) in accordance with the OMA Representation Rights and Joint Negotiation and Dispute Resolution Agreement. In 2017, the MOH and the OMA successfully negotiated a Binding Arbitration Framework, an agreement that governs the process for PSA negotiations, mediation, and arbitration.

On February 19, 2019, a board of arbitration released its award establishing the parameters for physician compensation for the period of April 1, 2017 to March 30, 2021.

5.3 Payments to Hospitals

Ontario hospitals are funded through a combination of global funding, volume-based funding, and Patient-Based Funding—which provides funding on a spectrum between activity-based, and performance- based approaches.

Since April 1, 2012, Ontario shifted hospital funding from a predominantly global budget system towards a patient-based funding (PBF) system. PBF ensures that patients get the right care, at the right place, at the right time, and at the right price. PBF offers an integrated approach to health system funding and puts the patient at the centre through adopting a 'funding follows the patient' principle.

For purposes of funding, publicly funded hospitals are classified based on whether they receive funding through the Growth and Efficiency Model (GEM) or not. In addition, GEM hospitals are further classified based on whether they provide specialized care (e.g. teaching, pediatric) or by their size (e.g. large, medium).

Stand-alone psychiatric and small-sized hospitals do not receive GEM funding. Instead, they rely primarily on global budgets for their operational funding.

Hospital Funding Sources

Global funding: Non-targeted base funding that is carried over year-to-year. This funding is not tied to the delivery of specific procedures.

Growth and Efficiency Model (GEM) (Formerly Health-Based Allocation Model [HBAM]): This is an evidence-based funding formula that uses clinical and financial information to redistribute about $5.135 billion annually among all modeled hospitals, based on the number of patients treated and the complexity of their care. The model also takes into account the efficiency of hospitals.

In 2019-2020, the redistribution of HBAM was suspended, pending development of a long-term plan that considers a consolidated approach to address growth in services, which resulted in the introduction of the Growth and Efficiency Model (GEM). GEM is used to allocate incremental growth funding, rather than re-distributing existing funds.

Quality Based Procedures (QBP): QBP are episodes of care (e.g. hip/knee replacement surgery, stroke) for which evidence-based best practices have been defined and providers are compensated for providing the services included in the episode based on an established price.

Funding is allocated by assigning a number of cases (volumes) and a provincial price that is specific to identified surgical or medical procedures. The provincial price is adjusted to reflect patient cohort differences at each hospital using a measure of acuity, known as the Case Mix Index (CMI).

The funding amount for QBP is based on historical utilization, population growth projections and other risk factors and is intended to address the demands of a growing and aging population.

Bundled Care: Like QBP, Bundled Care funding is allocated by an assigned number of cases and a price. However, a Bundled QBP encompasses services that cross providers, specifically including hospital and post-acute community care like home care. Bundled QBP provide a single payment for an episode of care across multiple settings and providers, like hip/knee replacement surgery and post-surgical rehabilitation.

Funding is allocated to a Bundle Holder (a health service provider) who is responsible for partnering with and transferring funds to other service providers for surgical care and/or post- acute rehabilitation, providing a more integrated service from the time patients enter hospital for surgery to their recovery at home and in the community. Bundle Holders must ensure that patients are receiving the full scope of care in an integrated pathway, regardless of where the patient lives.

Bundled care is being implemented for hip and knee replacement surgery and chronic kidney disease, and being tested in other clinical areas.

Priority Programs and Services: Funding for life-saving procedures and specialized services (i.e. cardiovascular, neurosurgical, bariatric, critical care) as well as maternal/newborn health programs.

Funding rates are pre-set, and volume amounts are determined using a number of data points, including: historical utilization information, changes in the population of interest for the catchment area, and direct discussions with the hospitals and Local Health Integration Networks (LHIN), regarding their respective projections.

Post Construction Operating Plan (PCOP): PCOP funding provides operating funds to hospitals for clinical service and space expansions incurred after the completion of an approved capital project.

Post Construction Operating Plan funding may be provided for service volume increases, one-time start up and transition costs, equipment amortization and/or incremental facility costs.

Wait Times: Allocated to support additional diagnostic imaging (e.g. Magnetic Resonance Imaging [MRI] & Computerized Axial Tomography [CT] Hours) and select surgical procedures (price per procedure). Funding allocation is determined based on prior year performance, current capacity and wait lists.

Pay for Results (P4R): Provides annual one-time performance-related funding incentives to hospitals with high volume Emergency Departments with over 30,000 annual visits.

6.0 Recognition Given To Federal Transfers

The Government of Ontario publicly acknowledged the federal contributions provided through the Canada Health Transfer in its Public Accounts of Ontario 2019-2020.

Registered Persons
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
1. Number as of March 31st (#):Ontario Table 1 Footnote 1 13,723,465 13,829,743 14,042,917 14,231,376 14,295,514
Ontario table 1 Footnote 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)

Ontario table 1 Return to footnote 1 referrer
Insured Hospital Services Within Own Province or Territory
Public Facilities 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
2. Number (#):Ontario table 2 Footnote 1 143 143 141 141 140
3. Payments for insured health services ($):Ontario table 2 Footnote 2 16,386,982,327 16,784,015,574 17,356,176,130 18,024,589,979 18,400,652,198
Private For-Profit Facilities 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
4. Number of private for-profit facilities providing insured health services (#):Ontario table 2 Footnote 3 Not available Not available Not available Not available Not available
5. Payments to private for-profit facilities for insured health services ($):Ontario table 2 Footnote 3 Not available Not available Not available Not available Not available
Ontario table 2 Footnote 1

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.

Ontario table 2 Return to footnote 1 referrer

Ontario table 2 Footnote 2

Amount represents funding for all public and private hospitals excluding specialty psychiatric hospitals.

Ontario table 2 Return to footnote 2 referrer

Ontario table 2 Footnote 3

Data are not collected in a single system in MOH. Further, the MOH is unable to categorize providers/facilities as "for-profit" as MOH does not have financial statements detailing service providers' disbursement of revenues from the Ministry.

Ontario table 2 Return to footnote 3 referrer
Insured Hospital Services Provided to Residents in Another Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
6. Total number of claims, in-patient (#): 7,160 6,337 6,473 6,230 5,809
7. Total payments, in-patient ($): 66,194,339 61,781,960 61,748,658 59,696,706 54,158,972
8. Total number of claims, out-patient (#): 129,182 120,710 119,325 122,863 119,206
9. Total payments, out-patient ($): 42,834,485 43,097,597 43,821,288 46,325,610 45,498,572
Insured Hospital Services Provided Outside CanadaOntario table 4 Footnote 1Ontario table 4 Footnote 2
Pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
10. Total number of claims, pre-approved in-patientOntario table 4 Footnote 3 Not applicable Not applicable Not applicable 805 800
11. Total payments, pre-approved in-patient ($)Ontario table 4 Footnote 3 Not applicable Not applicable Not applicable 49,236,770 76,038,140
12. Total number of claims, pre-approved out-patient Not applicable Not applicable Not applicable Not applicable Not applicable
13. Total payments, pre-approved out-patient ($) Not applicable Not applicable Not applicable Not applicable Not applicable
Non pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
14. Total number of claims, non pre-approved in-patientOntario table 4 Footnote 3 Not applicable Not applicable Not applicable 4,343 4,419
15. Total payments, non pre-approved in-patient ($)Ontario table 4 Footnote 3 Not applicable Not applicable Not applicable 3,936,420 3,986,091
16. Total number of claims, non pre-approved out-patientOntario table 4 Footnote 3 Not applicable Not applicable Not applicable 13,693 13,891
17. Total payments, non pre-approved out-patient ($)Ontario table 4 Footnote 3 Not applicable Not applicable Not applicable 1,393,745 1,385,304
Ontario table 4 Footnote 1

Indicators 10 & 11 include both in-patient and out-patient for insured hospital and physician services provided outside Canada

Ontario table 4 Return to footnote 1 referrer

Ontario table 4 Footnote 2

Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report,but did not require provinces or territories to report on previous years.

Ontario table 4 Return to footnote 2 referrer

Ontario table 4 Footnote 3

Data pertains to hospital services to out-of-country travellers for emergency services that are acute, unexpected, arose outside of Canada and require immediate treatment.

Ontario table 4 Return to footnote 3 referrer
Insured Physician Services Within Own Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
18. Number of participating physicians (#): 30,177 30,893 31,718 32,566 33,245
19. Number of opted-out physicians (#): 21 20 19 17 15
20. Number of non-participating physicians (#):Ontario table 5 Footnote 1 0 0 0 0 0
21. Total payments for services provided by physicians paid through all payment methods ($):Ontario table 5 Footnote 2 11,918,882,881 12,113,803,206 13,199,726,871 13,024,319,815 13,910,893,530
22. Total payments for services provided by physicians paid through fee-for-service ($) 7,803,728,926 8,028,037,940 13,199,726,871 8,469,716,136 9,013,952,400
Ontario table 5 Footnote 1

Ontario has no non-participating physicians, only opted-out physicians who are reported under item #20

Ontario table 5 Return to footnote 1 referrer

Ontario table 5 Footnote 2

Total payments includes payments made to Ontario physicians through Fee-for-Service, Primary Care, Alternate Payment Programs, Academic Health Science Centres, the Hospital On Call Program and Health Care Connect. Services and payments related to Other Practitioner Programs, Out-of-Country/ Out-of-Province Programs, Nurse Practitioners, Interprofessional Shared Care, NP Led Clinics, ECHO & Chronic Pain, Fertility Services, Family Health Teams and Community Labs are excluded.

Ontario table 5 Return to footnote 2 referrer
Insured Physician Services Provided to Residents in Another Province or Territory
Private For-Profit Facilities 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
23. Number of services (#):Ontario table 6 Footnote 1 589,688 585,353 539,598 573,828 506,698
24. Total payments ($):Ontario table 6 Footnote 1 29,524,980 30,851,717 28,646,930 30,818,175 28,626,840
Ontario table 6 Footnote 1

Data pertains to physician services for out-of-country travellers for emergency services that are acute, unexpected, arose outside of Canada and require immediate treatment

Ontario table 6 Return to footnote 1 referrer
Insured Physician Services Provided Outside CanadaOntario 7 Footnote 1
Pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
25. Number of pre-approved services Not applicable Not applicable Not applicable Not applicable Not applicable
26. Total pre-approved payments ($) Not applicable Not applicable Not applicable Not applicable Not applicable
Non pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
27. Number of non pre-approved servicesOntario table 7 Footnote 2 Not applicable Not applicable Not applicable 80,534 79,937
28. Total non pre-approved payments ($)Ontario table 7 Footnote 2 Not applicable Not applicable Not applicable 2,750,057 2,771,990
Ontario table 7 Footnote 1

Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report,but did not require provinces or territories to report on previous years.

Ontario table 7 Return to footnote 1 referrer

Ontario table 7 Footnote 2

Data pertains to physician services for out-of-country travellers for emergency services that are acute, unexpected, arose outside of Canada and require immediate treatment

Ontario table 7 Return to footnote 2 referrer
Insured Surgical-Dental Services Within Own Province
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
29. Number of participating dentists (#): 278 281 276 280 276
30. Number of opted-out dentists (#):Ontario table 8 Footnote 1 Not applicable Not applicable Not applicable Not applicable Not applicable
31. Number of non-participating dentists (#):Ontario table 8 Footnote 1 Not applicable Not applicable Not applicable Not applicable Not applicable
32. Number of services provided 99,570 98,823 105,438 106,109 101,668
33. Total payments ($): 12,442,618 13,124,123 12,981,062 13,131,908 12,527,790
Ontario table 8 Footnote 1

Health Canada requested this data as of the 2016-2017 report, but did not require provinces or territories to report data for 2015-16

Return to footnote 1 referrer

Manitoba

Manitoba Health, Seniors and Active Living (MHSAL) provides leadership and support to protect, promote and preserve the health of all Manitobans. MHSAL continues efforts to improve access, service delivery, capacity, innovation, sustainability and improve the health status of Manitobans while reducing health disparities. The roles and responsibilities of the department include policy, program and standards development; fiscal and program accountability; and evaluation. In addition, some direct services continue to be provided through Selkirk Mental Health Centre, Cadham Provincial Laboratory, public health inspections, and provincial nursing stations.

COVID-19 Measures

Steps have been taken in relation to the COVID-19 pandemic, to ensure that newcomers to Manitoba and other applicants for coverage have expedited access to registration for health care benefits under the Provincial Health Insurance Plan, including the temporary relaxation of documentation requirements, extensions of benefits in instances where delays due to travel or processing of immigration or other government documents may impact the application process, and other similar extensions and exceptions.

1.0 Public Administration

1.1 Health Care Insurance Plan and Public Authority

The Manitoba Health Services Insurance Plan (MHSIP) is administered by Manitoba Health, Seniors and Active Living (MHSAL) under the Health Services Insurance Act, R.S.M. 1987, c. H35.

The MHSIP is administered under this Act, and insures the costs of hospital, personal care, and medical and other health services referred to in acts of the legislature or related regulations.

The Minister of Health, Seniors and Active Living (the Minister) is responsible for administering and operating the MHSIP. The Minister may also enter into contracts and agreements with any person or group that he or she considers necessary for the purposes of the Act.

The Minister may also make grants to any person or group for the purposes of the Act on such terms and conditions that are considered advisable. Also, the Minister may, in writing, delegate to any person any power, authority, duty or function conferred or imposed upon the Minister under the Act or under the Regulations.

There were no legislative amendments to the Act or the Regulations in the 2019-2020 fiscal year that affected the public administration of the MHSIP.

1.2  Reporting Relationship

Section 6 of the Health Services Insurance Act requires the Minister to have audited financial statements of the MHSIP showing separately the expenditures for hospital services, medical services and other health services. The Minister is required to prepare an annual report, which must include the audited financial statements, and to table the report before the Legislative Assembly within 15 days of receiving it, if the Assembly is in session. If the Assembly is not in session, the report must be tabled within 15 days of the beginning of the next session.

1.3 Audit of Accounts

Section 7 of the Health Services Insurance Act requires that the Office of the Auditor General of Manitoba (or another auditor designated by the Office of the Auditor General of Manitoba) audit the accounts of the MHSIP annually and prepare a report on that audit for the Minister. The most recent audit reported to the Minister and available to the public is for the 2019-2020 fiscal year and is contained in the Manitoba Health, Seniors and Active Living Annual Report.

2.0 Comprehensiveness

2.1 Insured Hospital Services

Sections 46 and 47 of the Health Services Insurance Act, as well as the Hospital Services Insurance and Administration Regulation (M.R. 48/93), provide for insured hospital services.

There were no amendments to Sections 46 and 47 of the Health Services Insurance Act or the Hospital Services Insurance and Administration Regulation in 2019-2020.

As of March 31, 2019, there were 96 facilities providing insured hospital services to both in-and out-patients. Hospitals are designated by the Hospitals Designation Regulation (M.R. 47/93) under the Act.

Services specified by the Regulation as insured in-patient and out-patient hospital services include:

The Regulation states that hospital in-patient services include routine medical and surgical supplies, thereby ensuring reasonable access for all residents. The regional health authorities and Manitoba Health, Seniors and Active Living (MHSAL) monitor compliance.

No additional services were added to the list/schedule of insured hospital services in 2019-2020.

Manitoba Health, Seniors and Active Living (MHSAL), for the period of 2019-2020, had no formal evidence, investigations or actions against any diagnostic clinics where there was an assertion of inappropriate charging of patients for services that would be considered insured if provided in a hospital. Manitoba Health, Seniors and Active Living (MHSAL), do not have any recent or upcoming legislative or regulatory changes in this regard.

Manitoba residents maintain high expectations for quality health care and insist that the best available medical knowledge and service be applied to their personal health situations.

2.2 Insured Physician Services

The enabling legislation that provides for insured physician services is the Medical Services Insurance Regulation (M.R. 49/93) made under the Health Services Insurance Act.

Physicians providing insured services in Manitoba must be lawfully entitled to practice medicine in Manitoba, and be registered and licensed under the Medical Act. As of April 30, 2020, there were 3,029 physicians registered in Manitoba, with 2,678 participating in the Manitoba Health Services Insurance Plan.

A physician, by giving notice to the Minister of Health, Seniors and Active Living (the Minister) in writing, may elect to collect the fees other than from the Minister for medical services rendered to insured persons, in accordance with section 91 of the Act and section 5 of the Medical Services Insurance Regulation. The election to opt out of the health care insurance plan takes effect on the first day of the month following a 90-day period from the date the Minister receives the notice.

Before rendering a medical service to an insured person, physicians must give the patient reasonable notice that they propose to collect any fee for the medical service from them or any other person except the Minister. The physician is responsible for submitting a claim to the Minister on the patient's behalf and cannot collect fees in excess of the benefits payable for the service under the Act or Regulations. No physicians opted-out of the medical plan in 2019-2020.

The range of physician services insured by MHSAL is listed in the Payment for Insured Medical Services Regulation (M.R. 95/96). Coverage is provided for all medically required personal health care services that are not excluded under the Excluded Services Regulation (M.R. 46/93) of the Act, rendered to an insured person by a physician.

During fiscal year 2019-2020, a number of new insured services were added to a revised fee schedule. The Physician's Manual can be found on the Health, Seniors and Active Living website.

The process for a medical service to be added to the list of those covered by MHSAL is that physicians must put forward a proposal to their specific section of Doctors Manitoba. Doctors Manitoba will negotiate the item, including the fee, with MHSAL. MHSAL may also initiate this process, which may include stakeholder and public consultation.

2.3 Insured Surgical-Dental Services

Insured surgical and dental services are listed in the Hospital Services Insurance and Administration Regulation (M.R. 48/93) under the Health Services Insurance Act. Surgical services are insured when performed by a certified oral and maxillofacial surgeon or a licensed dentist in a hospital, when hospitalization is required for the proper performance of the procedure. This Regulation also provides benefits relating to the cost of insured orthodontic services in cases of cleft lip and/ or palate for persons registered under the program by their 18th birthday, when provided by a registered orthodontist.

Providers of dental services, by giving to the minister at any time notice in writing, may elect to collect their fees directly from the patient in the same manner as physicians in accordance with section 91(1) of the Health Services Insurance Act and may not charge to, or collect from, an insured person a fee in excess of the benefits payable under the Act or Regulations. No providers of dental services opted-out in 2019-2020.

In order for a dental service to be added to the list of insured services, a dentist must put forward a proposal to the Manitoba Dental Association (MDA) for discussion with MHSAL, which may include stakeholder and public consultation. The MDA negotiates the item and fee with MHSAL.

2.4 Uninsured Hospital, Physician and Surgical-Dental Services

The Excluded Services Regulation (M.R. 46/93) made under the Health Services Insurance Act sets out those services that are not insured. These include:

The Hospital Services Insurance and Administration Regulation states that hospital in-patient services include routine medical and surgical supplies, thereby ensuring reasonable access for all residents. The regional health authorities and MHSAL monitor compliance.

All Manitoba residents have equitable access to services. Third parties such as private insurers or the Workers Compensation Board do not receive priority access to services through additional payment. Manitoba has no formalized process to monitor compliance; however, feedback from physicians, hospital administrators, medical professionals and staff allows regional health authorities and MHSAL to monitor usage and service concerns.

To de-insure services covered by MHSAL, the Ministry prepares a submission for approval by Cabinet. The need for public consultation is determined on an individual basis depending on the subject.

No services were removed from the list of those insured by Manitoba Health in 2019-2020.

3.0 Universality

3.1 Eligibility

The Health Services Insurance Act defines the eligibility of Manitoba residents for coverage under the provincial health care insurance plan.

Section 2(1) of the Act states that a resident is a person who is legally entitled to be in Canada, makes his or her home in Manitoba, is physically present in Manitoba for at least six months in a calendar year, and includes any other person classified as a resident in the Regulations, but does not include a person who holds a temporary resident permit under the Immigration and Refugee Protection Act (Canada), unless the Minister of Health, Seniors and Active Living (the Minister) determines otherwise, or is a visitor, transient or tourist.

The Residency and Registration Regulation (M.R. 54/93) extends the definition of residency. The extensions are found in sections 7(1) and 8(1). Section 7(1) allows missionaries, individuals with out-of-country employment and individuals undertaking sabbatical leave to be outside Manitoba for up to two years while still remaining residents of Manitoba. Students are deemed to be Manitoba residents while in full-time attendance at an accredited educational institution. Section 8(1) extends residency to individuals who are legally entitled to work in Manitoba and have a work permit of 12 months or more under the Immigration and Refugee Protection Act (Canada). Additionally, section 8.1.1 of the Residency and Registration Regulation extends deemed residency to temporary foreign workers (and their dependents) in the province to provide agricultural services on the basis of a work permit, regardless of the duration of their work permit.

No amendments were made to the Residency and Registration Regulation (M.R. 54/93) in 2019-2020.

The Residency and Registration Regulation, section 6, defines Manitoba’s waiting period as follows:

“A resident who was a resident of another Canadian province or territory immediately before his or her arrival in Manitoba is not entitled to benefits until the first day of the third month following the month of arrival.”

Section 6 of the Residency and Registration Regulation stipulates that there is no waiting period for dependents of members of the Canadian Armed Forces.

There are currently no other waiting periods in Manitoba.

The Manitoba Health Services Insurance Plan (MHSIP) excludes residents covered under any federal plan, including the following federal statutes:

These residents become eligible for health services insurance coverage upon discharge from the Canadian Forces, or in the case of an inmate of a penitentiary, upon discharge if the inmate has no resident dependents. Upon change of status, these persons have one month to register with Manitoba Health, Seniors and Active Living (MHSAL) (Residency and Registration Regulation (M.R. 54/93, subsection 2[3]).

RCMP members are insured persons in Manitoba and are eligible for benefits under the MHSIP.

The process of issuing health insurance cards requires that individuals inform and provide documentation to MHSAL that they are legally entitled to be in Canada, and that they intend to be physically present in Manitoba for six months in a calendar year. They must also provide a primary residence address in Manitoba. Upon receiving this information, Manitoba Health, Seniors and Active Living will provide a registration card for the individual and all qualifying dependents.

Manitoba has two health-related numbers. The registration number is a six-digit number assigned to an individual 18 years of age or older who is not classified as a dependent. The six-digit number may be shared by all members of a family including a spouse and dependents. A nine-digit Personal Health Identification Number is used for payment of all medical service claims and hospital services.

As of June 1, 2020, there were 1,385,225 residents registered with the Manitoba Health Services Insurance Plan.

Individuals may appeal decisions of MHSAL with respect to eligibility before the Manitoba Health Appeal Board, an independent quasi-judicial tribunal established pursuant to The Health Services Insurance Act.

There is no provision for a resident to opt out of the Manitoba Health Services Insurance Plan.

3.2 Other Categories of Individuals

The Residency and Registration Regulation (M.R. 54/93, sub-section 8[1]) requires that temporary workers possess a work permit issued by Immigration, Refugees and Citizenship Canada for at least 12 consecutive months, be physically present in Manitoba for six months in a calendar year, and be legally entitled to be in Canada before receiving MHSIP coverage.

Section 8.1.1 of the Residency and Registration Regulation extends deemed residency to temporary foreign workers (and their dependents) in the province to provide agricultural services on the basis of a work permit, regardless of the duration of their work permit.

4.0 Portability

4.1 Minimum Waiting Period

The Residency and Registration Regulation (M.R. 54/93, section 6) identifies the waiting period for insured persons from another province or territory. A resident who lived in another Canadian province or territory immediately before arriving in Manitoba is entitled to benefits on the first day of the third month following the month of arrival.

4.2 Coverage during Temporary Absences in Canada

The Residency and Registration Regulation (M.R. 54/93 section 7[1]) defines the rules for portability of health insurance during temporary absences in Canada.

Students are considered residents and will continue to receive health coverage for the duration of their fulltime enrollment at any accredited educational institution. The additional requirement is that they intend to return and reside in Manitoba after completing their studies.

Manitoba has formal agreements with all Canadian provinces and territories for the reciprocal billing of insured hospital services.

In-patient costs are paid at standard rates approved by the host province or territory. Payments for in-patient, high-cost procedures and out-patient services are based on national rates agreed to by provincial and territorial health plans. These include all medically necessary services as well as costs for emergency care.

Except for Quebec, medical physician services incurred in all provinces or territories are paid through a reciprocal billing agreement at host province or territory rates. Claims for physician medical services received in Quebec are submitted by the patient or physician to Manitoba Health, Seniors and Active Living (MHSAL) for payment at host province rates.

4.3 Coverage during Temporary Absences outside Canada

The Residency and Registration Regulation (M.R. 54/93, sub-section 7[1]) defines the rules for portability of health insurance during temporary absences from Canada.

Section 7(1)(g) of the Residency and Registration Regulation extends the period during which a person may be temporarily absent from Manitoba for the purpose of residing outside of Canada from six months to a maximum of seven months in a 12-month period.

Residents on full-time employment contracts outside Canada will receive health services insurance coverage for up to 24 consecutive months. Individuals must return and reside in Manitoba after completing their employment terms. Individuals serving as humanitarian aid workers or missionaries on behalf of a religious organization approved as a registered charity under the Income Tax Act (Canada) will be covered by MHSAL for up to 24 consecutive months. Students are considered residents and will continue to receive health coverage for the duration of their full-time enrollment at an accredited educational institution. The additional requirement is that they intend to return and reside in Manitoba after completing their studies. Residents on sabbatical or educational leave from employment will be covered by MHSAL for up to 24 consecutive months. These individuals also must return and reside in Manitoba after completing their leave.

Manitoba residents receiving coverage under the provincial health insurance plan who receive medical and hospital services outside of Canada are eligible to be reimbursed at the rates set out in the Medical Services Insurance Regulation and the Hospital Services Insurance and Administration Regulation. Emergency doctors' services outside of Canada are reimbursed at a rate equal to what a Manitoba doctor would receive for a similar service. Emergency hospital care is paid on an average daily rate established by MHSAL.

4.4 Prior Approval Requirement

Prior approval is not required for procedures that are covered under the interprovincial reciprocal agreements with other provinces. Prior approval by MHSAL is required for high cost items or procedures that are not included in the reciprocal agreements.

In order to be eligible for reimbursement, all non-emergency hospital and medical care provided outside Canada requires prior approval from MHSAL. Manitobans requiring medically necessary medical and/or hospital services unavailable in Manitoba or elsewhere in Canada may be eligible for reimbursement of costs incurred outside of Canada, pursuant to the Medical Services Insurance Regulation, by providing MHSAL with a recommendation from a specialist stating that the patient requires a specific, medically necessary service.

Individuals may appeal decisions of MHSAL with entitlement to medical benefits before the Manitoba Health Appeal Board, an independent quasi-judicial tribunal established pursuant to The Health Services Insurance Act.

5.0 Accessibility

5.1 Access to Insured Health Services

Manitoba Health, Seniors and Active Living (MHSAL) ensures that medical services are equitable and reasonably available to all Manitobans. Effective January 1, 1999, the Surgical Facilities Regulation (M.R. 222/98) under the Health Services Insurance Act came into force to prevent private surgical facilities from charging additional fees for insured medical services.

The Health Services Insurance Act and The Private Hospitals Act include definitions and other provisions to ensure:

The Accessibility for Manitobans Act includes definitions and principles to ensure accessibility by preventing and removing barriers that disable people with respect to receiving health care services including:

In the event that a Manitoba resident feels that they have been inappropriately charged for a service that is insured under the provincial health insurance plan (i.e., a potential incidence of extra-billing or a user charge), the resident is encouraged to contact Manitoba to report this occurrence at the following coordinates:

Manitoba Health Seniors and Active Living
300 Carlton Street
Winnipeg, MB R3B 3M9
1-800-392-1207

Inquiries are made by the Insured Benefits Branch of Manitoba Health, Seniors and Active Living into the specifics of the fee(s) charged to assess whether the service provided was an insured service, and any required further action. Generally, contact from MHSAL to the medical service provider, advising that the provider must reimburse the patient and submit a claim to MHSAL, is sufficient to address the concern. Further incidents on the part of the same service provider may result in an investigation by MHSAL's Audit and Investigation Unit. Concerns regarding the professional conduct of medical service providers are referred to the appropriate regulatory agency.

Manitoba Health, Seniors and Active Living remains committed to the principles of Medicare and improving the health status of all Manitobans. In 2019-2020, Manitoba continued to support these commitments through a number of activities including the following:

System Transformation

As recommended in the KPMG Health System Sustainability and Innovation Review, the government of Manitoba announced the creation of a Transformation Management Office in order to guide the integration of structural and organizational reform of the health system between government, regional health authorities and health-care facilities to ensure fiscal sustainability while addressing wait times. The government is now focused on the implementation of the review's recommendations to ensure the realization of sustainable benefits over the 2019-2020 year and moving forward.

Additionally, Shared Health Manitoba, a new provincial health organization announced in 2017–2018, continues to focus on patient-centred planning to ensure consistent standards across the province for the provision of care. Input was sought from over 10 provincial clinical teams comprised of health-care providers with varied professional backgrounds and experience across rural, urban and northern Manitoba communities with the objective of developing of a multi-year clinical and preventive services plan for Manitoba. A strategic plan, known as the Manitoba Clinical and Preventative Services Plan was created, and published publicly. An implementation plan was in its early stages of development.

The province also continued its focused efforts on the implementation of the provincial mental health and addictions strategy by aligning the needs identified in the Improving Access and Coordination of Mental Health and Addictions Services: A Provincial Strategy for all Manitobans report (the Virgo report) with the provincial clinical services plan, to ensure alignment with the broader health care system—a key recommendation within the Virgo report.

Additionally, Manitoba continued to implement the patient centred medical home model through two complementary and aligned initiatives—MyHealth Teams and Home Clinic. The goal of these is to improve access and demonstrate achievement of quality primary care standards for Manitobans and to build a more integrated primary care system. Adoption rate of home clinics remained high, representing approximately 70 per cent of all primary care providers. Both initiatives remain aligned with the broader provincial preventive and clinical services plan.

Facilities

As an ongoing component of Healthcare System Transformation, a Provincial ICT Governance model was integrated within Shared Health Manitoba with the intent of ensuring that a more equitable and provincial perspective was taken when considering investments focused on improving and where possible enhancing access and quality of services.

Manitoba Health provided strategic guidance for infrastructure investment to establish expectations and conditions to enable success for stakeholders to progress a cross-functional approach to planning and delivery of infrastructure including investments in repair, renovation and construction of buildings, specialized equipment and ICT.

Manitoba Health established a multi-year infrastructure plan which supports provincial population health objectives and is sustainable and sufficiently flexible to meet the changing needs of the population, as well as requirements of innovation in service delivery. This included a review of prioritized requests for major capital and on-going repairs/replacement related to infrastructure, ICT and specialized equipment repairs and replacement received from regional health authories (RHA's) / service delivery organizations (SDO's) as well as providing advice to inform government decision making for investment.

Manitoba Health planned, developed and completed infrastructure based projects across the multi-year strategic capital plan to address the operation service needs of the provincial health system. For the 2019-2020 fiscal year, 18 major projects within capital and ICT plus over 300 individual projects with the infrastructure repair and upgrades and specialized equipment categories. Projects with an estimated $401.9 million were submitted to MHSAL and progressed.

Manitoba secured and sustained government funding to support the execution of the provincial strategic infrastructure/ICT capital plan that is defined and implemented in accordance with government direction and with regional need and best practices, appropriate standards (program, design and construction), approved scope and timeline, and negotiated costs limits. Oversight for the implementation of investments of approximately $227 million in infrastructure, ICT, specialized equipment was provided and five innovative health-related initiatives targeted at improving health care processes and health outcomes were approved for implementation.

Manitoba applied policies related to procurement practices, infrastructure development, infrastructure sustainment, departmental funding and community cost-sharing and provided oversight and guidance to ensure that requirements were known to and complied with by RHA's and SDO's.

Manitoba provided efficient and accurate information on the department's infrastructure program including accurate forecasting of maintenance requirements, emerging program standards and models, capital financing and development of appropriate program and policy options. Oversight was provided for 31 Infrastructure/ICT major capital projects valued at approximately $356 million, of these four ICT projects with a total estimated value of $52 million were completed.

Manitoba provided upgrades and functional changes to existing infrastructure in a timely, prioritized sequence and continued to oversee the annual ICT Infrastructure Renewal Program managed by Digital Health, which focuses and on the execution of a risk-based approach to replacing and upgrading old, obsolete and failing technical infrastructure in Manitoba's health information systems operating environment. Policy, planning and project management oversight was provided to support department initiatives to ensure appropriate resourcing and solution delivery including significant efforts to update and sustain departmental ICT systems supporting critical administrative systems and information management and analytical capability. Continued oversight for the annual safety and security program including the review of the prioritized list of potential projects from the regional health authorities / service delivery organizations and the monitoring of the projects to completion as well as the oversight of the annual specialized equipment program including monitoring expenditures and completion of delivery/installation.

Manitoba provided necessary data and information for department staff to achieve corporate goals and objectives and consulted with other department branches/areas to ensure that all proposed projects fit with the department's planned priorities as well as managing, maintaining and provide security of the department systems and processes in support of user's access to information and in compliance with required availability targets.

Manitoba regularly reviewed and updated existing websites, which include new web-based information developed to provide ongoing support to the department, with the intent of increasing public access to the department’s online information, as measured by website analytics.

Health Professionals

In 2019-2020, the province provided funding for the following complement of medical and nursing professionals registered to practice in Manitoba:

The transition to the Regulated Health Professions Act (RHPA) continues to be a significant undertaking for the province. The RHPA came into effect in January 2014 to ensure all regulated health professions are governed by consistent, uniform regulations with enhanced focus on patient safety and accountability. The legislation includes a list of activities and procedures called reserved acts, that regulated health professionals may be authorized to perform when providing health care based on their competence and training.

The RHPA sets out consistent rules and processes for governance, registration, complaints and discipline, as well as regulation and bylaw making authority. To date audiologists and speech language pathologists, physicians and surgeons, and registered nurses have transitioned to self-regulation under the RHPA. It is expected that the profession of para-medicine will be next to transition to self-regulation with the new College of Paramedics of Manitoba commencing operations in fall 2020. Psychologists and Registered Psychiatric Nurses are the next two health care professions that will be transitioning to self-regulation under the RHPA. The transition of other health professions to the RHPA will continue to be a focus for the province, as it will have a significant long-term impact on the provincial health workforce.

In 2019-2020 the province provided funding to increase the number of medical and nursing professionals registered in Manitoba as follows:

The number of Registered Nurses decreased by 166 (from 13,522 to 13,356).

5.2 Physician Compensation

Manitoba continues to employ the following methods of payment for physicians:

The Health Services Insurance Act governs remuneration to physicians for insured services. There were no amendments to the Health Services Insurance Act related to physician compensation during the 2019-2020 fiscal year.

Fee-for-service remains the primary method of payment for physician services. Alternate payment arrangements constitute a significant portion of the total compensation to physicians in Manitoba. Alternate-funded physicians are those who receive non fee-for-service compensation, including through a salary (employment relationship) or those who work on an independent contract basis. Manitoba also uses blended payment methods where appropriate. As well, physicians may receive sessional payments for providing medical services on a time based arrangement, as well as stipends for on-call and other responsibilities.

In 2019-2020 MHSAL, in collaboration with Shared Health, represented Manitoba in its negotiations with Manitoba physicians. The physicians are typically represented by Doctors Manitoba with some exceptions, such as oncologists engaged by CancerCare Manitoba.

Doctors Manitoba and Manitoba reached a four-year agreement in July of 2019, to renew the physician Master Agreement. The new physician Master Agreement took effect on April 1, 2019, and will expire on March 31, 2023.

The Manitoba Physician’s Manual lists all of the fee tariff descriptions, rates, rules of application and the dispute resolution process in relation to fee-for-service payments to physicians. This document is the Schedule of Benefits payable to physicians on behalf of insured persons in Manitoba pursuant to the Medical Services Insurance Regulation under the Health Services Insurance Act.

All fee-for-service claims must be submitted electronically. The submission of paper claims is permitted on a limited basis and only with the prior approval of MHSAL. Fee-for-service claims must be received within six months of the date upon which the physician rendered the service.

5.3 Payments to Hospitals

Division 3.1 of Part 4 of The Regional Health Authorities Act sets out the requirements for operating agreements between regional health authorities and the operators of hospitals and personal care homes, defined as “health corporations” under the Act.

Pursuant to the provisions of division 3.1, regional health authorities are prohibited from providing funding to a health corporation for operational purposes unless the parties have entered into a written agreement for this purpose that:

If the parties cannot reach an agreement, the Act enables them to request that the Minister appoint a mediator to help them resolve outstanding issues. If the mediation is unsuccessful, the Minister is empowered to resolve the matter or matters in dispute. The Minister’s resolution is binding on the parties.

There are three regional health authorities which have hospitals operated by health corporations in their health regions. The regional health authorities have required agreements with health corporations that enable the regional health authority to determine funding based on objective evidence, best practices and criteria that are commonly applied to comparable facilities. In all other regions, the hospitals are operated by regional health authorities. The allocation of resources by regional health authorities for providing hospital services is approved by MHSAL through the approval of regional health plans, which the regional health authorities are required to submit for approval pursuant to section 24 of the Regional Health Authorities Act. Section 23 of the Act requires that regional health authorities allocate their resources in accordance with the approved regional health plan.

Pursuant to subsection 50(2.1) of the Health Services Insurance Act, payments from the Manitoba Health Services Insurance Plan for insured hospital services are to be paid to the regional health authorities. In relation to those hospitals that are not owned and operated by a regional health authority, the regional health authority is required to pay each hospital in accordance with any agreement reached between the regional health authority and the hospital operator.

No legislative amendments to the Act or the Regulations in 2019-2020 had an effect on payments to hospitals.

6.0 Recognition Given To Federal Transfers

Manitoba regularly recognizes the federal role regarding the contributions provided under the Canada Health Transfer in public documents. Federal transfers are identified in the Estimates of Expenditures and Revenue (Manitoba Budget) document and in the Public Accounts of Manitoba. Both documents are published annually by the Manitoba government.

Registered Persons
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
1. Number as of March 31st 1,320,343 1,339,308 1,369,673 1,370,642Manitoba table 1 Footnote 1 1,385,225
Manitoba table 1 Footnote 1

Population as of June 1st, 2020.

Manitoba table 1 Return to footnote 1 referrer
Insured Hospital Services Within Own Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
2. Number 96 96 96 96 96
3. Payments for insured health services ($) Not available Not available Not available Not available Not available
Private For-Profit Facilities 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
4. Number of private for-profit facilities providing insured health services 0 0 0 0 0
5. Payments to private for-profit facilities for insured health services ($) 0 0 0 0 0
Insured Hospital Services Provided to Residents in Another Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
6. Total number of claims, in-patient 2,507 2,458 2,569 2,491 2,502
7. Total payments, in-patient ($) 27,875,311 28,194,575 31,845,644 33,989,616 35,646,832
8. Total number of claims, out-patient 30,485 30,412 30,843 31,401 30,616
9. Total payments, out-patient ($) 10,542,720 11,535,541 12,579,590 12,742,040 13,949,642
Insured Hospital Services Provided Outside CanadaManitoba table 4 Footnote 1
Pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
10. Total number of claims, pre-approved in-patient Not available Not available Not available Not available Not available
11. Total payments, pre-approved  in-patient ($) Not available Not available Not available Not available Not available
12. Total number of claims, pre-approved out-patient Not available Not available Not available Not available Not available
13. Total payments, pre-approved out-patient ($) Not available Not available Not available Not available Not available
Non pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
14. Total number of claims, non pre-approved in-patientManitoba table 4 Footnote 2 616 589 613 567 567
15. Total payments, non pre-approved in-patient ($)Manitoba table 4 Footnote 2 5,162,892 3,148,170 3,160,654 1,930,540 1,713,770
16. Total number of claims, non pre-approved out-patientManitoba table 4 Footnote 2 1,982 10,842 11,615 10,542 7,718
17. Total payments, non pre-approved out-patient ($)Manitoba table 4 Footnote 2 3,790,531 3,652,283 4,463,261 6,790,798 2,876,572
Manitoba table 4 Footnote 1

Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report,but did not require provinces or territories to report on previous years.

Manitoba table 4 Return to footnote 1 referrer

Manitoba table 4 Footnote 2

The claims in our data system cannot be separated into pre-approved or non pre-approved, therefore, the numbers reflect the total claims and payments as reported for previous years.

Manitoba table 4 Return to footnote 2 referrer
Insured Physician Services Within Own Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
18. Number of participating physicians 2,533 2,660 2,709 2,755 2,678
19. Number of opted-out physicians 0 0 0 0 0
20. Number of non-participating physicians Not applicable Not applicable Not applicable Not applicable Not applicable
21. Total payments for services provided by physicians paid through all payment methods ($) 1,204,757,000 1,283,742,000 1,252,850,000 1,339,598,000 1,333,152,000
22. Total payments for services provided by physicians paid through fee-for-service ($) 784,398,000 867,122,000 845,522,000 901,784,000 895,650,638
Insured Physician Services Provided to Residents in Another Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
23. Number of services 263,393 254,395 273,056 271,009 251,133
24. Total payments ($) 12,545,113 13,062,681 13,818,753 13,898,168 13,440,993
Insured Physician Services Provided Outside CanadaManitoba table 7 Footnote 1
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
25. Number of pre-approved services Not available Not available Not available Not available Not available
26. Total pre-approved payments ($) Not available Not available Not available Not available Not available
Non pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
27. Number of non pre-approved services 7,995 6,641 6,867 5,888 5,482
28. Total non pre-approved payments ($) 1,269,879 1,042,755 788,816 768,212 602,938
Manitoba table 7 Footnote 1

Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report,but did not require provinces or territories to report on previous years.

Manitoba table 7 Return to footnote 1 referrer
Insured Surgical-Dental Services Within Own Province
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
29. Number of participating dentists 207 227 222 247 273
30. Number of opted-out dentistsManitoba table 8 Footnote 1 Not applicable Not applicable 0 0 0
31. Number of non-participating dentistsManitoba table 8 Footnote 1 Not applicable Not applicable 515 495 473
32. Number of services provided 6,561 7,249 7,415 7,081 7,098
33. Total payments ($) 1,531,281 1,851,615 2,047,349 1,872,000 2,205,750
Manitoba table 8 Footnote 1

Health Canada requested this data as of the 2016-2017 report, but did not require provinces or territories to report data for 2015-2016.

Manitoba table 8 Return to footnote 1 referrer

Saskatchewan

Saskatchewan's Ministry of Health strives for a patient-centred health care system, focused on better health, better care, better value, and better health care teams for Saskatchewan people. The Ministry supports innovative approaches to meet the needs of patients and families and provide culturally sensitive services.

Saskatchewan continues to make progress in the long-term transition from 12 regional health authorities to the Saskatchewan Health Authority. Since 2017, the province has been working to improve frontline patient care for residents, by standardizing processes and policies to better coordinate health services across the province and help ensure patients receive high-quality, timely health care, regardless of where they live in Saskatchewan. This work has been invaluable in supporting a more coordinated provincial response to the COVID-19 pandemic.

Within Saskatchewan's health system, the Saskatchewan Health Authority is supported by the Saskatchewan Cancer Agency, eHealth Saskatchewan, 3S Health (Shared Services Saskatchewan), the Athabasca Health Authority, affiliated health care organizations, and a diverse group of professionals, many of whom are in private practice. There are 28 self-regulated health professions in the province, overseen by 26 regulatory bodies. An estimated 46,000 people provide a broad range of services across the health system.

The Ministry continues to assess how it is organized to provide effective strategic oversight for health system partners, and supports leadership from boards, management, and health professionals at all levels.

The Ministry maintains partnerships with local, regional, provincial, national and international organizations, to help ensure that all Saskatchewan residents have access to quality health care services.

Visit saskatchewan.ca for more information about Ministry programs and services.

COVID-19

The Government of Saskatchewan has worked closely with health organizations, First Nations and Métis, the federal government, regulatory bodies, other provincial ministries, local governments and others in response to COVID-19 pandemic. The Saskatchewan Health Authority, with the support of the Government of Saskatchewan, prepared the acute care hospital system for surges in in-patient admissions due to the coronavirus. Actions that have been taken include creating a system-wide acute care surge plan designed for rural and urban areas; a centralized bed management and tracking system; plans to reduce elective and non-urgent services to create capacity in the system for COVID-19 patients; preserving supplies and personal protective equipment; ensuring hospital care in the north remains safe and accessible; increasing urban hospital capacity by relocating patients who do not require acute care to more appropriate facilities; equipping additional spaces to provide patient care, including development of two field hospitals that are ready to receive patients; and rapidly increasing medical equipment, including ventilators.

Effective March 13, 2020, the Ministry of Health implemented two temporary pandemic virtual care fee codes for telephone and video assessments to compensate physicians for direct patient care provided over the telephone and secure video conferencing. Subsequently, the Ministry of Health also implemented eight additional temporary pandemic virtual care fee codes for telephone and secure video conferencing for specialist consultations and visits, psychotherapy, and other psychiatric services effective March 24, 2020. The ministry further amended the temporary pandemic fee codes to be payable for services performed by medical learners under the supervision of a physician. These temporary pandemic virtual care fee codes are not insured services – they were implemented to address service delivery gaps caused by COVID-19 and are not intended for permanent use post-pandemic. Planning for implementing permanent virtual care fee codes post-pandemic is occurring within the process between the Saskatchewan Medical Association and Ministry of Health.

1.0 Public Administration

1.1 Health Care Insurance Plan and Public Authority

The provincial government is responsible for funding and ensuring the provision of insured hospital, physician and surgical-dental services in Saskatchewan. Section 6.1 of the Health Administration Act authorizes that the Saskatchewan Minister of Health (the Minister) may:

Sections 8 and 9 of the Saskatchewan Medical Care Insurance Act provide the authority for the Minister to establish and administer a plan of medical care insurance for residents of Saskatchewan. The Provincial Health Authority Act, implemented in 2017, provided the authority to amalgamate the 12 regional health authorities to a single health authority.

Sections 3 and 9 of the Cancer Agency Act provide the authority for establishing a Saskatchewan Cancer Agency and for the Agency to coordinate a program for diagnosing, preventing and treating cancer.

The mandates of the Saskatchewan Ministry of Health, provincial health authority, and the Saskatchewan Cancer Agency are outlined in the Health Administration Act, the Provincial Health Authority Act and the Cancer Agency Act.

No amendments were made to these Acts during 2019-2020.

1.2 Reporting Relationship

The Ministry of Health is directly accountable, and regularly reports, to the Minister on the funding, and administering the funds, for insured physician, surgical-dental and hospital services.

Section 36 of the Saskatchewan Medical Care Insurance Act requires that the Minister submit an annual report concerning the medical care insurance plan to the Legislative Assembly.

The Provincial Health Authority Act requires that the provincial health authority submit to the Minister:

Pursuant to legislation, the Minister submits these reports and corresponding statements to the Legislative Assembly.

Section 7-4 of the Provincial Health Authority Act requires that the provincial health authority and the Cancer Agency submit any reports that the Minister may request from time to time. The provincial health authority and the Cancer Agency are required to submit various financial documents and a health service plan to the Ministry.

1.3 Audit of Accounts

The Provincial Auditor conducts an annual audit of government ministries and agencies, including the Ministry. The audit of the Ministry includes a review of Ministry payments including, but not limited to, payments made to the Saskatchewan Health Authority (SHA), the Saskatchewan Cancer Agency (SCA), and physicians and dental surgeons for insured physician and surgical-dental services.

Section 7-7 of the Provincial Health Authority Act requires that an independent auditor, who possesses the prescribed qualification and is appointed for that purpose by the SHA and the SCA, audit the accounts of the SHA or the SCA at least once in every fiscal year. The SHA and the SCA must annually submit to the Minister a detailed, audited set of financial statements.

The most recent audits were for the year ending March 31, 2020. The SHA and SCA each table annual reports in the Saskatchewan Legislature each year which include their audited financial statements. The Government of Saskatchewan tables its audited financial statements (Public Accounts) in the Legislature each year as well. The reports are available to the public directly from each entity and are available on their websites.

The Office of the Provincial Auditor for Saskatchewan provides independent assurance (audit reports) and advice on the Government's management of and accountability practices for the public resources entrusted to it. They inform the Legislative Assembly about the reliability of the Government's financial and operational information, the Government's compliance with legislative authorities and the adequacy of the Government's management of public resources. Their reports are available on the Provincial Auditor of Saskatchewan site. The most recent report was released December 8, 2020 and examined the SHA and eHealth Saskatchewan.

The SHA and Saskatchewan Cancer Agency each table annual reports in the Saskatchewan Legislature each year, which include their audited financial statements. The Government of Saskatchewan tables its audited financial statements (Public Accounts) in the Legislature each year as well. The reports are available to the public directly from each entity and are available on their websites. The annual reporting requirements for the provincial health authority are specified in Section 7.5 of the Provincial Health Authority Act. 

2.0 Comprehensiveness

2.1 Insured Hospital Services

Section 2-7 of the Provincial Health Authority Act gives the Saskatchewan Minister of Health (the Minister) the authority to provide funding to the provincial health authority or a health care organization for the purpose of the Act. There were no amendments made to the Act in 2019-2020.

Section 2-9 of the Act permits the Minister to designate facilities including hospitals, special care homes and health centres. Section 2-10 allows the Minister to prescribe standards for delivering services in those facilities in the provincial health authority, including health care organizations that have entered into service agreements with the provincial health authority.

The Act sets out the accountability requirements for the provincial health authority and health care organizations. These requirements include, for example, submitting annual financial and health service plans for ministerial approval (section 7-2), and reporting critical incidents (section 8-2). The Minister also has the authority to establish a provincial surgical registry to help manage surgical wait times (section 2-11). The Minister retains authority to inquire into matters (section 8-3), appoint a public administrator if necessary (section 8-4), and approve general and practitioner staff by-laws (sections 6-1 to 6-3).

Funding for hospitals is included in the funding provided to the provincial health authority. A comprehensive range of insured services is provided by hospitals. These may include:

Hospitals are grouped into the following six categories: community or northern, district, regional, provincial, rehabilitation, and field. The hospitals are grouped this way so that people know what they can expect at each hospital. While not all hospitals will offer the same services, reliability and predictability means:

The provincial health authority has the authority to change the manner in which they deliver insured hospital services based on an assessment of their population health needs, available health providers and financial resources.

The process for adding a hospital service to the list of services covered by the health care insurance plan involves a comprehensive review, which takes into account such factors as service need, anticipated service volume, health outcomes by the proposed and alternative services, cost and human resource requirements, including availability of providers as well as initial and ongoing competency assurance demands. Typically the provincial health authority initiates the process and, depending on the specific service request, it could include consultations involving several branches within the Ministry of Health as well as external stakeholder groups such as service providers and the public. No new hospital services were added to the health care insurance plan in 2019-2020.

2.2 Insured Physician Services

Sections 8 and 9 of the Saskatchewan Medical Care Insurance Act enable the Minister of Health to establish and administer a plan of medical care insurance for provincial residents. There were no amendments to the Act in 2019-2020. All insured fee items for physicians can be found in the Physician Payment Schedule. As of March 31, 2020, there were 2,622 physicians licensed to practise in the province and eligible to participate in the Medical Care Insurance Plan. Of these, 1,330 (50.7 per cent) were family practitioners and 1,292 (49.3 per cent) were specialists. Physicians may choose to not participate in the Medical Services Plan (known in Saskatchewan legislation as opting-out), but if doing so, they must fully opt out of all insured physician services. As per legislation the non-participating physician must also advise beneficiaries that the physician services to be provided are not insured and that the beneficiary is not entitled to be reimbursed for those services. Written acknowledgement from the beneficiary indicating that he or she understands the advice given by the physician is also required.

As of March 31, 2020, there were no non-participating physicians in Saskatchewan.

Insured physician services are those that are medically necessary, are covered by the Medical Services Plan of the Saskatchewan Ministry of Health, and are listed in the Physician Payment Schedule of the Saskatchewan Medical Care Insurance Payment Regulations (1994) of the Saskatchewan Medical Care Insurance Act.

A process of formal discussion and negotiation between the Medical Services Plan and the Saskatchewan Medical Association addresses new insured physician services and definition or assessment rule revisions to existing selected services. The Executive Director of the Medical Services Branch manages this process. When the Medical Services Plan covers a new insured physician service, or a change is made to an existing physician service, the changes are reflected in the Physician Payment Schedule. A regulatory amendment to the Saskatchewan Medical Care Insurance Payment Regulations is required to provide the authority to pay updated rates to physicians and new insured services.

Although formal public consultations are not held, any member of the public may make recommendations about physician services to be added to the Medical Services Plan.

2.3 Insured Surgical-Dental Services

Dentists may choose to not participate in the Medical Services Plan, but if doing so, they must opt out of all insured surgical-dental services. The non-participating dentist must also advise beneficiaries that the surgical-dental services to be provided are not insured and that the beneficiary is not entitled to reimbursement for those services, or advise the beneficiaries to seek services from a dental specialist who is participating. Written acknowledgement from the beneficiary indicating that he or she understands the advice given by the dentist is also required.

There was one non-participating general and specialist dentist in Saskatchewan as of October 15, 2020.

Insured surgical-dental services are limited to:

In addition, all dental anaesthetic for beneficiaries under age 14 is publicly funded.

Surgical-dental services can be added to the list of insured services covered under the Medical Services Plan through a process of negotiation with provincial dental surgeons. The Executive Director of the Medical Services Branch manages the process of adding a new service. Although formal public consultations are not held, any member of the public may recommend that surgical-dental services be added to the Medical Services Plan.

As of March 31, 2020, there were approximately 518 practicing dentists and dental surgeons located in all major centres in Saskatchewan. Seventy-six provided services insured under the Medical Services Plan.

2.4 Uninsured Hospital, Physician and Surgical-Dental Services

Uninsured hospital, physician and surgical-dental services in Saskatchewan include:

As a matter of policy and principle, insured hospital, physician and surgical-dental services are provided to residents on the basis of assessed clinical need. There are no charges allowed in Saskatchewan for insured hospital, physician or surgical-dental services. Charges for enhanced medical services or products are permitted only if the medical service or product is not deemed medically necessary and/or not deemed to be an insured service. Compliance is monitored through consultations with the provincial health authority, physicians and dentists, as well as via complaints from members of the public.

The Patient Choice Medical Imaging Act and The Medical Imaging Facilities Licensing Regulations authorize private MRI and CT facilities in Saskatchewan to accept payment directly from patients in exchange for MRI and CT services. However, for every scan that is paid for privately, the Regulations require private providers to provide a second scan, free of charge, to an individual who is waiting on the public list. Private-pay MRI service and its unique two-for-one provision gives patients more options in accessing MRI service and has added capacity to the publicly-funded system at no extra cost to the health system or the patient receiving the reciprocal scan. Along with increases in public capacity, through expanded hospital volumes, new CT and MRI scanners, and increased volumes in publicly funded contracts, these privately funded scans and second scans are assisting in the management of MRI wait times.

Insured hospital services are typically de-insured by the government if they were determined to be no longer medically necessary and/or clinically appropriate. The process involves discussions among stakeholders, practitioners, and officials from the Saskatchewan Ministry of Health.

Insured physician services could be de-insured if they were determined not to be medically required and/or clinically appropriate. The process involves consultations with the Saskatchewan Medical Association and managed by the Executive Director of the Medical Services Branch.

Insured surgical-dental services could be de-insured if they were determined not to be medically necessary and/or clinically appropriate. The process involves discussion and consultation with the dental surgeons of the province, and is managed by the Executive Director of the Medical Services Branch.

Formal public consultations about de-insuring hospital, physician or surgical-dental services may be held if warranted. There were no services de-insured during 2019-2020.

3.0 Universality

3.1 Eligibility

The Saskatchewan Medical Care Insurance Act (sections 2 and 12) and the Medical Care Insurance Beneficiary and Administration Regulations define eligibility for insured health services in Saskatchewan. Section 11 of the Act requires that all residents register for provincial health coverage.

While the Regulations set out classes of beneficiaries exempt from insured services under the Act, it is possible for individual residents to request that the Health Registry not issue a provincial health card in certain cases (e.g., for religious reasons).

Eligibility is limited to residents. A “resident” means a person who is legally entitled to remain in Canada, who makes his or her home and is ordinarily present in Saskatchewan, or any other person declared by the Lieutenant Governor-in-Council to be a resident. Canadian citizens and permanent residents of Canada relocating from within Canada to Saskatchewan are generally eligible for coverage on the first day of the third month following establishment of residency in Saskatchewan. There were no changes to residency requirements in 2019-2020.

Returning Canadian citizens, the families of returning members of the Canadian Forces, international students, and international workers are eligible for coverage on establishing residency in Saskatchewan, provided that residency is established before the first day of the third month following their admittance to Canada.

The following persons are not covered under Saskatchewan’s Medical Services Plan:

Such people become eligible for coverage as follows:

Individuals who are not successful when applying for a provincial health card may appeal the decision by submitting to Health Registries - eHealth Saskatchewan, a Saskatchewan Health Services Card Application—Appeal Form.

The number of persons registered for health services in Saskatchewan on June 30, 2019, was 1,216,490.

3.2 Other Categories of Individuals

Other categories of individuals who are eligible for insured health service coverage include persons allowed to enter and remain in Canada under authority of a work permit, study permit or Minister’s permit issued by Immigration, Refugees and Citizenship Canada. Their accompanying family may also be eligible for insured health service coverage.

Refugees are eligible on confirmation of Convention status or with a study or work permit, Minister’s permit or permanent resident or landed immigrant record.

People moving to Saskatchewan from outside of Canada may be eligible for Saskatchewan health converge on, or before, the first day of the third month after arriving in Canada, if among one of the follow groups:

4.0 Portability

4.1 Minimum Waiting Period

In general, insured persons from another province or territory who move to Saskatchewan are eligible on the first day of the third month following establishment of residency. However, where one spouse arrives in advance of the other, the eligibility for the initial arriving spouse is established on either a) the first day of the third month following arrival of the second spouse; or b) the first day of the thirteenth month following the establishment of residency by the first spouse. The second spouse would be eligible on the first day of the third month following arrival.

4.2 Coverage during Temporary Absences in Canada

Section 3 of the Medical Care Insurance Beneficiary and Administration Regulations of the Saskatchewan Medical Care Insurance Act prescribes the portability of health insurance provided to Saskatchewan residents while temporarily absent within Canada.

Residents of Saskatchewan are able to maintain health coverage during a period of temporary absence, conditional upon the registrant's intent to return to Saskatchewan residency.

In 2015–2016, Saskatchewan amended the Medical Care Insurance Beneficiary and Administration Regulations to increase the amount of time residents are allowed to be out-of-province while still maintaining their health care benefits. Residents are now able to maintain health coverage after spending a maximum of seven months outside of Saskatchewan. Residents were only allowed to be absent for a maximum of six months over any 12 month period before their health benefits were discontinued. The new policy took effect January 1, 2016.

Section 6.6 of the Health Administration Act provides the authority for paying in-patient hospital services to Saskatchewan beneficiaries temporarily residing outside the province. Section 10 of the Saskatchewan Medical Care Insurance Payment Regulations (1994) provides payment for physician services to Saskatchewan beneficiaries temporarily residing outside the province but within Canada. No amendments were made to the Act or the Regulations in 2019-2020.

Saskatchewan has bilateral reciprocal billing agreements with all provinces for hospital services. Quebec does not participate in reciprocal billing of physician services.

4.3 Coverage during Temporary Absences outside Canada

Section 3 of the Medical Care Insurance Beneficiary and Administration Regulations of the Saskatchewan Medical Care Insurance Act prescribes the portability of health insurance provided to Saskatchewan residents who are temporarily absent from Canada.

Residents of Saskatchewan are able to maintain health coverage during a period of temporary absence, conditional upon the registrant's intent to return to Saskatchewan residency.

Section 3 of the Medical Care Insurance Beneficiary and Administration Regulations provides open-ended temporary absence coverage for persons whose principal place of residence is in Saskatchewan, but who are not able to satisfy the annual five months physical presence requirement because the nature of their employment requires travel from place to place outside Canada (e.g., cruise line workers).

Section 6.6 of the Health Administration Act provides the authority under which a resident is eligible for health coverage when temporarily outside Canada. In summary, a resident is eligible for medically necessary hospital services at the rate of $100 per in-patient and $50 per out-patient visit per day. No amendments were made to the Regulations in 2019-2020.

4.4 Prior Approval Requirement

Out-of-Province

The Saskatchewan Ministry of Health covers most hospital and medical out-of-province care received by its residents in Canada through reciprocal billing arrangements. These arrangements mean that residents do not need prior approval and may not be billed for most hospital and medical services received within the publicly funded health care system in other provinces or territories while travelling within Canada. The cost of travel, meals and accommodation are not covered. Prior approval is required for the following services provided out-of-province:

Prior approval from the Saskatchewan Ministry of Health must be obtained by the patient's specialist before the out-of-province services are received.

Out-of-Country

If a specialist physician refers a patient outside Canada for treatment not available in Saskatchewan or another province, the referring specialist must obtain prior approval for coverage from the Medical Services Plan of the Saskatchewan Ministry of Health. The Saskatchewan Cancer Agency is consulted for out-of-country cancer treatment requests. If approved, the Saskatchewan Ministry of Health will pay the full cost of treatment, excluding any items that would not be covered in Saskatchewan.

In Saskatchewan, the Health Services Review Committee (HSRC) is an arms-length panel that reviews government decisions made on requests for out-of-province and out-of-country medical coverage, ensuring legislation, policy, and guidelines are followed appropriately.

The Ministry of Health informs eligible applicants of their right to request a review by the HSRC upon denial of their out-of-province or out-of-country coverage request. A person can request a review by the HSRC only if the coverage request was for out-of-province insured medical health services, elective out-of-country insured medical services (physician and hospital care) or community care programs (mental health, alcohol and drug, problem gambling, and rehabilitative services).

If a case is ineligible for HSRC or if HSRC upholds the Saskatchewan Ministry of Health's coverage decision, a person may contact the Provincial Ombudsman for their review.

5.0 Accessibility

5.1 Access to Insured Health Services

To ensure that access to insured hospital, physician and surgical-dental services is not impeded or precluded by financial barriers, extra-billing by physicians or dental surgeons, and user charges by hospitals for insured health services are not allowed in Saskatchewan.

Pursuant to section 18 (1.1) of the Saskatchewan Medical Care Insurance Act, no physician or other person who provides an insured service to a beneficiary shall demand or accept payment for that service in an amount that he knows exceeds the payment to be made for that service prescribed in the Saskatchewan Medical Care Insurance Regulations.

With regard to extra-billing and user charges, compliance is monitored through consultations with the provincial health authority, physicians and dentists, as well as complaints from members of the public. The Saskatchewan Ministry of Health's General Inquiry contact information is as follows:

Saskatchewan Ministry of Health
1-800-667-7766
info@health.gov.sk.ca

When requests are made by a beneficiary to reimburse monies paid directly to a physician for insured physician services that are extra-billing charges, correspondence is sent to the beneficiary (copying the physician) advising them of Section 18 (1.1) of the Saskatchewan Medical Care Insurance Payment Act that a physician must accept the negotiated rate as payment in full for insured services provided to a beneficiary. Once they have received payment from Medical Services Plan for the eligible service(s), reimbursement for any difference in the amount charged by the practitioner and the amount paid by Medical Services should be collected directly from the practitioner. If further complaint is made, the beneficiary is directed to address complaints to the Saskatchewan College of Physicians and Surgeons.

In addition, a private third-party facility must obtain a health facility license to provide certain insured services (e.g., surgical services) on behalf of the publicly funded health system. The Health Facilities Licensing Act (HFLA) or the Patient Choice Medical Imaging Act (PCMIA) authorizes and prescribes the conditions under which a health facility license may be issued to a private facility. The HFLA or PCMIA stipulate that a licensee may not charge or permit any other person to charge any fee to any beneficiary for any insured health service as defined under the HFLA or PCMIA.

Legislation prescribes that the Saskatchewan Minister of Health may amend, suspend or cancel a license if, in the opinion of the Minister, the licensee has failed to comply with the above clause.

Persons who have a complaint of an extra-billing and user charge may also raise the concern with the College of Physicians and Surgeons of Saskatchewan. The College has in their bylaws 7.1 Code of Ethics that includes:

Contravention of, or failure to comply with, the Code of Ethics is unbecoming, improper, unprofessional or discreditable conduct for the purposes of the Medical Care Insurance Act.

The health system continues to strengthen coordination, communication, and referral guidelines to better coordinate services to ensure patients have timely access to the most appropriate specialist and diagnostic services. By reducing the wait time for a consult with a specialist or diagnostic services (such as MRI and CTs), patients will be able to access treatment sooner.

Other Programs and Initiatives to Improve Access

The Family Physician Comprehensive Care Program is intended to support recruitment and retention of family physicians by recognizing those physicians who provide a full range of services to their patients and the continuity of care that result from these comprehensive services.

Leveraging Immediate Non-Urgent Knowledge (LINK) is a provincial telephone consultation service that allows primary care providers to consult with a specialist about serious and/or complex non-urgent patient health concerns. LINK helps patients get answers to their health concerns sooner, prevents unnecessary referrals and supports better referrals to the right specialist when required.

Specialist's wait times can vary for a variety of reasons and can result in two patients with the same condition and acuity having very different wait times. Pooled referrals offer referring physicians and their patients more choices to reduce wait times and improve patient access. Pooled referral systems direct patients to the next available specialist able to treat the patient's condition yet still allow physicians to make direct referrals to a specific specialist using the same referral process.

Saskatchewan's online Specialist Directory makes it easier to find current surgical wait times and information about surgical specialists in Saskatchewan. It can help patients and their family doctors view their options for surgical services and help them to easily identify the most appropriate surgeon for them. One of the many benefits is it can enable patients who are willing to travel to have the surgery more quickly in a location other than their nearest surgical centre.

5.2 Physician Compensation

Section 6 of the Saskatchewan Medical Care Insurance Payment Regulations (1994) outlines the obligation of the Minister of Health to make payments for insured services in accordance with the Physician Payment Schedule and the Dentist Payment Schedule.

Fee-for-service is the most widely used method of compensating physicians for insured health services in Saskatchewan, although sessional payments, salary, and blended methods are also used. Fee-for-service is the only mechanism used to fund dentists for insured surgical-dental services. Total expenditures for in-province physician services and programs in 2019-2020 amounted to $1.051 billion: $556.4 million for fee-for-service billings; $32.9 million for Specialist Emergency Coverage Programs; and $395.3 million in non-fee-for-service expenditures. There was also an additional $65.8 million for the Clinical Services Fund and other Saskatchewan Medical Association and bursary programs.

The Saskatchewan Joint Medical Professional Review Committee (JMPRC) is a physician peer-review Committee that was established by section 49 of The Saskatchewan Medical Care Insurance Act (1988) to review the billing patterns of Saskatchewan physicians who are directly billing the publicly funded system for insured services. The JMPRC reviews billing patterns of physicians referred by the Director of Professional Review of the Ministry of Health and in cases where they determine that monies have been paid by the Minister inappropriately, they may order recovery from the physician.

Saskatchewan physicians do not charge block fees.

5.3 Payments to Hospitals

Funding to the Saskatchewan Health Authority (SHA) takes into account status quo funding levels and is adjusted for inflation, utilization increases, collective agreement increases, new programs and other adjustments as outlined in the current year provincial budget. The SHA is given a global budget and is responsible for allocating funds within that budget to address service needs and priorities identified through its needs assessment processes. The SHA may receive additional funds for providing specialized hospital programs and services (e.g., renal dialysis, medical imaging, respiratory, surgical and mental health and addictions services).

Payments to the SHA for delivering services are made pursuant to section 2-7 of the Provincial Health Authority Act. The legislation provides the authority for the Minister of Health to make grants to the SHA and health care organizations for the purposes of the Act, and to arrange for providing services in any area of Saskatchewan if it is in the public interest to do so.

The SHA provides an annual report on the aggregate financial results of its operations.

6.0 Recognition Given to Federal Transfers

Federal contributions provided through the Canada Health Transfer are publicly acknowledged by the Government of Saskatchewan in:

These documents were tabled in the Legislative Assembly and are publicly available to Saskatchewan residents. Federal contributions have also been acknowledged in news releases and issue papers, and in speeches and remarks made at various conferences, meetings and public policy forums.

Registered Persons
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
1. Number as of March 31st 1,154,257 1,176,932 1,199,429 1,196,842Saskatchewan table 1 Footnote 1 1,216,490Saskatchewan table 1 Footnote 1
Saskachewan table 1 Footnote 1

Saskatchewan's numbers as of June 30, 2019.

Saskatchewan table 1 Return to footnote 1 referrer
Insured Hospital Services Within Own Province or Territory
Public Facilities 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
2. Number 66 66 66 66 66
3. Payments for insured health services ($)
 1,943,748,000 1,976,162,750 1,968,702,500Saskatchewan table 2 Footnote 1 2,067,238,750Saskatchewan table 2 Footnote 1 2,141,445,000Saskatchewan table 2 Footnote 1
Private For-Profit Facilities 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
4. Number of private for-profit facilities providing insured health services 5 5 6 6 6
5. Payments to private for-profit facilities for insured health services ($)  Not available Not availableSaskatchewan table 2 Footnote 2 Not availableSaskatchewan table 2 Footnote 2 Not availableSaskatchewan table 2 Footnote 2 Not availableSaskatchewan table 2 Footnote 2
Saskatchewan table 2 Footnote 1

As reported by the Saskatchewan Health Authority in their annual audited financial statements.

  • Includes acute care services, specialized hospital services, and in-hospital specialist services.
  • Does not include in-patient mental health or addiction treatment services.
  • Does not include payments to Saskatchewan Cancer Agency for out-patient chemotherapy and radiation.
  • Physician compensation is included under the appropriate functional areas.

Saskatchewan table 2 Return to footnote 1 referrer

Saskatchewan table 2 Footnote 2

CT and MRI services are not considered insured services in Saskatchewan within the meaning of the Saskatchewan Medical Care Insurance Act. Private facilities providing surgical, MRI and CT services may receive payments for these services under contract with the provincial health authority. The Ministry of Health does not directly provide payments to these facilities.

Saskatchewan table 2 Return to footnote 2 referrer
Insured Hospital Services Provided to Residents in Another Province or TerritorySaskatchewan table 3 Footnote 1
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
6. Total number of cases, in-patient 4,923 4,376 4,277 4,174 3,991
7. Total payments, in-patient ($) 67,838,500 49,817,000 54,776,000 64,494,900 55,922,600
8. Total number of cases, out-patient 77,250 68,995 71,933 72,192 74,539
9. Total payments, out-patient ($) 28,739,900 27,218,000 28,957,000 29,364,100 30,332,600
Saskatchewan table 3 Footnote 1

Data for prior years has been re-stated to reflect total number of hospital cases rather than claims as a single hospitalization can result in numerous claims.

Saskatchewan table 3 Return to footnote 1 referrer
Insured Hospital Services Provided Outside CanadaSaskatchewan table 4 Footnote 1
Pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
10. Total number of cases, pre-approved in-patient 7 5 2 7 8
11. Total payments, pre-approved  in-patient ($) 1,096,600 933,300 37,900 3,078,800 1,855,300
12. Total number of cases, pre-approved out-patient 176 52 53 218 216
13. Total payments, pre-approved out-patient ($) 1,066,600 405,900 269,600 2,055,800 1,433,700
Non Pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
14. Total number of cases, non pre-approved in-patient 344 335 308 317 283
15. Total payments, non pre-approved    in-patient ($) 203,100 116,700 248,800 193,800 2,431,900
16. Total number of cases, non pre-approved out-patient 1,403 1,285 1,191 1,244 920
17. Total payments, non pre-approved out-patient ($) 69,700 62,200 58,700 69,400 45,200
Saskatchewan table 4 Footnote 1

Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report,but did not require provinces or territories to report on previous years.

Saskatchewan table 4 Return to footnote 1 referrer
Insured Physician Services Within Own Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
18. Number of participating physicians 2,375 2,491 2,560 2,600 2,622
19. Number of opted-out physicians 0 0 0 0 0
20. Number of non-participating physicians 0 0 0 0 0
21. Total payments for services provided by physicians paid through all payment methods ($) 941,409,025 982,568,484 997,950,125 1,009,110,700 1,050,449,400
22. Total payments for services provided by physicians paid through fee-for-service ($) 535,162,606 557,334,395 561,557,167Saskatchewan table 5 Footnote 1 556,831,300Saskatchewan table 5 Footnote 1 556,434,500Saskatchewan table 5 Footnote 1
Saskatchewan table 5 Footnote 1

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.

Saskatchewan table 5 Return to footnote 1 referrer
Insured Physician Services Provided to Residents in Another Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
23. Number of services 753,736 785,072 740,342 757,219 770,674
24. Total payments ($) 40,339,800 42,855,888 41,691,900 42,976,000 44,549,700
Insured Physician Services Provided Outside CanadaSaskatchewan table 7 Footnote 1
Pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
25. Number of pre-approved services Not  available Not  available Not  available 596 764
26. Total pre-approved payments ($) Not  available Not  available Not  available 500,368 747,889
Non Pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
27. Number of non pre-approved services Not  available Not  available Not  available 4,906 4,817
28. Total non pre-approved payments ($) Not  available Not  available Not  available 274,585 289,000
Saskatchewan table 7 Footnote 1

Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report, but did not require provinces or territories to report on previous years.

Saskatchewan table 7 Return to footnote 1 referrer
Insured Surgical-Dental Services Within Own Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
29. Number of participating dentists 79 78 78 88 76
30. Number of opted-out dentistsSaskatchewan table 8 Footnote 1 Not  available 0 0 0 0
31. Number of non-participating dentistsSaskatchewan table 8 Footnote 1 Not  available 0 0 0 1
32. Number of services provided 18,777 13,139 11,550 10,916 12,656
33. Total payments ($) 2,146,101 1,688,771 1,516,900 1,529,800 1,565,900
Saskatchewan table 8 Footnote 1

Health Canada requested this data as of the 2016-2017 report, but did not require provinces or territories to report 2015-16 data.

Saskatchewan table 8 Return to footnote 1 referrer

Alberta

The Minister of Health, the Department of Health (Alberta Health) and the Regional Health Authority (Alberta Health Services) play key roles in Alberta's health care system. All persons and entities work together to provide safe, high quality and universally accessible, publicly funded health care services for Albertans.

COVID-19 Measures   

As COVID-19 began to impact the entire health system in Alberta, many measures were initiated to adapt and respond to the pandemic. Early in the pandemic, Alberta Health Services established a leading testing program, procured personal protective equipment and set aside acute care capacity to respond to a range of COVID-19 scenarios. In March 2020, health service billing codes for practitioners delivering health care through means other than face-to-face interactions were activated and non-urgent surgical procedures undertaken in hospitals and chartered surgical facilities were paused. Up-to-date information about changes made to Alberta Health Care Insurance Plan (AHCIP) coverage as part of Alberta's pandemic response is available through the AHCIP website, including coverage for temporary residents.

With the benefit of expert advice from Alberta's Chief Medical Officer of Health, public health measures were put in place that minimized the spread of COVID-19, while balancing the economic impact. Alberta has one of the highest testing rates in the world; ongoing testing and contact tracing has enabled the province to:

1.0 Public Administration

1.1 Health Care Insurance Plan and Public Authority

Alberta Health administers and operates the Alberta Health Care Insurance Plan (AHCIP), in accordance with the Canada Health Act. Since 1969, the Alberta Health Care Insurance Act (AHCIA), which is available on the Alberta Queen's Printer website, has governed the operation of the AHCIP. Alberta Health sets policy and direction to achieve a sustainable and accountable health system to promote and protect the health of Albertans. Section 3 of the AHCIA enables the AHCIP and designates the Alberta Minister of Health, as the public authority responsible for the administration and operation of the AHCIP.

1.2 Reporting Relationship

The Alberta Minister of Health (the Minister) is accountable for the AHCIP. The Minister, as the public authority responsible for the administration and operation of the AHCIP, is required under the AHCIA to administer and operate the AHCIP on a non-profit basis, in accordance with the AHCIA and the regulations to provide benefits for basic health services to all residents of Alberta. The legislation includes a number of accountability measures relating to the administration and operation of the AHCIP including provisions that enable the Minister to audit and review claims for benefits and recover overpayments to practitioners.

The Fiscal Planning and Transparency Act (FPTA), which is available on the Alberta Queen's Printer website, provides a framework for government budgeting and fiscal planning. A ministry annual report is prepared under the direction of the Minister in accordance with the FPTA and the government's accounting policies. The 2019-2020 Annual Report of the Ministry of Health, covering the fiscal year April 1, 2019 to March 31, 2020, was released to the public on August 27, 2020.  

1.3 Audit of Accounts

The Auditor General of Alberta is an independent office responsible for conducting annual financial audits and other audits pertaining to the government's management of public resources. In accordance with Alberta's Auditor General Act, audit reports are tabled with the Legislative Assembly. The Auditor General's opinion on the audit of the province's consolidated financial statements, which includes the financial transactions and other information of the Ministry of Health, was published on August 27, 2020, in the Government of Alberta's 2019-2020 annual report. The report indicated that the consolidated financial statements present fairly, in all material respects, the financial position and results of operations for the year ended March 31, 2020.

2.0 Comprehensiveness

2.1 Insured Hospital Services

In Alberta, Alberta Health Services (AHS) is the entity responsible to the Minister for ensuring the provision of insured hospital services. The Hospitals Act, the Hospitalization Benefits Regulation (AR 244/1990), the Health Care Protection Act (HCPA) and the Health Care Protection Regulation (HCPR) govern the provision of insured services by hospitals or chartered surgical facilities. After the reporting period, in July 2020, the Health Facilities Act (HFA) and Health Facilities Regulation (AR 208/2000), which are available on the Alberta Queen's Printer website, replaced the HCPA and HCPR. The new title of the HFA better reflects the purpose and nature of the Act.

During 2019-2020, no amendments were made to the legislation regarding insured hospital services. A directory of approved hospitals in Alberta is available online.

The publicly funded services provided by approved hospitals in Alberta include all of the hospital services listed in the Canada Health Act. The insured hospital services range from advanced levels of diagnostic and treatment services for in-patients and out-patients, to routine care and management of patients with previously diagnosed chronic conditions. The benefits available to hospital patients in Alberta are established in the Hospitalization Benefits Regulation. The Regulation is available on the Alberta Queen's Printer website.

The list of insured services included in the Regulations is intended to be both comprehensive and generic, thereby limiting the need for routine review and updating. No new services were added during 2019-2020 to the insured hospital services covered by the Alberta Health Care Insurance Plan (AHCIP).

Computerized Tomography (CT) and Magnetic Resonance Imaging (MRI) diagnostic procedures are not considered insured services under the Schedule of Medical Benefits but are publicly funded and provided to eligible Albertans by AHS at an AHS or AHS contracted facility. AHS has a system that sets priorities and manages wait times. If a patient chooses to attend a private diagnostic clinic and self pay, AHS has a process for reimbursement if criteria are met.

2.2 Insured Physician Services

The Alberta Health Care Insurance Act (AHCIA) governs the payment to physicians for insured physician services under section 6. Only physicians who meet the requirements stated in the AHCIA are permitted to make a claim for payment of benefits for providing insured services under the AHCIP.

Alberta had 10,618 physicians participating under the AHCIP as of March 31, 2020. Within this, 8,721 physicians were paid exclusively under fee-for-service, 884 were compensated solely through an Alternative Relationship Plan, and the remaining 1,013 physicians received compensation from both fee-for-service and through an Alternative Relationship Plan. As of March 31, 2020, there were two non-participating physicians in the province.

Before being registered with the AHCIP, a physician must complete the appropriate registration forms and include a copy of the licence issued to them by the College of Physicians and Surgeons of Alberta.

Under section 8 of the AHCIA, all physicians are deemed to participate in the AHCIP. Under section 8(2), a physician may choose to not participate in the AHCIP by taking the following actions at least 180 days prior to the effective date of not participating: a) notifying the Minister of Health in writing indicating the effective date of not participating, b) publishing a notice of the proposed non-participation in a newspaper having general circulation in the area in which the physician practises, and c) posting a notice of the proposed non-participation in a part of the physician's office to which patients have access.

Legal requirements are set out in section 8(3) of the AHCIA for a physician who has not previously practised in Alberta. Under section 8(3) the physician may choose to not participate in the AHCIP prior to commencing practice by: (a) notifying the Minister in writing indicating the date on which the physician will commence non-participating practice, and (b) publishing a notice of the proposed non-participation in a newspaper having general circulation in the area in which the physician intends to practise.

By not participating in the AHCIP, a physician agrees that, commencing on the effective date, they will not participate in the publicly funded health system. This means that the physician cannot make a claim from the AHCIP for payment for providing what would otherwise be insured health services and the patient cannot seek reimbursement for any amounts paid by the patient for receiving health services from the non-participating physician.

Section 12 of the Alberta Health Care Insurance Regulation (AR 76/2006) lists services that are not considered basic or extended health services. The Medical Benefits Regulation (AR 84/2006) establishes the benefits payable for insured medical services provided to a resident of Alberta. Descriptions of those services are set out in the Schedule of Medical Benefits.

The Ministry of Health is committed to having a Schedule of Medical Benefits that supports continuous improvement and is responsive to health reform. The medical community is continuously consulted and health services codes are created to ensure the schedule reflects the current standard of practice within Alberta. There is no public consultation. All changes to the benefit schedule require the approval of the Minister of Health.

During 2019-2020, new virtual care health service codes were added to the Schedule of Medical Benefits to ensure continuation of essential medical services during the COVID-19 pandemic. Effective March 12, 2020, the Ministry of Health activated health service code 03.01AD (telephone advice to a patient or their agent, during a viral epidemic). This health service code was previously active during the H1N1 epidemic. On March 17, 2020, a further six health services codes were added to the Schedule to cover telephone and videoconference visits, consultations, and mental health services (psychotherapy) with a family physician or specialist. Prior to the introduction of these health service codes, the Schedule already contained codes for physician to patient telephone calls, videoconferences, and secure electronic communications. These pre-existing health service codes were intended for follow-up patient management such as the communication of test results. However, the new health service codes are designed to replicate an in-person assessment. 

2.3 Insured Surgical-Dental Services

In Alberta, a small number of medically necessary oral surgical and dental procedures are insured. These are listed in the Schedule of Oral and Maxillofacial Surgery Benefits. In 2019-2020, no updates were made to this schedule.

The majority of dental procedures that can be billed to the AHCIP can only be performed by a dentist certified as an oral and maxillofacial surgeon who meets the requirements stated in the AHCIA. Insured dental-surgical services must be performed in either a public hospital or a chartered surgical facility. Major surgical services, as described in section 2(2) (b) of the HFA, may only be provided in a public hospital. As of March 31, 2020, there were 219 dentists participating under the AHCIP for eligible dental procedures and no dentists were opted-out of the AHCIP. Routine dental care is not covered by the AHCIP.

Although there is no formal agreement with dentists, the Ministry of Health meets with members of the Alberta Dental Association and College to discuss changes to the Schedule of Oral and Maxillofacial Surgery Benefits. There is no public consultation. All changes to the benefit schedule require the approval of the Minister of Health.

Under section 7 of the AHCIA, all dentists are deemed to participate in the AHCIP. Under section 7(2), a dentist may choose to opt out of the AHCIP by taking the following actions at least 30 days prior to the effective date of opting out: (a) notifying the Minister in writing indicating the effective date of not participating; (b) publishing a notice of the proposed non-participation in a newspaper having general circulation in the area in which the dentist practises; and, (c) posting a notice of the proposed non-participation in a part of the dentist's office to which patients have access. Legal requirements are set out in section 7(3) of the AHCIA for a dentist who has not previously practised in Alberta. Under section 7(3), the dentist may choose to not participate in the AHCIP prior to commencing practice by (a) notifying the Minister in writing indicating the date on which the dentist will commence non-participating practice, and (b) publishing a notice of the proposed non-participation in a newspaper having general circulation in the area in which the dentist intends to practise.

By choosing to not participate in the AHCIP, a dentist agrees that, commencing on the effective date, they will not participate in the publicly funded health system. This means that the dentist cannot make a claim from the AHCIP for payment for providing what would otherwise be publicly funded surgical-dental services and the patient cannot seek reimbursement for any amounts paid by the patient for receiving surgical-dental services from the non-participating dentist.

2.4 Uninsured Hospital, Physician, and Surgical-Dental Services

Section 12 of the Alberta Health Care Insurance Regulation lists services that are not considered basic or extended health services unless otherwise approved by the Minister of Health. Section 4(2) and section 5(2) of the Oral and Maxillofacial Surgery Benefits Regulation (AR 86/2006) indicate no benefits are payable for oral and maxillofacial surgery services provided to an Alberta resident in another province or territory of Canada or outside of Canada if they are not insured services in Alberta. Section 4(2) of the Hospitalization Benefits Regulation provides a list of hospital services that are not considered to be insured.

Services not covered by the AHCIP include:

The Preferred Accommodation and Non-Standard Goods or Services Policy describes the Government of Alberta's expectations of AHS and guides the provision of preferred accommodation and enhanced or non-standard goods and services. This policy framework requires AHS to provide 30 days advance notice to the Minister of Health's designate regarding the categories of preferred accommodation offered and the charges associated with each category. AHS is also required to provide 30 days advance notice to the Minister of Health's designate regarding any goods or services that will be provided as non-standard goods or services. AHS must also provide information about the associated charge for these goods or services, and when applicable, the criteria or clinical indications that may qualify patients to receive it as a standard good or service. Alberta's policy for Preferred Accommodation and Non-Standard Goods or Services is available online.

Health services that are deleted from the Schedule of Medical Benefits are those services that the medical community has identified as obsolete. The process to engage the medical community is completed through consultation with the Alberta Medical Association and AHS. The Alberta Medical Association acts as the representative for each physician section. AHS is engaged in this decision process in order to understand how changes may impact current service delivery models or the health system at a macro level.

Effective March 31, 2020, Alberta de-insured the medical examination, including completion of a form, required to obtain or renew an operator's license, where the patient is 74.5 years of age or older. This service was never insured for patients under 74.5 years of age. Also effective March 31, 2020, one health service code was de-listed as the activity was included under another insured health service code.

3.0 Universality

3.1 Eligibility

Under the terms of the Alberta Health Care Insurance Act (AHCIA), Alberta residents are eligible to receive publicly funded health care services under the Alberta Health Care Insurance Plan (AHCIP). There were no changes made to eligibility requirements for the AHCIP in 2019-20.

A resident is defined as a person who is lawfully entitled to be or to remain in Canada, who makes the province their home and is ordinarily present in Alberta, and any other person deemed by the regulations to be a resident. The term "resident" does not include a tourist, transient or visitor to Alberta.

Persons moving permanently to Alberta from outside Canada are eligible for coverage if they have permanent resident status, are returning permanent residents , or are returning Canadian citizens. Persons residing in Alberta on an approved Canada entry document may also be eligible for coverage under the AHCIP, and their eligibility is reviewed on a case-by-case basis.

A resident is not entitled to AHCIP coverage if the resident is a member of the Canadian Armed Forces or a person serving a term in a federal penitentiary as defined in the Corrections and Conditional Release Act. These residents receive health care coverage from the federal government. Spouses or partners and dependants of these residents are provided with AHCIP coverage if they are Alberta residents.

The AHCIP will cover individuals released within Alberta from the Canadian Armed Forces or federal penitentiaries, effective the date of release, if notified within three months. If individuals are released in another part of Canada, they are eligible for coverage on the first day of the third month after becoming a resident of Alberta.

In order to access insured services under the AHCIP, Alberta residents are required to register themselves and their eligible dependants. Family members are registered on the same account. Persons moving to Alberta should apply for coverage within three months of arrival or effective dates may be affected. For persons moving to Alberta from within Canada, their registration is effective on the first day of the third month after they become an Alberta resident. For persons moving to Alberta from outside Canada, their registration is effective the day they become an Alberta resident. The process for registering Albertans requires registrants to provide documentation that proves their identity, legal entitlement to be in Canada, and Alberta residency.

When a cancellation or denial of AHCIP coverage is questioned, an individual may contact the AHCIP by phone, e-mail, or mail to discuss the issue. If it cannot be resolved by front-line staff, it is escalated to a supervisor, then a manager, if needed. The manager will conduct a thorough investigation and send a letter with reasons for the decision, as it relates to legislation.

Individuals can choose not to participate in the AHCIP by filing a “Declaration of Election to Opt Out” at any time for themselves and their dependants. Coverage is cancelled for 36 months or until the declaration is revoked by the individual. A new declaration is required every 36 months of non-participation.

As of March 31, 2020, there were 4,783,609 Alberta residents registered with the AHCIP and 214 Alberta residents who were non-participants.

3.2 Other Categories of Individuals

Under the Alberta Health Care Insurance Regulation, a person may be deemed a resident for the purpose of AHCIP coverage if they are residing in Alberta to work, study, or are the spouse or partner or dependant of someone who is here to work or study. A Canada Entry Document such as a Work Permit or Study Permit, is required as proof of their legal entitlement to be, and remain, in Canada. Dependants accompanying temporary residents on a Work or Study Permit must have a Visitor Record (that limits the length of stay) as proof of their legal entitlement to be, and remain, in Canada. Deemed residents must intend on residing in Alberta for 12 months or more. AHCIP coverage is provided to temporary residents and their accompanying dependants who meet all the eligibility requirements. There were 75,110 people covered by the AHCIP under these conditions as of March 31, 2020.

Individuals who hold a Study Permit that does not indicate a school in Alberta are required to provide proof of registration from the accredited school they are attending. Open or employer-specific work permits must be valid for six months or more. Employer-specific work permits must state the individual is employed by a company operating in Alberta. With the exception of clergy, athletes or members of the British army, individuals with a Visitor Record must be the spouse, partner or dependant of an eligible resident or deemed resident.

Individuals with a Canada Entry Document that has the remark 'does not confirm resident status', are not eligible for AHCIP coverage. Permanent Residents who have proof of Permanent Resident Status and Convention Refugees who have a positive Notice of Decision letter are eligible for AHCIP coverage. Refugee claimants are not eligible.

Children of non-entitled residents (e.g., residents on a Visitor Record, with expired permits, or refugee claimants) who are born in Canada and meet residency requirements are eligible for AHCIP coverage. Children born to Canadian citizens who are temporarily absent from Alberta (and have maintained their coverage) are also eligible; however, documentation may be required.

Seasonal workers from outside Canada are considered Temporary Foreign Workers. To obtain AHCIP coverage, they must meet the definition of deemed resident, have a Work Permit as proof of their legal entitlement to be, and remain, in Canada and intend on residing in Alberta for 12 months or more. Seasonal workers from other provinces retain health coverage from their home province.

Returning Canadians whose residency has expired must provide evidence of their legal entitlement to be, and remain, in Canada (typically a permanent resident card) and meet residency requirements to be eligible for AHCIP coverage. Individuals who have applied for Permanent Resident status must maintain legal entitlement to be, and remain in Canada, (for example, a valid Work Permit, Study Permit or Visitor Record) while they await a decision on the Permanent Resident application. During this period, AHCIP coverage may be granted if they meet the eligibility requirements for a deemed resident.

4.0 Portability

4.1 Minimum Waiting Period

Under the Alberta Health Care Insurance Plan (AHCIP), generally, persons moving permanently to Alberta from another part of Canada are eligible for coverage on the first day of the third month following the date they establish residency in Alberta.

4.2 Coverage during Temporary Absences in Canada

The AHCIP provides coverage under the Alberta Health Care Insurance Regulation for eligible Alberta residents who temporarily leave Alberta for other parts of Canada.

A person is considered temporarily absent from Alberta if the person stays in another province or territory for a period that will not exceed 12 consecutive months and where the person intends to return to and maintain permanent residence in Alberta on the conclusion of their stay outside Alberta. Albertan students who attend an accredited school in Canada, and who intend to return to Alberta after completing their studies, maintain their AHCIP coverage.

Temporary Foreign Workers who are deemed residents retain their AHCIP coverage if they travel to another Canadian province for vacation; however, they do not retain their coverage if they leave Alberta to work in another province or if they leave Canada.

Individuals who are routinely absent from Alberta every year normally must spend a cumulative total of 183 days in a 12-month period in Alberta to maintain continuous coverage. Individuals not present in Alberta for the required 183 days may be considered residents of Alberta if they satisfy the Ministry of Health of their permanent and principal place of residence within the province. Individuals may also remain eligible for coverage if, on a recurring basis, they are absent from Alberta for up to 212 days in a 12-month period for the purpose of vacation.

Alberta participates in interprovincial hospital and medical reciprocal billing agreements. All provinces and territories, except Quebec, participate in medical reciprocal agreements. These agreements were established to minimize complex billing processes and to help ensure timely payments to physicians and hospitals when they provide services to residents from other provinces or territories. Under the agreements, where an eligible Albertan receives an insured physician service or hospital service in another participating province or territory, Alberta will reimburse for the insured service provided at the host province's or territory's rates for medical services and the applicable rate for hospital services.

In 2019-2020, no amendments were made to the legislation regarding portability within Canada. More information on coverage during temporary absences outside Alberta is available online.

Section 16 of the Hospitalization Benefits Regulation addresses payment for hospital services obtained outside of Alberta but within Canada. Section 4 of the Medical Benefits Regulation addresses payment of physician services obtained outside of Alberta but within Canada. These sections were not amended in 2019-2020.

4.3 Coverage during Temporary Absences outside Canada

The AHCIP provides coverage under the Alberta Health Care Insurance Regulation to eligible Alberta residents who are temporarily absent from Canada.

A person is considered to be temporarily absent from Alberta if the person stays outside Canada for a period that will not exceed six consecutive months, and the person intends to return to and maintain permanent residence in Alberta on the conclusion of their stay outside Alberta.

Individuals who are routinely absent from Alberta every year normally must spend a cumulative total of 183 days in a 12-month period in Alberta to maintain continuous coverage. Exceptions may be considered by the Ministry of Health depending on the individual circumstance. Individuals may also remain eligible for coverage if, on a recurring basis, they are absent from Alberta for up to 212 days in a 12-month period for the purpose of vacation.

Individuals leaving the province temporarily on extended vacations, or for temporary employment, may be eligible for coverage for 24 to 48 consecutive months. Students attending an accredited educational institute outside Canada on a full-time basis are entitled to coverage for the duration of their studies providing they intend to reside in Alberta at the conclusion of their studies.

The maximum amount payable for out-of-country in-patient hospital services is $100 (CAD) per day (not including day of discharge). The maximum hospital out-patient visit rate is $50 (CAD), with a limit of one visit per day. The only exception is haemodialysis received as an out-patient, which is paid at a maximum of $496 (CAD) per visit, with a limit of one visit per day. Physician and dental specialist or oral surgeon services are paid according to Alberta rates as per the Schedule of Medical Benefits. Funding may also be available through the Out-of-Country Health Services Committee. The committee evaluates requests made by Alberta physicians or dentists for eligible Alberta residents to be considered for funding of insured services covered under the AHCIP that are not available in Canada.

More information on coverage during temporary absences outside Canada is available online.

Section 16 of the Hospitalization Benefits Regulation also addresses payment for goods and services provided by hospitals or approved facilities outside of Canada. Section 5 of the Medical Benefits Regulation addresses payment of physician services obtained outside Canada. These sections were not amended in 2019-2020.

4.4 Prior Approval Requirement

Prior approval is not required for elective (non-emergency) insured services in another Canadian province or territory. Prior application is required for elective services received out-of-country and approval may only be given through the Out-of-Country Health Services Committee for insured services that are medically required, are not experimental, and are not available in Alberta or elsewhere in Canada.

Decisions made by the committee can be appealed. Appeals may be submitted by an Alberta physician or dentist on behalf of the Alberta resident or by the Alberta resident. The Out-of-Country Health Services Appeal Panel, was established under the Alberta Health Care Insurance Act, and continues under the Out-of-Country Health Services Regulation (AR 78/2006). The Appeal Panel reviews the application, the committee decision, and determines whether to confirm, vary or substitute the committee’s decision under appeal.

5.0 Accessibility

5.1 Access to Insured Health Services

The Government of Alberta is committed to meeting the health care needs of all Albertans. To ensure Albertans have the best possible access to primary health care services, the Alberta Ministry of Health funds Primary Care Networks (PCNs). PCNs support inter-disciplinary teams made up of family physicians and other health care professionals who work with Alberta Health Services (AHS) to coordinate the delivery of primary health care services for their patients. Each PCN has the flexibility to develop programs and provide services to meet the specific needs of patients. Access to health care services can be limited by geography, hours of operation, and wait times. As of March 31, 2020, there were 41 PCNs operating in Alberta. More than 3.8 million Albertans were enrolled in a PCN. A total of 4,707 primary care providers (including family physicians, general practitioners, pediatricians, and nurse practitioners), and the full-time equivalent of 1,305 other health care providers were registered providers in PCNs.

Section 9 of the Alberta Health Care Insurance Act (AHCIA) prohibits extra-billing by opted-in physicians or dentists (i.e., physicians and dentist participating in the Alberta Health Care Insurance Plan (AHCIP)). No physician or dentist who participates in the AHCIP and who provides insured services to a resident with coverage under the AHCIP is allowed to charge or collect from any person an amount in addition to the benefits payable by the Minister of Health for those insured services.

Section 11 of the AHCIA prohibits any person from charging or collecting from any person the following payments, where the amount is in addition to the benefits payable by the Minister of Health for the insured service:

  1. an amount for any goods or services that are provided as a condition to receiving an insured service provided by a physician or dentist who is participating in the AHCIP; or
  2. an amount the payment of which is a condition to receiving an insured service provided by a physician or dentist who is participating in the AHCIP.

When an individual questions extra-billing or user charges, they may contact AHCIP staff by phone, e-mail, fax, or mail as follows:

Alberta Health
Attention: Alberta Health Care Insurance Plan
PO Box1360, Stn Main
Edmonton AB T5J 2N3
Phone: Edmonton: 780-427-1432; Toll free in Alberta: 310-0000 then 780-427-1432
Fax: 780-422-0102
E-mail: health.ahcipmail@gov.ab.ca
(This email address is for general information or non-personal questions regarding the AHCIP)

If the matter cannot be resolved with the health practitioner through communication or education, it may proceed to a compliance review.

The Ministry of Health monitors and enforces compliance with the AHCIA through a dedicated compliance unit. The unit reviews billing compliance, recovers inappropriately paid funds, and contributes to education on appropriate billing practices. These reviews are conducted under section 18 of the AHCIA. If a compliance review uncovers evidence of non-compliance with sections 9 or 11 of the AHCIA, then sections 9, 11, 12, 13 and 14 set out the fines and other steps that may be taken by the Minister of Health.

Sections 9(2), 9(2.1) and 9(3) set out the escalating disciplinary actions the Minister may take in response to extra billing, in addition to any actions taken under sections 13 and/or 14.

Section 11(3) and 11(4) establish that the Minister can recover from any person a prohibited fee that has been collected and must then reimburse the recovered amount to the person who was charged the amount.

Section 12(1) establishes that a physician or dentist who is opted into the AHCIP and provides insured services in circumstances where the physician or dentist knows, or reasonably ought to have known, that a person has been charged an amount in contravention of section 11 should not receive payment of benefits from the Minister for those insured services and that if benefits have been received in contravention of section 12(1), then the sanctions set out in section 9(2) of the AHCIA apply.

Section 13 of the AHCIA sets out the Minister’s right to recover amounts received in contravention of sections 9, 10 or 12 by one or more of the following means: (a) by withholding those amounts from any benefits payable to the physician, dentist or person referred to in section 20.1; (b) by civil action as though those amounts were a debt owing to the Crown in right of Alberta; or (c) pursuant to any agreement between the Minister and the physician, dentist or person referred to in section 20.1 that provides for the repayment of those amounts. Repayment of those amounts is set out in section 13 (3) as follows: The Minister shall reimburse a person in respect of whom benefits may be paid for any amounts recovered under this section that were paid by the person and have not been previously reimbursed.

Section 14 establishes that contravention of sections 9, 10, 11, or 12 is an offence and subject to the fines set out in section 14.

Health infrastructure is important in ensuring current and future health care needs are met. The Ministries of Health and Infrastructure share the responsibility for planning and management of the Health Capital Plan and projects. The Ministry of Health is responsible for setting strategic directions and implementing health policy, legislation, standards and providing global operating funding to AHS. AHS identifies and prioritizes health service needs requiring capital development. The Government of Alberta supports health infrastructure by funding capital development and the Infrastructure Maintenance Program. The Ministry of Infrastructure is responsible for the design, construction and delivery of major health capital projects throughout the province. Health legislation also stipulates the requirements for the purchase and disposition of assets and properties and the general provisions for health infrastructure.

Budget 2019 included $3.55 billion over four years for health facilities, equipment and IT infrastructure. In 2019-20, a detoxification and residential treatment facility in Red Deer was completed; seven projects representing 438 new designated supportive living and long-term care spaces were opened; nine new health facilities were in progress; and seven existing health facilities were in progress for major renovations, modernizations or expansions. 

5.2 Physician Compensation

The AHCIA governs the eligibility and payment to physicians for providing insured medical services to eligible Alberta residents. Physicians are compensated through the AHCIP on a volume-driven, fee-for-service basis or through the use of alternative compensation models such as Clinical Alternative Relationship Plans and the Academic Medicine and Health Services Program. Some primary care physicians are compensated through a Blended Capitation Model which blends fee-for-service and capitation payments.

Under the Oral and Maxillofacial Surgery Benefits Regulation (AR 86/2006), benefits are payable in accordance with the regulations under the AHCIA for oral and maxillofacial surgery services provided to a resident of Alberta by a dentist.

In Alberta, the College of Physicians and Surgeons of Alberta enforces standards of practice for charging for uninsured professional services (non-insured services under the AHCIA), which include rules related to block billing by physicians.

The Academic Medicine and Health Services Program has accountability and reporting expectations for physicians participating in the academic alternative compensation arrangements, as well as for the Faculties of Medicine at both the University of Alberta and Calgary and AHS. Key performance themes include clinical service delivery, administration and leadership, research productivity, and educational quality. These themes are used to measure performance on an annual basis.

Clinical Alternative Relationship Plans and the Academic Medicine and Health Services Program are used by specialists and family physicians and offer alternative compensation models to the traditional fee-for-service payment system. Their purpose is to enhance physician recruitment and retention, team-based approaches to service delivery, access to services, patient satisfaction, and value for money. They also support innovative health care delivery, which will result in better health outcomes. The predictable funding provided through Clinical Alternative Relationship Plans and the Academic Medicine and Health Services Program enables physician groups to recruit new physicians to their programs and retain their services while in some cases providing additional funding to support service delivery.

The Government of Alberta and the Alberta Medical Association (AMA) entered into the Alberta Medical Association Agreement in 2013, which was retroactive to April 1, 2011. In 2018, the Alberta Medical Association Agreement was amended and included no increases to physician rates and prices paid for insured medical services. Certain financial terms in the Alberta Medical Association Agreement were to expire March 31, 2020. After several months of negotiations and mediation, the Government of Alberta utilized the language in the agreement to terminate it on February 20, 2020. This decision was necessary with an estimated $2 billion budget cost pressure over three years expected if the status quo remained in place. In the absence of an agreement, the Government of Alberta implemented a new physician funding framework on March 31, 2020. The Government of Alberta continues to engage the AMA, in good faith, on physician compensation matters and other health matters that concern physicians.

To ensure accountability with the AHCIA, the Ministry of Health conducts regular reviews of claims filed by physicians to assess their compliance within the AHCIA. The Ministry of Health uses statistical and risk assessment methodologies to identify errors or issues in the claims that were paid under the AHCIP. Compliance reviews can be initiated for a practitioner or group of practitioners to determine compliance with specific legislative or contractual requirements. Further, a compliance review may be triggered as a result of a specific complaint about a physician from an external party.

5.3 Payments to Hospitals

Alberta's public hospitals are operated by AHS or by faith-based voluntary organizations under service agreements with AHS. In Alberta, public hospitals are operated in accordance with the Hospitals Act. The Health Facilities Act (HFA) prohibits the operation of private hospitals.

The Regional Health Authorities Act governs the funding of AHS, Alberta's single regional health authority. The Ministry of Health funds AHS through base operating funds provided twice each month. AHS determines funding for individual hospitals and for chartered surgical facilities that are under contract to provide insured surgical services. The HFA governs the provision of insured and uninsured surgical services performed in public hospitals and chartered surgical facilities. The HFA prohibits queue jumping. Specifically, no person shall give or accept any money or other valuable consideration, pay for or accept payment for enhanced medical goods or services or non-medical goods or services, or provide an uninsured surgical service for the purpose of giving any person priority for the receipt of an insured surgical service. Access to insured surgical services is based on the medical needs of patients and determined by physicians and dentists.

The Minister of Health is required to approve any service agreement between operators of a chartered surgical facility and AHS in order for the facility to provide insured surgical services. Ministerial designation of a chartered surgical facility and accreditation by the College of Physicians and Surgeons of Alberta is also required.

According to the HFA, ministerial approval for a proposed facility services agreement shall not be given unless:

A) the Minister of Health is satisfied:

B) the Minister has considered the assessment of the proposed agreement with respect to the factors referred to in section 8(1.1).

Pursuant to the terms of any agreement between AHS and the operator of a chartered surgical facility, AHS agrees to pay a contracted "facility fee". This fee covers certain services specified under the HFA that are medically necessary and are directly related to the provision of a surgical service at an approved surgical facility. Physicians who provide insured surgical services to patients within an accredited chartered surgical facility are paid on a fee-for-service basis through the AHCIP. These fees are the same regardless of whether the physician provides the insured service in a public hospital setting or in a chartered surgical facility.

6.0 Recognition Given To Federal Transfers

The Government of Alberta publicly acknowledged the federal contribution provided through the Canada Health Transfer in the 2019-2020 Government of Alberta Annual Report.

Registered Persons
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
1. Number as of March 31st 4,449,483 4,529,842 4,598,089 4,700,840 4,783,609
Insured Hospital Services Within Own Province or Territory
Public Facilities 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
2. Number 225 228 228 228 228
3. Payments for insured health services ($) Not available Not available Not available Not available Not available
Private For-Profit Facilities 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
4. Number of private for-profit facilities providing insured health services Not available Not available Not available Not available Not available
5. Payments to private for-profit facilities for insured health services ($)  Not available Not available Not available Not available Not available
Insured Hospital Services Provided to Residents in Another Province or TerritoryAlberta table 3 Footnote 1
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
6. Total number of claims, in-patient 6,787 7,059 6,668 6,484 5,872
7. Total payments, in-patient ($) 48,651,644 48,492,921 46,468,281 48,297,039 45,985,705
8. Total number of claims, out-patient 135,369 147,350 135,149 130,737 124,744
9. Total payments, out-patient ($) 43,000,306 50,582,365 47,508,204 48,132,671 46,258,409
Alberta table 3 Footnote 1

Data reported reflect claims processed up to three months after the close of the fiscal year. Any claims processed after this date are not reflected in the presented information.

Alberta table 3 Return to footnote 1 referrer
Insured Hospital Services Provided Outside CanadaAlberta table 4 Footnote 1Alberta table 4 Footnote 2Alberta table 4 Footnote 3
Pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
10. Total number of claims, pre-approved in-patientAlberta table 4 Footnote 4 4,216 3,855 4,014 3,672 3,225
11. Total payments, pre-approved in-patient   ($)Alberta table 4 Footnote 4 407,398 372,724 389,741 349,087 307,394
12. Total number of claims, pre-approved out-patientAlberta table 4 Footnote 4 5,008 4,945 4,709 4,402 3,287
13. Total payments, pre-approved out-patient ($)Alberta table 4 Footnote 4 479,625 458,265 459,683 394,654 345,422
Non Pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
14. Total number of claims, non pre-approved in-patientAlberta table 4 Footnote 4 Not available Not available Not available Not available Not available
15. Total payments, non pre-approved in-patient ($)Alberta table 4 Footnote 4 Not available Not available Not available Not available Not available
16. Total number of claims, non pre-approved out-patientAlberta table 4 Footnote 4 Not available Not available Not available Not available Not available
17. Total payments, non pre-approved out-patient ($)Alberta table 4 Footnote 4 Not available Not available Not available Not available Not available
Alberta table 4 Footnote 1

Data reported reflect claims processed up to three months after the close of the fiscal year. Any claims processed after this date are not reflected in the presented information.

Alberta table 4 Return to footnote 1 referrer

Alberta table 4 Footnote 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.

Alberta table 4 Return to footnote 2 referrer

Alberta table 4 Footnote 3

Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report,but did not require provinces or territories to report on previous years.

Alberta table 4 Return to footnote 3 referrer

Alberta table 4 Footnote 4

The claims in our data system cannot be separated into pre-approved or non pre-approved, therefore, the numbers reflect the total claims and payments as reported for previous years.

Alberta table 4 Return to footnote 4 referrer
Insured Physician Services Within Own Province or TerritoryAlberta table 5 Footnote 1
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
18. Number of participating physiciansAlberta table 5 Footnote 2 9,331 9,684 10,058 10,326Alberta table 5 Footnote 3 10,618Alberta table 5 Footnote 3
19. Number of opted-out physiciansAlberta table 5 Footnote 4 0 0 0 0 0
20. Number of non-participating physicians 1 1 2 2 2
21. Total payments for services provided by physicians paid through all payment methods ($) Not available Not available Not available Not available Not available
22. Total payments for services provided by physicians paid through fee-for-service ($) 3,336,009,256 3,531,947,298 3,602,354,459 3,779,015,740 3,947,765,122
Alberta table 5 Footnote 1

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.

Alberta table 5 Return to footnote 1 referrer

Alberta table 5 Footnote 2

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.

Alberta table 5 Return to footnote 2 referrer

Alberta table 5 Footnote 3

8,721 of these are paid under fee-for-service, 884 under an Alternative Relationship Plan and the remaining 1,013 received compensation from both fee-for-service and alternative relationship plans.

Alberta table 5 Return to footnote 3 referrer

Alberta table 5 Footnote 4

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.

Alberta table 5 Return to footnote 4 referrer
Insured Physician Services Provided to Residents in Another Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
23. Number of services 795,738 840,246 796,364 738,060 726,338
24. Total payments ($) 34,639,878 37,906,996 35,943,674 35,826,012 35,406,860
Insured Physician Services Provided Outside CanadaAlberta table 7 Footnote 1Alberta table 7 Footnote 2Alberta table 7 Footnote 3
Pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
25. Number of pre-approved services 32,980 31,224 30,653 27,434 Not available
26. Total pre-approved payments ($) 2,589,749 2,474,336 2,494,650 2,204,584 Not available
Non Pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
27. Number of non pre-approved services Not available Not available Not available Not available Not available
28. Total non pre-approvedAlberta table 7 Footnote 4 payments ($) Not available Not available Not available Not available Not available
Alberta table 7 Footnote 1

These data do not include Alberta residents who have received health services through the Out-of-Country Health Services Committee application process. Additionally, following a methodology change in 2015-2016, there is a one-year lag from fiscal year end to date of payment for out-of-country data. This means data for out-of-country physician services are still being processed for 2019-2020.

Alberta table 7 Return to footnote 1 referrer

Alberta table 7 Footnote 2

Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report, but did not require provinces or territories to report on previous years.

Alberta table 7 Return to footnote 2 referrer

Alberta table 7 Footnote 3

The claims in our data system cannot be separated into pre-approved or non pre-approved, therefore, the numbers reflect the total claims and payments as reported for previous years.

Alberta table 7 Return to footnote 3 referrer

Alberta table 7 Footnote 4

Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report,but did not require provinces or territories to report on previous years.

Alberta table 7 Return to footnote 4 referrer
Insured Surgical-Dental Services Within Own Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
29. Number of participating dentists 215 217 232 226 219
30. Number of opted-out dentistsAlberta table 8 Footnote 1Alberta table 8 Footnote 2 0 0 0 0 0
31. Number of non-participating dentistsAlberta table 8 Footnote 1Alberta table 8 Footnote 2 0 0 0 0 0
32. Number of services provided 31,309 34,603 39,647 42,766 46,593
33. Total payments ($) 9,185,042 9,756,738 11,402,793 12,616,145 13,967,172
Alberta table 8 Footnote 1

Alberta's legislation provides that all dentists are deemed to be participating in the Alberta Health Care Insurance Plan, unless they opt out in accordance with the procedure set out in section 7 of the Alberta Health Care Insurance Act.

Alberta table 8 Return to footnote 1 referrer

Alberta table 8 Footnote 2

Health Canada requested this data as of the 2016-2017 report, but did not require provinces or territories to report 2015-16 data.

Alberta table 8 Return to footnote 2 referrer

British Columbia

British Columbia (BC) has a progressive and integrated health care system, which includes a health care insurance plan that provides publicly funded health care services to residents of BC in accordance with the guiding principles of the Canada Health Act. The Ministry of Health (the Ministry) has overall responsibility for ensuring that quality, appropriate, and timely health care services are available to all British Columbian residents.

To read more about BC’s publicly funded health system, please refer to the Ministry of Health’s 2019-2020 to 2021–2022 Service Plan.

COVID-19 Measures

A number of measures specific to the COVID-19 public health emergency were put into place to support British Columbia’s health care system during the 2019-2020 reporting period.

In response to the COVID-19 pandemic, a public health emergency was declared in BC on March 17, 2020,Footnote 7 followed by a state of emergency declared on March 18, 2020,Footnote 8 both of which continue to be in effect (as of late November 2020). An additional measure was put in effect on April 8, 2020 that required all returning travellers to have an approved self-isolation plan upon arrival.Footnote 9 BC has been in Phase 3 of BC’s Restart Plan since June 24, 2020,Footnote 10 having previously moved from Phase 1 to Phase 2 on May 19, 2020.Footnote 11  On August 21, 2020, additional enforcement measures were introduced for owners or organizers contravening the Provincial Health Officer’s order on gatherings and events.Footnote 12

The Management of COVID-19: Health Sector Plan for Fall/Winter 2020/21Footnote 13 was released on September 9, 2020, which includes key health system management actions to be completed by the end of October. Key areas of ongoing focus include:

Health Professional Regulation:

A number of regulatory actions, including amendments to health profession regulations and regulatory college bylaws, have been taken to support the timely delivery of safe health services and the effective use of health human resources. These regulatory actions include the following:

1.0 Public Administration

1.1 Health Care Insurance Plan and Public Authority

The Ministry of Health (Ministry) sets goals and standards, and issues health authority mandate letters and performance expectations for provincial health service delivery. The Ministry works with the six health authorities (HA) throughout the province to provide quality, appropriate, and timely health services to British Columbians. There are five regional HAs that deliver health care services to meet the needs of the population within their respective geographic regions. A sixth health authority, the Provincial Health Services Authority (PHSA), is responsible for managing the quality, coordination, and accessibility of province-wide health programs and services across the full continuum of care.   The Ministry also works in partnership with the First Nations Health Authority to improve the health status of Indigenous Peoples in BC.

The BC Medical Services Plan (MSP), which is managed by the Medical Services Commission (MSC) on behalf of the Government of BC, provides health care coverage (including for diagnostic services) to beneficiaries and corresponding payments to medical and health care practitioners.

MSP is administered pursuant to the Medicare Protection Act (MPA). The purpose of the MPA is to preserve a publicly managed and fiscally sustainable health care system for British Columbia (BC), in which access to necessary medical care is based on need and not on an individual’s ability to pay. It expressly incorporates the principles of the Canada Health Act.

The MSC reports to the Minister of Health (the Minister), in accordance with the MPA. Under the MPA, the function and legislative mandate of the MSC is to facilitate reasonable access, throughout British Columbia (BC), to quality medical care, health care, and prescribed diagnostic services for British Columbians.

The MSC is a nine-member statutory body comprised of three representatives of the Government of BC, three representatives from the BC Medical Association (operating as the Doctors of BC), and three members from the public who have been jointly nominated by the Doctors of BC and the Government of BC to represent beneficiaries. General hospital services are publicly funded in BC under the Hospital Insurance Act, the Hospital Insurance Act Regulations under the Hospital Insurance Act, the Hospital Act, and Hospital District Act.

Medically required laboratory services are publicly funded under the Laboratory Services Act. The Minister is responsible for all matters related to laboratory services (including the facility approval process), governance, accountability and provision of benefits for all laboratory services in BC. Following the amalgamation of the BC Clinical Support Services Society with the PHSA on June 29, 2018, the Minister delegated the delivery of operational laboratory services activities to Provincial Laboratory Medicine Services (previously the BC Agency for Pathology and Laboratory Medicine), a program under PHSA. The PHSA’s mandate is to provide effective provincial oversight, which includes provincial planning, coordination, monitoring, evaluating, and reporting on province-wide results and health outcomes for publicly funded laboratory and pathology services.

1.2 Reporting Relationship

The Ministry provides information on the performance of BC’s publicly funded health care system in its Annual Service Plan Report. Tracking and reporting this information is consistent with the Ministry’s strategic approach to performance planning and reporting, and it is consistent with requirements contained in the provincial Budget Transparency and Accountability Act.

The MSC is accountable to the Government of BC through the Minister. The MSC Annual Report, which provides an annual accounting of the business of the MSC, its advisory committees and other delegated bodies, is published annually for the prior fiscal year.

Regional health authorities and the PHSA have independent boards; however, in practice the Board Chairs report to the Minister of Health.

1.3 Audit of Accounts

The Ministry’s accounts and financial transactions are subject to audit as follows:

The OAG’s annual audit of the Ministry’s accounts and financial transactions are reflected in the OAG’s overall review and opinion related to the BC Public Accounts, which can be found on the Government of BC website. The OAG’s special audits and reports can be located on the Office of the Auditor  General of BC website.

1.4 Designated Agency

Since 2005, the Ministry has contracted with MAXIMUS Canada to deliver many of the administrative operations of MSP and PharmaCare (the Province’s drug insurance plan), including responding to public inquiries, registering clients, and processing medical and pharmaceutical claims from health professionals. MAXIMUS Canada administers the Province’s medical and drug insurance plans under the Health Insurance BC (HIBC) program. Policy and decision-making functions remain within the responsibility of the Ministry.

HIBC submits monthly reports to the Ministry regarding performance on service levels to the public and health care providers. HIBC processes payments for health care services in accordance with payment schedules approved by the MSC.

As of January 1, 2020, MSP premiums have been eliminated. The MPA was amended pursuant to the Medicare Protection Amendment Act, 2019 to effect this change. Premiums for periods of enrollment after January 1, 2020, will no longer be paid by beneficiaries.

Prior to January 1, 2020, adult MSP beneficiaries who did not meet the (primarily income-based) exceptions were obligated to pay premiums. With respect to MSP premiums incurred prior to this time, Advanced Solutions (a DXC Technology Company) performed revenue management services associated with MSP premiums, including account management and collection, on behalf of the Government of BC (Ministry of Finance) under the Revenue Services of BC (RSBC) program. The Government of BC remains responsible for and retains control of all government administered collection actions.

HIBC and RSBC are required to comply with all applicable laws, including the:

2.0 Comprehensiveness

2.1 Insured Hospital Services

The Hospital Act and Hospital Act Regulation provide authority for the Minister to: designate facilities as hospitals and societies as hospital societies; license private long-term care hospitals (also referred to as long-term care homes); approve the bylaws of hospitals; inspect hospitals; and appoint a public administrator. This legislation also establishes broad parameters for the operation of hospitals.

The Hospital Insurance Act and the Hospital Insurance Act Regulation provide authority for the Minister to make payments to health authorities for the purpose of operating hospitals. They also outline who is entitled to receive publicly funded services and define the “general hospital services” that are to be provided as benefits.

Hospital services are publicly funded benefits when they are provided to a beneficiary in a public hospital, are medically required, and are recommended by the attending physician, midwife, nurse practitioner, or oral and maxillofacial surgeon. There is no scheduled or regular process to review publicly funded hospital services, as these services are intended to be inclusive.

All hospital services that were funded in 2018-2019 continued to be funded in 2019-2020.

When medically required, the following are provided to beneficiaries who are in-patients in a general hospital:

When medically required, the following are provided as benefits to out-patients who are beneficiaries:

When medically required, the following diagnostic services—which are specified in the Medical and Health Care Services Regulation under the MPA—are provided as benefits to out-patients who are beneficiaries. Depending on the service, they may be provided at hospitals or privately-owned facilities that the Medical Services Commission (MSC) has approved to provide the service, including:

Medically required in-patient and out-patient laboratory services are provided as benefits under the Laboratory Services Act (LSA).

Insured hospital services are provided to beneficiaries without charge, with a few exceptions, such as:

Some facilities providing long-term care services (the term “extended care” is also sometimes used) are regulated under Part 2 of the Hospital Act. Health authorities and hospital societies are required to follow Home and Community Care policies to determine benefits in such cases.

2.2 Insured Physician Services

Unless specifically excluded, the following medical services are publicly funded as benefits under the MPA or the LSA:

To practice in BC, physicians must be registered and in good standing with the College of Physicians and Surgeons of BC. To receive payment for publicly funded services, they must be enrolled with MSP. In the fiscal year 2019-2020, 11,849 physicians were enrolled with MSP and received payments through fee-for-service (FFS).

The types of practitioners (in addition to physicians and dentists) who may enrol and provide benefits under MSP include midwives, optometrists, osteopaths and supplementary benefit practitioners. For eligible beneficiaries, the Supplementary Benefits Program provides partial payment for acupuncture, massage therapy, physiotherapy, chiropractic, naturopathy, and non-surgical podiatry services. The program contributes $23 towards the cost of each patient visit to a maximum of ten visits per patient per annum summed across the six types of providers. Eligibility for the program is based on income. Income is verified by way of an automated Canada Revenue Agency income verification process that runs once per year.

Practitioners enrolled in MSP may choose to be “opted-in” or “opted-out”. Opted-in practitioners are those who are enrolled in MSP and who elect to bill MSP directly for MSP benefits provided to MSP beneficiaries. Except in certain very rare circumstances, an opted-in practitioner may not bill a patient directly for a benefit. Opted-out practitioners are enrolled in MSP but elect to bill patients directly for benefits. Enrolled practitioners wishing to opt out of MSP must give written notice to the MSC. In this case, beneficiaries may apply to MSP for reimbursement of the fee for benefits rendered. Under the MPA, an opted-out physician may not charge a patient more for a benefit than the prescribed MSP fee amount.

Under the Physician Master Agreement between the Government of BC, MSC and Doctors of BC, modifications to the MSC Payment Schedule such as additions, deletions or fee changes are made by the MSC upon advice from Doctors of BC or the Government of BC. To modify the MSC Payment Schedule, the parties must submit proposals to the Tariff Committee. On recommendation of the Doctors of BC and Government of BC, interim listings may be designated by the MSC for new procedures or other services for a limited period while definitive listings are established.

During fiscal year 2019-2020, 24 net new physician services were added to the MSC Payment Schedule to reflect current practice standards including, for example, the introduction of two new Obstetrics and Gynecology services for insertion of intra-peritoneal catheters for chemotherapy under general anaesthetic, the removal of intra-peritoneal catheters for chemotherapy, and two new General Surgery services for Oncoplastic breast-conserving surgery.

Additionally, 10 physician services were deleted from the MSC Payment Schedule in fiscal 2019-2020, including, for example, Therapeutic Radiology Consultation services.  These services were deleted as they had not been billed in the past five fiscal years. Also, as part of the response to, and planning for the COVID-19 pandemic, the MSC Payment Schedule was amended on a temporary basis to support access to physician services during the pandemic, including virtual care. Temporary changes to the Payment Schedule, including new fees, were implemented with the end dates of the temporary fees to be determined by the Provincial Health Officer.

Temporary fee changes include:

2.3 Insured Surgical-Dental Services

In certain circumstances, in-patient or out-patient hospitalization is medically required for the safe and proper completion of surgical-dental services. In such cases, the surgical-dental procedure component is publicly funded if the service falls within the meaning of covered dental or orthodontic services by the Medical and Health Care Services Regulation under the MPA. The hospitalization component is funded by the health authority.  Further, in 2015 it was clarified that dental services which are provided in privately owned/operated surgical facilities under contract with a health authority and are listed in the Dental Payment Schedule are insured benefits under MSP.

Publicly funded surgical-dental procedures include those related to remedying a disorder of the oral cavity or a functional component of mastication. Generally, this includes oral surgery related to trauma, orthognathic surgery, medically required extractions, and surgical treatment of temporomandibular joint dysfunction.

The dental procedures funded by MSP are established through the negotiation of a master agreement between the BC Dental Association (BCDA) and the Government of BC. Public consultation is not used. The master agreement outlines any changes to surgical-dental benefits during the term of the agreement, including any additional benefit procedures. Additions or changes to the list of benefits are managed by MSP on the advice of the Dental Liaison Committee, which consists of representatives from both the Ministry of Health (Ministry) and the BCDA. Additions and changes to the Dental Payment Schedule must be approved by the MSC. No new procedures were added as benefits during the 2019-2020 fiscal year.

Any general dentist in good standing with the BC College of Dental Surgeons of British Columbia (CDSBC) who is enrolled in MSP and has hospital privileges may provide surgical-dental benefits in a hospital or other approved facility. There were 201 dentists enrolled with MSP in 2019-2020 (including general dentists, pediatric dental specialists, oral surgeons, oral medicine dental specialists, and orthodontists billing through MSP).

Dentists must register with the CDSBC in order to practise, but they are not required to participate in MSP. If they do choose to participate, they must enroll in MSP in order to receive payment for MSP insured services. Dentists enrolling in MSP may choose to opt out of billing MSP for insured services, instead billing the patient directly. The patient may then submit a claim to MSP for reimbursement of the insured service.

2.4 Uninsured Hospital, Physician and Surgical-Dental Services

Medical necessity is the criterion for public funding of hospital and medical services. Coverage is excluded for out-patient take-home drugs, and any drugs not clinically approved by the hospital. Procedures not publicly funded under the Hospital Insurance Act and Hospital Insurance Act Regulations include:

Non-publicly funded hospital services also include:

Health authorities are required by Ministry policy to fund medically necessary transfers between acute care hospitals within BC, but beneficiaries are required to pay a fee to partially off-set costs when an ambulance or contracted alternative service provider is used for transport in other situations.

Services not covered under MSP include:

With respect to MSP, the MSC has authority to determine which services are benefits.

3.0 Universality

3.1 Eligibility

Section 7 of the Medicare Protection Act (MPA) sets out the Medical Services Plan (MSP) enrollment requirement for residents of BC (as defined in the MPA) to enroll in MSP. A person must be a resident of BC to qualify for provincial health care benefits.

Section 1 of the MPA defines a resident as a person who is either deemed to be a resident under regulation, or:

Deemed residents include individuals such as some holders of permits issued under the federal Immigration and Refugee Protection Act (see section 3.2 of this report) among others, but this does not include a tourist or visitor to BC.

Residents who do not want to participate in the BC’s public health care plan may choose to opt out of the publicly funded program. Individuals are required to file an Election to Opt Out statement and submit that statement to the MSC. A statement, once signed, is irrevocable and results in the resident being responsible for paying the entire cost of all hospital, medical and other health care services they may receive during the 12-month opted-out period. Residents cannot opt out retroactively and must reapply to opt out at the expiry of each 12-month period.

All residents are entitled to medically required hospital and medical care coverage. Those residents who are members of the Canadian Forces and those serving a term of imprisonment in a federal penitentiary, as defined in the Corrections and Conditional Release Act, are eligible for federally funded health insurance. MSP provides first-day coverage to discharged members of the Canadian Forces and to those returning from an overseas tour of duty, as well as to released inmates of federal penitentiaries located in BC.

It is possible for a beneficiary’s enrollment to be cancelled by order of the MSC, if MSC determines that the beneficiary was not eligible for enrollment or believes that the beneficiary has ceased to be a resident. Section 11 of the MPA requires that the beneficiary must be notified that they have a right to a hearing, prior to making an order cancelling a beneficiary’s enrollment. If the beneficiary requests a hearing, the hearing is conducted by a delegate of the MSC—either in person or in writing. Decisions of the MSC or its delegates may be judicially reviewed by the Supreme Court of BC.

The number of residents registered with MSP as of March 31, 2020, was 5,108,915.

3.2 Other Categories of Individuals

Holders of study permits, and work permits, as well as applicants for permanent resident status who are the spouse or child of an eligible resident, are eligible for enrollment and benefits when they are deemed to be residents under the MPA in accordance with section 2 of the Medical and Health Care Services Regulation.

3.3 Premiums

Until January 1, 2020, the MPA and the Medical and Health Care Services Regulation provided authority for the MSC to collect premiums from beneficiaries.  As announced by the Government of BC, and further to amendments enacted through the Medicare Protection Amendment Act, 2019, MSP premiums were eliminated for all beneficiaries effective January 1, 2020.

Enrollment in MSP is mandatory (subject to an adult’s right to formally opt out). Outstanding premium debt is not a barrier to receiving coverage.

The MSP monthly premium rates for 2019 were $37.50 for one adult and $75 for two adults in a family. Additionally, there were no MSP premiums for children under the age of 19, or for dependent post-secondary students enrolled in full-time studies (including trade, technical or high schools).

Prior to January 1, 2020, MSP had two programs that offered assistance with the payment of premiums based on financial need. Firstly, regular premium assistance had several levels of assistance and was based on a person’s net income for the preceding tax year, combined with that of the person’s spouse, if applicable, less MSP deductions. Premium assistance rates were no longer calculated to include children. The maximum income for premium assistance eligibility 2018–2019 was $42,000 adjusted net income per year. The sum net income for premium assistance eligibility of a beneficiary and spouse when one spouse is in long-term care was $54,000. The monthly premium rates that were paid by beneficiaries receiving premium assistance ranged from $11.50 to $32.50 for a single adult, and $23 to $65 for a family of two adults.

There were groups of specified beneficiaries, including those in receipt of assistance under the Employment and Assistance Act or the Employment and Assistance for Persons with Disabilities Act, where no premium was payable in accordance with section 10 of the Medical and Health Care Services Regulation.

Additionally, for short-term periods, up to 100 per cent subsidy was offered under the temporary premium assistance program based on current, unexpected financial hardship. Premium assistance was available only to beneficiaries who, for the last 12 consecutive months, had resided in Canada and were either a Canadian citizen or a holder of permanent resident (landed immigrant) status under the federal Immigration and Refugee Protection Act.

Given that MSP premiums were eliminated effective January 1, 2020, the premium assistance and temporary premium assistance programs ceased being effective as of that date. The MPA was amended pursuant to the Medicare Protection Amendment Act, 2019 to reflect this change.

Retroactive premium assistance for premiums incurred prior to January 1, 2020 will remain available.

3.4 International Student Health Fee

As the Province has eliminated MSP premiums for British Columbians, an updated payment method will ensure international students continue to contribute to, and benefit from, BC health care coverage. Under the updated system, effective September 1, 2019, all international K-12 and post-secondary students began paying a monthly health care coverage fee of $37.50.

For post-secondary students who were paying $37.50 per month in MSP premiums, the health fee restored their contributions to the $75 per month that was charged prior to 2018. Effective January 1, 2020, the health fee for international students is $75 per month.

International students with a study permit valid for a period of six or more months are required to apply for the MSP as soon as they arrive in BC. Through this application process, they will be enrolled and then invoiced for the new health fee.

4.0  Portability

4.1 Minimum Waiting Period

New residents or persons re-establishing residence in British Columbia (BC) are eligible for coverage after completing a waiting period that normally consists of the balance of the month in which residence is established, plus two additional months. For example, if an eligible person applies during the month of July, coverage is available October 1. If absences from Canada exceed a total of 30 days during the waiting period, eligibility for coverage may be affected. New residents from other parts of Canada are advised to maintain coverage with their former provincial or territorial health insurance plan during the waiting period.

4.2 Coverage during Temporary Absences in Canada

Sections 3, 3.1, 4, and 5 of the Medical and Health Care Services Regulation set out the portability provisions for persons temporarily absent from BC regarding publicly funded services.

In general terms, residents who spend part of every year outside BC must be physically present in BC at least six months in a calendar year, and continue to maintain their home in BC, in order to retain coverage. As of January 1, 2013, longer term vacationers who are deemed residents may qualify for a total absence of up to seven months per calendar year for vacation purposes only, provided they give prior notice to the Medical Services Commission (MSC) and continue to meet the other requirements, such as maintaining their home in BC.

Individuals leaving BC temporarily on extended vacations, or for temporary employment, may be eligible to retain their medical coverage for up to 24 consecutive months provided they receive prior approval of the MSC and meet other requirements of section 4 of the Medical and Health Care Services Regulation. Approval is limited to once in five years for absences exceeding six months in a calendar year. When a beneficiary stays outside BC longer than the approved period, there is a requirement to fulfill a waiting period upon re-establishing residence in the province before coverage can be renewed. Students and extended family of students attending a recognized school in another province or territory on a full-time basis are entitled to coverage for the duration of their studies.

According to inter-provincial/territorial reciprocal billing arrangements, physicians, except in Quebec, bill their own medical plans directly for services rendered to BC residents who are eligible for MSP coverage, upon presentation of a valid Personal Health Number or BC Services Card. BC then reimburses the province or territory at the rate of the fee schedule in the province or territory in which services were rendered. For in-patient hospital care, services are paid at the ward rate approved for each hospital by the Assistant Deputy Ministers Policy Advisory Committee. For out-patient services, the payment is at the inter-provincial/ territorial reciprocal billing rate. Payment for these services, except for excluded services that are billed to the patient, is handled through inter-provincial/territorial reciprocal billing procedures.

Quebec does not participate in reciprocal billing agreements for physician services. As a result, claims for services provided to BC beneficiaries by Quebec physicians must be handled individually. When travelling in Quebec (or outside of Canada), the beneficiary is usually required to pay for medical services and seek reimbursement later from the Government of BC.

BC pays host provinces/territories the approved hospital billing rates and out-patient rates. These rates are recommended by the Interprovincial Health Insurance Agreements Coordinating Committee and approved by provincial-territorial Deputy Ministers of Health.

4.3 Coverage during Temporary Absences outside Canada

The provisions that define portability of health insurance during temporary absences outside Canada are as follows: section 24 of the Hospital Insurance Act; Division 6 of the Hospital Insurance Act Regulation; sections 5.5 and 29 of the Medicare Protection Act; and sections 3–5 and 35 of the Medical and Health Care Services Regulation.

Residents who leave BC temporarily to attend school or university are eligible for MSP coverage for the duration of their studies, provided they were physically present in Canada for six of the 12 months immediately preceding departure and are in full-time attendance at a recognized educational facility. Beneficiaries who have been studying outside BC must return to the province by the end of the month following the month in which studies are completed. Any student who will not return to BC within that timeframe is encouraged to contact MSP.

In some circumstances, while temporarily outside the province for work or vacation, an individual may be deemed an eligible resident during an 'extended absence' of up to 24 consecutive months, once in a five-year period. To qualify, an individual must obtain prior approval for status as a resident during the absence, continue to maintain their home in BC, be physically present in Canada for six of the 12 months immediately preceding departure, and have not been granted an extended absence in the previous five calendar years. In addition, they must not have taken advantage of the additional one-month absence available to vacationers during the year the extended absence begins, or during the calendar year prior to the start of the extended absence. In certain situations, if a person's employment requires them to routinely travel outside of BC for more than six months per calendar year, they can apply to the MSC for approval to maintain their eligibility.

BC residents who are temporarily absent from BC and cannot return due to extenuating health circumstances may be deemed residents for up to an additional 12 months, if they are visiting in Canada or abroad. This also applies to the person's spouse and children provided they are with the person, and they are also residents or deemed residents.

BC residents who are eligible for coverage while temporarily absent from BC may receive reimbursement from MSP for out-of-country medical expenses. MSP provides coverage for out-of-country emergency physician services up to the BC physician fee rates. Reimbursement for out-of-country emergency hospital services is limited to a maximum benefit of $75 per day.  Any excess cost is the responsibility of the beneficiary.

Reimbursements are made in Canadian dollars.

4.4 Prior Approval Requirement

No prior approval is required for medically required procedures that are covered under interprovincial reciprocal agreements with other provinces and territories. Prior approval from the MSC is required for procedures that are excluded under the reciprocal agreements.

The physician services excluded under the Interprovincial Agreements for the Reciprocal Processing of Out-of-Province Medical Claims are:

All non-emergency procedures performed outside Canada require approval from the MSC before the procedure is performed, in order to be eligible for reimbursement under the publicly funded program. All such applications for reimbursement are to be submitted to the Ministry of Health (Ministry) or its designate, Health Insurance BC. The beneficiary is notified of the decision in writing.

If a decision is made to deny the application for funding, the beneficiary may request an administrative review of the denial.

If, after the administrative review is concluded, the application for funding under MSP is denied again, the beneficiary may request a review of the decision.  For out-of-country applications, the review is conducted by an MSC Review Panel. The panel consists of three members—one delegate representing the Ministry, one delegate representing the Doctors of BC, and one delegate representing the general public. This tripartite structure ensures that decisions affecting administration of the provincial health care system reflect the best interest of all concerned.

For out-of-province but inside Canada applications, the review is conducted by an advisory committee of the MSC.

5.0 Accessibility

5.1 Access to Insured Health Services

The MSC has a legislative mandate to protect the integrity and sustainability of the health care system and uphold the MPA. Section 36 of the MPA gives the MSC the authority to audit private clinics for extra billing. Extra billing is the practice of charging beneficiaries for MSP benefits, or for matters relating to the rendering of benefits.

On October 1, 2018, the Government of BC brought sections of the MPA that had previously been passed by the Legislative Assembly in 2003 (Bill 92) into force. In general terms, these provisions enhance enforcement powers in relation to extra-billing to better ensure that eligible BC residents (beneficiaries) receive quality public health care based on need, not on ability to pay. These changes uphold the fundamental principles of the MPA, as well as the Canada Health Act.

A number of the new MPA provisions were subject to a series of injunctions of varying scope, as part of the Cambie Surgeries Corp. v. British Columbia (Attorney General) litigation in which the plaintiffs challenged the extra-billing provisions contained in the MPA.  In September 2020, the injunction expired when the British Columbia Supreme Court issued its decision in that litigation (dismissing the plaintiffs’ claims challenging the MPA).  As of November 2020, the plaintiffs had filed a notice of appeal of the decision and applied for an injunction to prevent use of the new MPA extra-billing enforcement provisions in relation to private surgical clinics pending the outcome of their appeal. 

The MPA (section 45) prohibits the sale or issuance of health insurance by private insurers to patients for services that would be a publicly funded benefit. Section 17 prevents extra-billing by prohibiting persons from being charged for, or in relation to, a benefit or for “materials, consultations, procedures, use of an office, clinic or other place or for any other matters that relate to the rendering of a benefit” provided by a practitioner who is enrolled in MSP.

In 2018–2019, the MPA was amended to strengthen requirements for beneficiaries to be notified of intended charges for services that would be benefits if rendered by a practitioner who is enrolled in MSP. If notice is not provided as required, a person is not liable to pay for the service unless the service was rendered in an emergency, making it impracticable to comply with the notice requirement.

The Ministry and the MSC respond to complaints of extra-billing made by patients and take appropriate actions to correct identified situations. Information regarding the extra-billing review process is available on the Government of BC site.

Beneficiaries in BC, as defined in section 1 of the Medicare Protection Act (MPA), are eligible for publicly funded health care services as medically necessary. To ensure equal access to all regardless of income, sections 17 and 18 of the MPA limit charges by medical practitioners in most contexts. Similarly, section 15 of the Laboratory Services Act prohibits extra-billing to beneficiaries for medically required laboratory services provided at an approved laboratory facility, and sections 12 and 13 of the Hospital Insurance Act prohibit extra-billing for hospital services.

If a benefit is provided by an enrolled medical practitioner who has opted out of MSP, any amount charged exceeding the amount allowed under the MPA is considered extra-billing and must be refunded. The Medical Services Commission (MSC) may apply for an injunction restraining a person from contravening the extra-billing provisions of the MPA.

The Audit and Inspection Committee (AIC) is a four-member panel of the MSC comprised of three physicians together with one member who represents the public. The MSC has delegated its powers and duties under section 36 of the MPA (i.e., to audit and inspect medical practitioners) to the AIC. On December 1, 2006, section 10 of the Medicare Protection Amendment Act 2003 was brought into force. This section expanded the audit and inspection powers of the Commission to include the power to audit clinics as corporate entities, rather than just physicians.

The AIC has responsibility for two types of audits. Patterns of practice audits are done to ensure that services billed to MSP have been delivered and billed accurately. Extra-billing audits focus on whether beneficiaries are being charged for services in contravention of the MPA. The AIC decides whether on-site audits are appropriate, and it outlines the nature and extent of the audits. It also reviews the audit results and makes recommendations to the Chair of the MSC for further appropriate action.

The Billing Integrity Program develops and analyses practitioner’s profiles, monitors trends, conducts audits, and, where appropriate, seeks recovery of inappropriately paid monies in accordance with the MPA.

A hearing is held before a panel of three or more persons who are appointed by the MSC to represent the Doctors of BC, beneficiaries and government. A panel has authority to make an order for recovery of money and other remedies. The hearing affords the practitioner a fair process that adheres to the rules of natural justice.

If a beneficiary believes they have been charged inappropriately for an insured medical benefit, they can request an inquiry by completing an extra-billing investigation form. This form is available publicly on the MSP website.

The MSC’s audit powers over health care practitioners have been delegated to various special committees. A special committee for each body of health care practitioners has been established. The special committees are: the Chiropractic Special Committee; the Dentistry Special Committee; the Massage Therapy Special Committee; the Naturopathy Special Committee; the Optometry Special Committee; the Physical Therapy Special Committee; the Podiatry Special Committee, the Acupuncture Special Committee; and the Midwifery Special Committee.

Each audit results in the submission of a detailed report to the individual Special Committee. Subsequently, the individual Special Committee makes recommendation to the Health Care Practitioners Special Committee for Audit Hearings to assist in determining if recovery should be pursued. Practitioners have a right to be heard before the Health Care Practitioners Special Committee for Audit Hearings makes a determination.

Further, access to publicly funded services continues to be enhanced. The Ministry of Heath (Ministry) is moving towards an integrated system of patient care with interdisciplinary teams of health care providers to meet the health needs of communities and populations and increase access and attachment of patients. To support team-based care, the Ministry has implemented or expanded alternate compensation options:

Infrastructure and Capital Planning

BC continues to make strategic investments in health sector capital infrastructure. The Ministry invests annually to renew and extend the asset life of existing health facilities, medical and diagnostic equipment, and information management technology at numerous health facilities across BC. The Ministry maintains a long-term capital plan to ensure health infrastructure is maintained and renewed within expected asset lifecycle timelines.

5.2 Physician Compensation

The PMA is a formal agreement signed by the Government of BC, the Doctors of BC, and the MSC. The three-year agreement (April 1, 2019 to March 31, 2022) supports ongoing efforts to recruit and retain physicians, while also improving access to FPs, specialists and health care in rural and remote communities.

The Doctors of BC represent the interests of all physicians who receive payment for the medical services they provide to beneficiaries in relation to the PMA. The PMA establishes mechanisms that promote enhanced collaboration and accountabilities between the Government of BC and Doctors of BC through various joint committees. It also provides a formal conflict management process at both the local and provincial levels, and language limiting physician service withdrawals. The role of health authorities in the planning and delivery of health care services is reinforced in the PMA.

The PMA establishes the compensation and benefit structure for physicians who provide publicly funded medical services whether via FFS, contract or blended capitation funding models. Through the PMA, the Government of BC also provides targeted financial support for areas such as: rural programs; specialist services; full-service family practice; and shared care models involving FPs, specialists and other health care professionals.

Physicians are registered by the College of Physicians and Surgeons of BC, a body established under the Health Professions Act. The PMA provides processes for monitoring and managing the funding established by the MSC under section 25 of the MPA for publicly funded medical services provided by physicians on a FFS basis. Mechanisms for revisions to the MSC Payment Schedule and for the payment of physicians are detailed in the PMA.

Dentists are registered by the College of Dental Surgeons of BC, which is also a body established under the Health Professions Act. The Province and the BC Dental Association (BCDA) are in the process of negotiating a new Dentistry Master Agreement for the period from April 1, 2019 to March 31, 2021 that covers the following services: dental surgery; oral surgery; orthodontic services; oral medicine; pediatric dental services; and dental technical procedures. The provisions of the prior Master Agreement, which was put into effect April 1, 2014 and expired on March 31, 2019, remain in place until a new agreement has been negotiated.Footnote 14 The Province and the BCDA collaborate through a Dentistry Liaison Committee.

Payment for medical services delivered in the province is made through MSP to the following: individual practitioners who submit claims under FFS; health authorities who contract and employ physicians for providing services to patients; and health authorities and/or physician groups who provide patient services under blended capitation funding models.

The MSC is authorized to monitor the billing and payment of claims in order to manage expenditures for medical and health care benefits on behalf of MSP beneficiaries. The Ministry's Billing Integrity Program monitors, audits and investigates billing patterns and practices of medical and health care practitioners to detect and deter inappropriate and incorrect billing of MSP claims to MSC. The Billing Integrity Program develops and analyzes practitioner's profiles, monitors trends, conducts audits, and, where appropriate, seeks recovery of inappropriately paid monies in accordance with the MPA.

5.3 Payments to Hospitals

Funding for publicly funded hospital services is included within annual funding allocations to health authorities, as well as specifically targeted funding from time to time. This funding allocation is used to fund the full range of necessary health services for the population of the region (or for specific provincial services, for the population of BC), including the provision of hospital services. Annual funding allocations to health authorities are determined as part of the Ministry's annual budget process in consultation with the Ministry of Finance and Treasury Board. The current year funding allocations and notional out-year allocations are conveyed to health authorities by means of annual funding letters.

The Hospital Insurance Act (including the Hospital Insurance Act Regulation) and the Health Authorities Act govern payments made by the Government of BC to health authorities. These statutes establish the authority of the Minister to make payments to regional health authorities and the Provincial Health Services Authority and specify in broad terms what services are publicly funded when provided within a hospital and in delivering regional and other health care services.

The BC Tripartite Framework Agreement on First Nation Health Governance and other negotiated agreements provide the basis for the Ministry to provide funding to the First Nations Health Authority. Funding to support the Nisga'a Nation health care services and programs is provided to the Nisga'a Valley Health Authority under the terms of the 1999 Nisga's Valley Health Board Transitional Funding Agreement.

The Ministry does not specifically fund hospitals directly; instead, health authorities are funded and provide operating budgets to hospitals within their regions to deliver specified services. The exception to this is when funding provided to health authorities (again not directly to hospitals) is targeted for specific priority projects (e.g., to fund wages or to provide operating funding to support large hospital construction projects coming on stream). Since it is specifically targeted, the funding must be reported on separately.

Annual incremental funding is allocated to health authorities using the Ministry's Population Needs-Based Funding model and other funding allocation methodologies (targeted funding allocations directed to specific health authorities, e.g., for wage costs related to collective bargaining). The annual funding allocation to health authorities does not include funding for programs directly operated by the Ministry, such as payments to physicians that occur through MSP and payments for prescription drugs that are covered under PharmaCare.

The accountability mechanisms associated with government funding for hospitals are part of several comprehensive documents that set expectations for health authorities. These include the annual funding letters, annual service plans, mandate letters, and annual bilateral agreements. Taken together, these documents convey the Ministry's broad expectations for health authorities and explain how performance will be monitored in relation to these expectations.

6.0 Recognition Given To Federal Transfers

Funding provided by the federal government through the Canada Health Transfer is recognized and reported by the Government of BC through various government websites and provincial government documents. In 2019–2020, these documents included:

Registered Persons
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
1. Number as of March 31st 4,746,685 4,827,696 4,925,188 4,997,617 5,108,915
Insured Hospital Services Within Own Province or Territory
Public Facilities 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
2. NumberBC table 2 Footnote 1 120 120 120 120 121
3. Payments for insured health services ($)BC table 2 Footnote 2 Not available Not available Not available Not available Not available
Private For-Profit Facilities 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
4. Number of private for-profit facilities providing insured health services Not available Not available Not available Not available Not available
5. Payments to private for-profit facilities for insured health services ($)  Not available Not available Not available Not available Not available
BC table 2 Footnote 1

As per the guidelines, the number of public facilities in this table excludes psychiatric hospitals and extended care facilities.

Return to footnote 1 referrer

Footnote 2

BC Ministry of Health Funding to Health Authorities for the provision of the full range of regionally delivered services are as follows: $11.5 billion in 2016-2017, $12.1 billion in 2017-2018, $12.7 billion in 2018-2019 and $13.7 billion in 2019-2020.

Return to footnote 2 referrer
Insured Hospital Services Provided to Residents in Another Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
6. Total number of claims, in-patient 7,159 5,270 5,898 5,417 5,622
7. Total payments, in-patient ($) 67,261,694 56,882,669 61,093,890 57,540,788 59,949,069
8. Total number of claims, out-patient 71,313 76,662 85,285 85,637 83,059
9. Total payments, out-patient ($) 29,450,951 28,619,689 31,232,700 31,331,256 31,703,771
Insured Hospital Services Provided Outside CanadaBC table 4 Footnote 1
Pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
10. Total number of claims, in-patient 38 18 47 28 44
11. Total payments, in-patient ($) 4,396,030 6,486,370 4,451,966 3,635,035 13,722,925
12. Total number of claims, out-patient Not Applicable Not Applicable Not Applicable Not Applicable 10
13. Total payments, pre-approved out-patient ($) Not Applicable Not Applicable Not Applicable Not Applicable 564,745
Non pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
14. Total number of claims, in-patient 2,380 1,982 1,743 2,092 1,817
15. Total payments, in-patient ($) 720,890 606,431 570,951 586,897 740,655
16. Total number of claims, out-patient 3,189 2,601 1,904 2,867 2,667
17. Total payments, out-patient ($) 2,375,378 2,782,841 2,987,362 2,652,836 6,749,987
BC table 4 Footnote 1

Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report, but did not require provinces or territories to report on previous years.

BC table 4 Return to footnote 1 referrer
Insured Physician Services Within Own Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
18. Number of participating physiciansBC table 5 Footnote 1 10,705 11,001 11,254 11,588 11,849
19. Number of opted-out physicians 2 2 2 2 2
20. Number of non-participating physicians Not available Not available Not available Not available Not available
21. Total payments for services provided by physicians paid through all payment methods ($) Not available Not available Not available Not available Not available
22. Total payments for services provided by physicians paid through fee-for-service ($) 2,907,582,518 3,023,409,095 3,097,014,160 3,234,028,029 3,342,862,100
BC table 5 Footnote 1

The number of participating physicians in item 18 is for physicians who received payments through fee-for-service.

BC table 5 Return to footnote 1 referrer
Insured Physician Services Provided to Residents in Another Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
23. Number of services 675,046 668,136 685,270 685,621 678,818
24. Total payments ($) 36,090,357 35,532,618 35,788,808 36,896,106 35,479,965
Insured Physician Services Provided Outside CanadaBC table 7 Footnote 1
Pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
25. Number of pre-approved services 1,891 2,178 1,931 2,260 3,783
26. Total pre-approved payments ($) 3,711,796 4,989,144 5,268,867 6,915,394 6,512,749
Non pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
27. Number of non pre-approved services 67,025 64,938 64,336 48,488 33,681
28. Total non pre-approved payments ($) 3,522,394 3,388,615 4,268,886 3,099,450 1,714,922
BC table 7 Footnote 1

Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report, but did not require provinces or territories to report on previous years.

Return to footnote 1 referrer
Insured Surgical-Dental Services Within Own Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
29. Number of participating dentists 207 192 200 208 201
30. Number of opted-out dentistsBC table 8 Footnote 1 Not available Not available Not available Not available Not available
31. Number of non-participating dentistsBC table 8 Footnote 1 Not available Not available Not available Not available Not available
32. Number of services provided 52,770 55,069 55,912 61,540 64,388
33. Total payments ($) 8,232,622 8,308,740 8,471,681 9,604,988 10,047,804
BC table 8 Footnote 1

Health Canada requested this data as of the 2019-2020 report, but did not require provinces or territories to report data for 2015-2016.

BC table 8 Return to footnote 1 referrer

Yukon

The Government of Yukon is committed to ensuring that Yukoners acquire the skills to live responsible, healthy and independent lives. The Minister of Health and 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).

The Health Services Division of DHSS is responsible for a variety of health care, disease prevention, and treatment services which assist eligible Yukon residents in attaining maximum independence within their community. The Health Services Division oversees Insured Health Services, Community Health Services, Community Nursing, Communicable Disease Control, Health Promotion, Dental Health, and Environmental Health.

In 2019–2020, DHSS focused on developing more comprehensive and coordinated programs and services that met people’s health needs, when and where services are required.

COVID-19

In March of 2020 the Yukon physician fee schedule was temporarily expanded to allow for the provision of additional telemedicine and virtual care services to make it safer for patients to connect with doctors during the COVID-19 pandemic.

1.0 Public Administration

1.1 Health Care Insurance Plan and Public Authority

The Insured Health and Hearing Services Branch (IHHS) is responsible for the delivery of health care benefits as set out in the Health Care Insurance Plan Act and Hospital Insurance Services Act. The overall objective of IHHS is to ensure access to, and portability of, insured physician and hospital services according to the provisions of these acts.

The Government of Yukon delivers insured health benefits according to the Yukon Health Care Insurance Plan (YHCIP) and the Yukon Hospital Insurance Services Plan (YHISP). Both the YHCIP and YHISP are administered by the Director, Insured Health and Hearing Services. This position is a joint appointment by the Minister of Health and Social Services (the Minister) and the Commissioner of the Yukon Territory.

The Health Care Insurance Plan Act, section 3(2) and section 4, establishes the public authority to operate the health care plan.

The Hospital Insurance Services Act, section 3(1) and section 5, establishes the public authority to operate the hospital care plan.

Subject to the Health Care Insurance Plan Act (section 5), the Hospital Insurance Services Act (section 6) and the Regulations, it is the responsibility of the Director, Insured Health and Hearing Services to:

Specific to the Hospital Insurance Services Act, the Director, Insured Health and Hearing Services has the responsibility to:

There were no amendments to either act in 2019–2020.

1.2 Reporting Relationship

The Department of Health and Social Services is accountable to the Legislative Assembly and the Government of Yukon through the Minister.

Section 6 of the Health Care Insurance Plan Act and section 7 of the Hospital Insurance Services Act require that the Director, Insured Health and Hearing Services make an annual report to the Minister of Health and Social Services respecting the administration of the two health insurance plans. A Statement of Revenue and Expenditures is tabled in the legislature and is subject to discussion at that level. The Statement of Revenue and Expenditures was tabled in the 2019 fall sitting of the Yukon legislature.

1.3 Audit of Accounts

The Health Care Insurance Plan and the Hospital Insurance Services Plan are subject to audit by the Office of the Auditor General of Canada. The Auditor General of Canada is the Auditor of the Government of Yukon in accordance with section 34 of the Yukon Act (Canada). The Auditor General is required to conduct an annual audit of the transactions and consolidated financial statements of the Government of Yukon. Further, the Auditor General of Canada is to report to the Yukon Legislative Assembly any matter falling within the scope of the audit that, in his or her opinion, should be reported to the Assembly.

Further, section 13(2) of the Hospital Act requires the Yukon Hospital Corporation to submit a report of their operations for that fiscal year to the Minister within six months after the end of each fiscal year. The report is to include the financial statements of the Corporation and the Auditor’s report.

2.0 Comprehensiveness

2.1 Insured Hospital Services

The Hospital Insurance Services Act, sections 3, 4, 5, 6 and 9, establish authority to provide insured hospital services to insured residents. The Yukon Hospital Insurance Services Ordinance was first passed in 1960 and came into effect April 9, 1960. No amendments were made to the Act in 2019-2020.

Adopted on December 7, 1989, the Hospital Act establishes the responsibility of the legislature and the government to ensure “compliance with appropriate methods of operation and standards of facilities and care.” Adopted on November 11, 1994, the annexed Hospital Standards Regulation sets out the conditions under which all hospitals in the territory are to operate. Section 4(1) provides for the Ministerial appointment of one or more investigators to report on the management and administration of a hospital. Section 4(2) requires that the hospital’s Board of Trustees establish and maintain a quality assurance program.

In April 1997, the Yukon Government assumed responsibility for operating health units in rural Yukon communities from the federal government. These health centres are staffed by one or more nurses and auxiliary staff. Primary Health Care Nurses in the absence of a physician, provide daily clinics for medical treatment, community health programs and 24-hour emergency services in 11 communities throughout Yukon along with the Whitehorse Health Centre which offers immunization clinics and prenatal and postnatal care.

In 2019–2020, insured in-patient and out-patient hospital services were delivered in 14 facilities throughout the territory. These facilities include Whitehorse General Hospital, Watson Lake Community Hospital, Dawson City Community Hospital and 11 Community Health Centres. In addition, in March 2020 a respiratory assessment centre was opened in Whitehorse, Yukon to assess patients with respiratory illnesses and test for COVID-19.

Pursuant to the Hospital Insurance Services Regulations, section 2(e) and (f), services provided in an approved hospital are insured. Section 2(e) defines in-patient insured services as all of the following services to in-patients, namely:

Section 2(f) of the Regulations defines “out-patient insured services” as all of the following services to out-patients, when used for emergency diagnosis or treatment within 24 hours of an accident (period may be extended by the Administrator, provided the service could not be obtained within 24 hours of the accident):

Pursuant to the Hospital Insurance Services Regulations, all in-patient and out-patient services provided in an approved hospital, by hospital employees, are insured services. Standard nursing care, pharmaceuticals, supplies, diagnostic and operating services are provided. Any new programs or enhancements with significant funding implications or reductions to services or programs require the prior approval of the Minister, Health and Social Services. This process is managed by the Director, Insured Health and Hearing Services. Public representation regarding changes in service levels is made through membership on the hospital board.

2.2 Insured Physician Services

Insured physician services in Yukon are defined as medically required services rendered by a medical practitioner. Sections 1 to 8 of the Health Care Insurance Plan Act and sections 2, 3, 7, 10 and 13 of the Health Care Insurance Plan Regulations provide for insured physician services. No amendments were made to the Act in 2019-2020.

The Yukon Health Care Insurance Plan covers physicians providing medically required services. In order to participate in the Yukon Health Care Insurance Plan, physicians must:

There were 80 physicians participating in the Yukon Health Care Insurance Plan in 2019–2020. These physicians were supplemented by visiting locum physicians who provide care throughout Yukon. In 2019-2020 there were no physicians practicing in the territory who were providing services outside of the Yukon Health Care Insurance Plan.

Section 7 of the Yukon Health Care Insurance Plan Regulations covers payment for medical services. Subsection 4 allows physicians to make arrangements for payment for insured services on a basis other than fee-for-service. Notice in writing of this election must be submitted to the Director, Insured Health and Hearing Services. In 2019–2020, physicians were remunerated by both fee-for-service and through alternative payment arrangements.

The process used to add a new fee to the Payment Schedule for Yukon is administered through a committee structure. This process requires physicians to submit requests in writing to the Yukon Health Care Insurance Plan, Yukon Medical Association Fee Liaison Committee. Following review by this committee, a decision is made to include or exclude the service. The relevant fees are normally set in accordance with similar fees in other jurisdictions. Once a fee-for-service value has been determined, notification of the service and the applicable fee is provided to all Yukon physicians. Public consultation is not required.

Alternatively, new fees can be implemented as a result of the fee negotiation process between the Yukon Medical Association and the Department of Health and Social Services.

The current Memorandum of Understanding (MOU) with the Yukon Medical Association maintains a focus on collaborative care and ensures greater access for patients, and targets the creation of multi-disciplinary teams that include further integration of nurse practitioners into the care system. The current five-year MOU with the Yukon Medical Association will end on March 31, 2022.

2.3 Insured Surgical-Dental Services

Dentists providing insured surgical-dental services under the Health Care Insurance Plan of Yukon must be licensed pursuant to the Dental Professions Act and are given billing numbers to bill the Yukon Health Care Insurance Plan for providing insured dental services. The Plan is also billed directly for services provided outside the territory.

Insured dental services are limited to those surgical-dental procedures listed in Schedule B of the Health Care Insurance Plan Regulations. The procedures must be performed in a hospital. In 2019-2020 no dentists provided insured surgical-dental services under the Yukon Health Care Insurance Plan.

The addition or deletion of new surgical-dental services to the list of insured services requires amendment by Order-in-Council to Schedule B of the Health Care Insurance Plan Regulations. Coverage decisions are made on the basis of whether or not the service must be provided in hospital under general anaesthesia. The Director, Insured Health and Hearing Services administers this process.

There were no new insured surgical-dental services added in 2019-2020.

2.4 Uninsured Hospital, Physician and Surgical-Dental Services

Only services prescribed by and rendered in accordance with the Health Care Insurance

Plan Act and Regulations and the Hospital Insurance Services Act and Regulations are insured. All other services are uninsured.

Uninsured hospital services include:

Section 3 of the Yukon Health Care Insurance Plan Regulations contains a list of services that are prescribed as non-insured. Uninsured physician services include:

Physicians in Yukon may bill patients directly for non-insured services. Block fees are not used at this time; however, some do bill by service item. Billable services include but are not limited to:

Payment does not affect patient access to services because not all physicians or clinics bill for these services and other agencies or employers may cover the cost.

Uninsured dental services include procedures considered restorative and procedures that are not performed in a hospital under general anaesthesia.

All Yukon residents have equal access to services. Third parties, such as private insurers or the Worker’s Compensation Health and Safety Board, do not receive priority access to services through additional payment. The purchase of non-insured services, such as fiberglass casts, does not delay or prevent access to insured services at any time. Insured persons are given treatment options at the time of service.

Yukon has no formal process to monitor compliance; however, feedback from physicians, hospital administrators, medical professionals and staff allows the Director, Insured Health and Hearing Services to monitor usage and service concerns.

The process used to de-insure services covered by the Yukon Health Insurance Plan is as follows:

Physician services—the joint Yukon Health Care Insurance Plan and Yukon Medical Association Fee Liaison Committee is responsible for reviewing changes to the Payment Schedule for Yukon including decisions to de-insure certain services. In consultation with the Yukon Medical Advisor, decisions to de-insure services are based on medical evidence that indicates the service is not medically necessary, is ineffective or a potential risk to the patient’s health. Once a decision has been made to de-insure a service, all physicians are notified in writing.

Hospital services—an amendment by Order-in-Council to sections 2(e) and 2(f) of the Yukon Hospital Insurance Services Regulations would be required. As of March 31, 2020, no insured in-patient or out-patient hospital services, as provided for in the Regulations, have been de-insured.

Surgical-dental services—an amendment by Order-in-Council to Schedule B of the Health Care Insurance Plan Regulations is required. A service could be de-insured if determined not medically necessary or is no longer required to be carried out in a hospital under general anaesthesia. The Director, Insured Health and Hearing Services manages this process. No surgical-dental services were de-insured in 2019–2020.

3.0 Universality

3.1 Eligibility

Eligibility requirements for insured health services are set out in the Health Care Insurance Plan Act and Regulations, sections 2 and 4, and the Hospital Insurance Services Act and Regulations, sections 2 and 4. There were no changes to the legislation in 2019-2020.

Subject to the provisions of these acts and regulations, every Yukon resident is eligible for and entitled to insured health services on uniform terms and conditions. The term “resident” is defined using the wording of the Canada Health Act and means a person lawfully entitled to be or to remain in Canada, who makes his or her home and is ordinarily present in Yukon, but does not include a tourist, transient, foreign student or visitor. Pursuant to section 4(1) of the Yukon Health Care Insurance Plan Regulations and the Yukon Hospital Insurance Services Regulations, an insured person is eligible for and entitled to insured services after midnight on the last day of the second month following the month of arrival to the Territory. All persons returning to or establishing residency in Yukon are required to complete this waiting period. The only exception is for children adopted by insured persons, and for newborns.

The following persons are not eligible for coverage in Yukon:

The above persons may become eligible for coverage if they meet one or more of the following conditions:

As of March 31, 2020, there were 42,382 registrants in the Yukon Health Care Insurance Plan.

3.2 Other Categories of Individuals

The Yukon Health Care Insurance Plan provides health care coverage for other categories of individuals, as follows:

International students, temporary workers, tourists, transients or visitors to Yukon do not qualify as residents of the territory and are not eligible for Yukon Health Care Insurance Plan coverage.

4.0 Portability

4.1 Minimum Waiting Period

Where applicable, the eligibility of all persons is administered in accordance with the Interprovincial Agreement on Eligibility and Portability. Under section 4(1) of both the Health Care Insurance Plan Act and the Hospital Insurance Services Act Regulations, “an insured person is eligible for and entitled to insured services after midnight on the last day of the second month following the month of arrival to the Territory.” All persons entitled to coverage are required to complete the minimum waiting period with the exception of children adopted by insured persons (see section 3.1), and newborns.

4.2 Coverage during Temporary Absences in Canada

The provisions relating to portability of health care insurance during temporary absences outside Yukon, but within Canada, are defined in sections 5, 6, 7 and 10 of the Yukon Health Care Insurance Plan Regulations and sections 6, 7(1), 7(2) and 9 of the Yukon Hospital Insurance Services Regulations. There were no changes to these regulations in 2019-2020.

The Regulations state that, “where an insured person is absent from the Territory and intends to return, he/she is entitled to insured services during a period of 12 months of continuous absence.” Persons leaving Yukon for a period exceeding six months must contact Yukon Insured Health Services and complete a Temporary Absence form. Failure to do so may result in cancellation of coverage.

Students attending educational institutions full-time outside Yukon remain eligible for the duration of their academic studies. 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. Requests for extensions must be renewed yearly and are subject to approval by the Director.

For temporary workers and missionaries, the Director may approve absences in excess of 12 consecutive months upon receiving a written request from the insured person. Requests for extensions must be renewed yearly and are subject to approval by the Director.

The provisions regarding coverage during temporary absences in Canada fully comply with the terms and conditions of the Interprovincial Agreement on Eligibility and Portability effective February 1, 2001. Definitions are consistent in regulations, policies and procedures.

Yukon participates fully with the Interprovincial Medical Reciprocal Billing Agreements and Hospital Reciprocal Billing Agreements in place with all other provinces and territories with the exception of Quebec, which does not participate in the medical reciprocal billing arrangement. Persons receiving medical (physician) services in Quebec may be required to pay directly and submit claims to the Yukon Health Care Insurance Plan for reimbursement.

The Hospital Reciprocal Billing Agreements provide for payment of insured in-patient and out-patient hospital services to eligible residents receiving insured services outside Yukon, but within Canada.

The Medical Reciprocal Billing Agreements provide for payment of insured physician services on behalf of eligible residents receiving insured services outside Yukon, but within Canada.

Insured services provided to Yukon residents while temporarily absent from the territory are paid at the rates established by the host province.

4.3 Coverage during Temporary Absences outside Canada

The provisions that define portability of health care insurance to insured persons during temporary absences outside Canada are defined in sections 5, 6, 7, 9, 10 and 11 of the Yukon Health Care Insurance Plan Regulations and sections 6, 7(1), 7(2) and 9 of the Yukon Hospital Insurance Services Regulations. There were no changes to these regulations in 2019-2020.

Sections 5 and 6 state that, where an insured person is absent from Yukon and intends to return, the person is entitled to insured services during a period of 12 months of continuous absence.

Persons leaving Yukon for a period exceeding six months must contact Yukon Health Care Insurance Plan and complete a Temporary Absence form. Failure to do so may result in cancellation of the coverage.

The provisions for portability of health insurance during out-of-country absences for students, temporary workers and missionaries are the same as for absences within Canada (see section 4.2 of this report).

Insured physician services provided to eligible Yukon residents temporarily outside the country are paid at rates equivalent to those paid had the service been provided in Yukon. Reimbursement is made to the insured person by the Yukon Health Care Insurance Plan or directly to the provider of the insured service.

Insured in-patient hospital services provided to eligible Yukon residents outside Canada are paid at the rate established in the Standard Ward Rates Regulation for the Whitehorse General Hospital. For 2019–2020 the in-patient rate was set at $2,010 per day at Whitehorse General Hospital, $1,788 per day at Watson Lake Community Hospital and $1,724 per day at Dawson City Community Hospital. These rates are set annually by the Interprovincial Health Insurance Agreements Coordinating Committee (IHIACC).

Insured out-patient hospital services provided to eligible Yukon residents outside Canada are paid at the rate established by the IHIACC.

4.4 Prior Approval Requirement

There is no legislated requirement that eligible residents must seek prior approval before seeking elective or emergency hospital or physician services outside Yukon or outside Canada.

When treatment is provided outside Yukon or outside Canada plan members will only be reimbursed the amounts as described in Sections 4.2 and 4.3.

Prior approval by the Director of Insured Health Services is required for full reimbursement of services sought outside of Canada.

5.0 Accessibility

5.1 Access to Insured Health Services

There are no user fees or user charges under the Yukon Health Care Insurance Plan. All services are provided on a uniform basis and are not impeded by financial or other barriers. There is no extra-billing in Yukon for any services covered by the Plan.

In 2019-2020 Yukon did not have any private for-profit health care facilities delivering insured health services.

If a patient has a complaint related to physician services including extra-billing or user charges they can contact the Yukon Medical Council (YMC).

Information on complaints can be found on the YMC’s website.

The YMC can be reached by phone at 867-667-3774 or by email to ymc@gov.yk.ca.

Access to hospital or physician services not available locally are provided through the Visiting Specialist Program, Telehealth Program, or the Travel for Medical Treatment Program. These programs ensure that there is minimal or no delay in receiving medically necessary services.

To improve access to insured health services, the number of resident specialists working in Yukon continues to increase to better serve Yukoners.

Additionally, Insured Health and Hearing Services provides extended health benefits to eligible Yukon residents which include the Travel for Medical Treatment Program, the Children’s Drug and Optical Program, the Chronic Disease and Disability Benefits Program, Pharmacare Program, Extended Benefits Program, and Hearing Services Program.

The Yukon Hospital Corporation operates the three hospitals in the territory: Whitehorse General Hospital, Watson Lake Community Hospital, and Dawson City Community Hospital.

5.2 Physician Compensation

The Department of Health and Social Services seeks its negotiating mandate from the Government of Yukon before entering into negotiations with the Yukon Medical Association (YMA). The YMA and the government each appoint members to the negotiating team. Meetings are held as required until an agreement has been reached. The YMA’s negotiating team then seeks approval of the tentative agreement from the YMA membership. The Department seeks ratification of the agreement from the Government of Yukon. The final agreement is signed with the concurrence of both parties.

The legislation governing payments to physicians and dentists for insured services are the Health Care Insurance Plan Act and the Health Care Insurance Plan Regulations.

The fee-for-service system is used to reimburse the majority of physicians providing insured services to residents. Other systems of reimbursement include alternative payment arrangements which are primarily used for specialist services in Whitehorse as well as physician services in rural communities.

5.3 Payments to Hospitals

The Government of Yukon funds the Yukon Hospital Corporation (Whitehorse General Hospital, Watson Lake Community Hospital, and Dawson City Community Hospital) through contribution agreements with the Department of Health and Social Services. Global operations and maintenance (O&M) and capital funding levels are negotiated and adjusted based on operational requirements. In addition to the established O&M and capital funding set out in the agreement, provision is made for the hospital to submit requests for additional funding assistance for implementing new or enhanced programs.

The legislation governing payments made by the health care plan to facilities that provide insured hospital services is the Hospital Insurance Services Plan Act and Regulations. The legislation and regulations set out the legislative framework for payment to hospitals for insured services provided by that hospital to insured persons.

6.0 Recognition Given to Federal Transfers

The Government of Yukon has acknowledged the federal contributions provided through the Canada Health Transfer (CHT) in its 2019–2020 annual Main Estimates and Public Accounts publications, which are available publicly. Section 3(1) (d) and (e) of the Health Care Insurance Plan Act and section 3 of the Hospital Insurance Services Act acknowledge the contribution of the Government of Canada.

Registered Persons
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
1. Number as of March 31st 38,736 39,960 40,726 41,412 42,382
Insured Hospital Services Within Own Province or Territory
Public FacilitiesYukon table 2 Footnote 1 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
2. Number 14 14 14 14 14
3. Payments for insured health services ($)
96,850,809 98,671,448 95,464,882 79,548,179 88,761,576
Private For-Profit Facilities 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
4. Number of private for-profit facilities providing insured health services 0 0 0 0 0
5. Payments to private for-profit facilities for insured health services ($)  0 0 0 0 0
Yukon table 2 Footnote 1

Public facilities are the 11 health centres (Beaver Creek, Carcross, Carmacks, Destruction Bay, Faro, Haines Junction, Mayo, Old Crow, Pelly Crossing, Ross River, and Teslin) and 3 hospitals (Whitehorse, Dawson City and Watson Lake). As Whitehorse, Dawson City and Watson Lake all have hospitals, the health centres in these communities are classified as a Public Health Offices.

Yukon table 2 Return to footnote 1 referrer
Insured Hospital Services Provided to Residents in Another Province or TerritoryYukon table 3 Footnote 1
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
6. Total number of claims, in-patient 1,235 1,218 1,220 1,236 1,491
7. Total payments, in-patient ($) 17,865,677 18,981,947 18,611,146 18,687,516 24,844,188
8. Total number of claims, out-patient 14,513 14,785 15,554 15,856 15,583
9. Total payments, out-patient ($) 4,851,075 5,429,919 5,615,333 5,786,856 5,809,521
Yukon table 3 Footnote 1

Hospitals have up to a year from date of service to bill jurisdictions (information is based upon date of service; therefore, 2019-20 billing period is open until March 31, 2021).

Yukon table 3 Return to footnote 1 referrer
Insured Hospital Services Provided Outside CanadaYukon table 4 Footnote 1Yukon table 4 Footnote 2
Pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
10. Total number of claims, in-patient Not available Not available Not available Not available Not available
11. Total payments, in-patient ($) Not available Not available Not available Not available Not available
12. Total number of claims, out-patient Not available Not available Not available Not available Not available
13. Total payments, out-patient ($) Not available Not available Not available Not available Not available
Non pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
14. Total number of claims, in-patient 23 18 10 19 7
15. Total payments, in-patient ($) 62,040 164,673 82,088 136,430 35,883
16. Total number of claims, out-patient 48 42 58 56 46
17. Total payments, out-patient ($) 12,646 13,482 16,590 18,166 29,558
Yukon table 4 Footnote 1

Yukon does not have an electronic method of capturing pre-approved claims versus non pre-approved claims. Totals are reported as non pre-approved claims.

Yukon table 4 Return to footnote 1 referrer

Yukon table 4 Footnote 2

Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report,but did not require provinces or territories to report on previous years.

Yukon table 4 Return to footnote 2 referrer
Insured Physician Services Within Own Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
18. Number of participating physicians 72 78 77 80 80
19. Number of opted-out physicians 0 0 0 0 0
20. Number of non-participating physicians 0 0 0 0 0
21. Total payments for services provided by physicians paid through all payment methods ($) 27,753,925 29,654,509 30,764,362 32,836,649 35,876,192
22. Total payments for services provided by physicians paid through fee-for-service ($) 19,851,219 20,625,637 21,013,041 22,675,907 25,066,841
Insured Physician Services Provided to Residents in Another Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
23. Number of services 62,027 52,766 55,902 56,302 71,257
24. Total payments ($) 3,954,752 4,018,173 4,422,905 4,333,394 5,376,424
Insured Physician Services Provided Outside CanadaYukon table 7 Footnote 1
Pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
25. Number of services Not available Not available Not available Not available Not available
26. Total payments ($) Not available Not available Not available Not available Not available
Non pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
27. Number of services Not available Not available Not available Not available Not available
28. Total payments ($) Not available Not available Not available Not available Not available
Yukon table 7 Footnote 1

Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report,but did not require provinces or territories to report on previous years.

Yukon table 7 Return to footnote 1 referrer
Insured Surgical-Dental Services Within Own Province or TerritoryYukon table 8 Footnote 1
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
29. Number of participating dentists 0 0 0 0 0
30. Number of opted-out dentistsYukon table 8 Footnote 2 0 0 0 0 0
31. Number of non-participating dentists Yukon table 8 Footnote 2 0 0 0 0 0
32. Number of services provided 0 0 0 0 0
33. Total payments ($) 0 0 0 0 0
Yukon table 8 Footnote 1

No insured surgical-dental services performed in Yukon.

Yukon table 8 Return to footnote 1 referrer

Yukon table 8 Footnote 2

Health Canada requested this data as of the 2016-2017 report, but did not require provinces or territories to report data for 2015-16.

Yukon table 8 Return to footnote 2 referrer

Northwest Territories

The Department of Health and Social Services (the Department) is responsible for setting the strategic direction for the health and social services system through the development of legislation, policy and standards; establishing approved programs and services; establishing and monitoring system budgets and expenditures; and evaluating and reporting on system outcomes and performance. The Department is responsible for ensuring that all statutory functions and requirements are fulfilled, ensuring professionals are appropriately licensed and managing access to health insurance.

The Health and Social Services Authorities are governed by the Leadership Council. Regional Wellness Councils provide advice to the Leadership Council and valuable input on the needs and priorities of the residents in their regions. The Leadership Council is responsible to the Minister of Health and Social Services for governing, managing and providing health and social services in accordance with the plan set out by the Minister.

The Department recognizes that the identification of priorities and the development and delivery of responsive programs and services is best managed in partnership with Indigenous people and communities through an integrated system.  

In response to the COVID-19 pandemic, the Northwest Territories Health and Social Services Authority expanded Virtual Care options to support care in remote communities, to reduce the need to travel for care, and to replace in-person appointments – where appropriate - with phone, telemedicine, or video conferencing applications.

To support the reduction of in-person appointments amendments were made to the Pharmacy Act Continuing Care Prescription Regulations to provide for additional refills. The amendments only have effect with the direction of the Chief Public Health Officer, during a Public Health Emergency declared by the Minister pursuant to the Public Health Act.

1.0 Public Administration

1.1 Health Care Insurance Plan and Public Authority

The Northwest Territories (NWT) Health Care Plan consists of the NWT Medical Care Plan and the NWT Hospital Insurance Plan.

The public authority responsible for the administration of the NWT Medical Care Plan is the Director of Medical Insurance, appointed by the Minister of Health and Social Services (the Minister), under s.23(1) of the Medical Care Act. The Minister establishes the Northwest Territories Health and Social Services Authority and the Health and Social Service Authorities' Boards of Management pursuant to s.5(1), s.10(1), and s.10(2) of the Hospital Insurance and Health and Social Services Administration Act. The Hospital Insurance and Health and Social Services Administration Act recognizes, at s.10.3(1), that the Tłı̨chǫ Community Services Agency established by the Tłı̨chǫ Community Services Agency Act is deemed to be a Board of Management. The territorial authority and the boards administer the Hospital Insurance Plan; their legislated mandate is to:

There were no amendments made in 2019-2020 to the Medical Care Act or the Hospital Insurance and Health and Social Services Administration Act.

1.2 Reporting Relationship

During the reporting period there were three Health and Social Service Authorities: Northwest Territories Health and Social Services Authority (Territorial Authority), Hay River Health and Social Services Authority, and Tłı̨chǫ Community Services Agency.

Territorial Authority affairs are directed by a Territorial Board of Management.

Six Regional Wellness Councils provide advice to the Territorial Board of Management, which is composed of the Regional Wellness Council chairpersons and the chairpersons of the Tłı̨chǫ Community Services Agency and Hay River Health and Social Services Authority. The Territorial Board of Management and the remaining Boards of Management are accountable to the Minister.

The Territorial Board of Management and the remaining Boards of Management are responsible for the delivery of health and social services and for the management, control, and operation of facilities and services throughout the Northwest Territories. The Territorial Board of Management and the Boards of Management are required under legislation to comply with the territorial plan, which is set by the Minister.

The Minister appoints the Director of Medical Insurance who is responsible for administering the Medical Care Act and its Regulations. The Director prepares an annual report for the Minister on the operation of the NWT Medical Care Plan. This report can be found within the NWT Health and Social Services Annual Report 2019-2020.Footnote 15

The Minister appoints the Chair of the Territorial Board of Management as well as the chairperson and members of each Regional Wellness Council. The Minister also appoints the Chair and Members of the Hay River Health and Social Services Authority. The chairpersons and members of the Regional Wellness Councils may serve for three years and may be re-appointed to serve another term.

The Minister may appoint a Public Administrator to assume the role of a Board of Management in certain circumstances if the Minister feels it is necessary. During 2019-2020, a Public Administrator was in place for the Hay River Health and Social Services Authority. The Public Administration acts in the place of a Board of Management.

The Tłı̨chǫ Community Services Agency was established under the Tłı̨chǫ Community Services Agency Act as part of the Tłı̨chǫ Land Claims and Self Government Agreement.  The Act, which is administered by the Minister of Executive and Indigenous Affairs, stipulates that the Tłı̨chǫ Community Services Agency has all the powers, duties and functions of a Board of Management under the Hospital Insurance and Health and Social Services Administration Act. Under the Act, each Tłı̨chǫ community government is responsible for appointing one board member and the Minister of Executive and Indigenous Affairs is responsible for appointing the Chairperson following a consultation with the board members.  The Act also sets the term for members to a maximum of four years with the Chairperson’s term being fixed by the Minister.

The Director of Medical Insurance and the Boards of Management are responsible to the Minister, as per section 8(1)(b) of the Canada Health Act.

In accordance with the Financial Administration Act and the Hospital Insurance and Health and Social Services Administration Act, there is an obligation to report to the Legislative Assembly on the preceding year’s operations and financial position of the Department of Health and Social Services (the Department).  Each year the NWT Health and Social Services System Annual Report meets these obligations, as well as meets the obligation to annually table a report on the operations of the Medical Care Plan.

1.3 Audit of Accounts

The Office of the Auditor General of Canada (OAG) audits payments made under the NWT Hospital Insurance Plan and the NWT Medical Care Plan through their annual audit of the Government of the NWT’s Public Accounts.

The Hospital Insurance Plan and the Medical Care Plan are administered by the Department of Health and Social Services. The latest OAG audit was on the 2018-2019 Public Accounts and was completed as of November 27, 2019. The GNWT, Public Accounts 2018-2019 was published on December 10, 2019.

2.0 Comprehensiveness

2.1 Insured Hospital Services

Insured hospital services in the Northwest Territories (NWT) are provided under the Hospital Insurance and Health and Social Services Administration Act.  No amendments were made to the Act.  In February 2020, the Critical Incident Regulations came into effect. The Critical Incident Regulations address mandatory notification of critical incidents or alleged critical incidents. A critical incident is an unintended event that occurs when health services are provided to an individual and results in a consequence to him or her that is serious and undesired, such as death, disability, injury or harm, unplanned admission to hospital or unusual extension of a hospital stay, and does not result from the individual's underlying health condition or from a risk inherent in providing health services.

During the reporting period, insured hospital services were provided to in-patients and out-patients by 23 facilities throughout the NWT. Consistent with Section 9 of the Canada Health Act, the NWT offers a comprehensive range of insured services to its residents.

Insured in-patient hospital services include:

Insured out-patient hospital services include:

The Minister of Health and Social Services (the Minister) may approve additions or deletions to insured services provided in the NWT.  While there were no changes to insured services in 2019-2020, assessment of additions is accomplished on a case by case basis. The Director of Medical Insurance makes such determinations based on the advice of the Medical Advisor. This process is a ‘right size’ approach, scaling the complexity of decision making to be appropriate to the size of the NWT health and social services system.  Public consultation is readily available through Regional Wellness Councils.

As outlined in the Government of the NWT Medical Travel Policy, travel assistance is provided to residents with a valid NWT Health Care Card who require medically necessary insured services that are not available in their home community or elsewhere in the NWT.Footnote 16 This ensures that residents of the NWT have reasonable access to insured hospital and physician services.

The NWT does not have any private diagnostic clinics charging patients for services that would be considered insured if provided in a hospital.

2.2 Insured Physician Services

The NWT Medical Care Act and the NWT Medical Care Regulations provide for insured physician services. Medically necessary services provided in approved facilities by physicians, nurses, nurse practitioners, and midwives are considered insured services under the NWT Health Care Plan. These professionals are required by legislation to be licensed to practice in the NWT under the Medical Profession Act (physicians), Nursing Profession Act (nurses and nurse practitioners) and Midwifery Profession Act. Amendments to the Midwifery Profession General Regulations to update the Continuing Competency Program and the Code of Conduct for registered midwives in the NWT were made in October 2019.

For the period 2019–2020, there were 411 licensed physicians (resident, locum and visiting) active in the NWT.

Physicians may opt out and collect fees other than under the NWT Medical Care Plan by providing written notice to the Director of Medical Insurance. There were no opted-out physicians in the NWT during the reporting period.

The NWT Medical Care Plan insures all medically necessary physician services such as:

Services not insured include:

The Director of Medical Insurance is responsible for recommending an insured services tariff for services payable by the NWT Medical Care Plan for the Minister's approval. The Minister ultimately determines if services will be added, altered, or removed from the tariff by:

While there were no changes to insured services in 2019-2020, assessment of additions is accomplished on a case by case basis. The Director of Medical Insurance makes such determinations based on the advice of the Medical Advisor. This process is a ‘right size’ approach, scaling the complexity of decision making to be appropriate to the size of the NWT health and social services system.  Public consultation is readily available through Regional Wellness Councils.

2.3 Insured Surgical-Dental Services

Licensed oral surgeons may submit claims for insured surgical-dental work in the NWT. The Province of Alberta's Schedule of Oral and Maxillofacial Surgery Benefits is used as a guide.Footnote 17

Dentists are unable to participate in the NWT Medical Care Plan except where medically necessary and performed in a hospital. Dentists, when delivering services in a hospital, bill third-party insurance providers for dental surgery, and the anaesthetic services are covered under the NWT Medical Care Plan.

The only surgical-dental related procedures, covered under insured services, are for procedures focusing on reconstructive surgery of the face, primarily of the mouth and jaw as a result of trauma or birth defect. Such procedures are not identified as dental surgery but are identified as medically necessary surgery and are subject to physician referral.  No procedures were added in 2019-2020 to list of insured surgical services covered by the NWT Medical Care Plan.

2.4 Uninsured Hospital, Physician and Surgical-Dental Services

Not all services provided by hospitals, medical practitioners and dentists are covered under the NWT Health Care Plan. Some uninsured services include:

Prior approval is required for NWT residents to receive items, services, or both, that are generally considered uninsured under the NWT Health Care Plan. A Medical Advisor makes recommendations to the Director of Medical Insurance regarding the appropriateness of the request.

The Workers' Safety and Compensation Commission (WSCC) covers the costs of the services to treat a worker who is injured on the job according to WSCC policy. The policy that covers requirements for entitlement can be found in NWT and Nunavut WSCC, Policy Manual, (Policy 03.02) available on the Workers' Safety and Compensation Commission site.

Changes to the list of uninsured hospital, physician, and surgical-dental services may be made by the Minister. While there were no changes to uninsured services in 2019-2020, assessment of additions is accomplished on a case by case basis. The Director of Medical Insurance makes such determinations based on the advice of the Medical Advisor. This process is a ‘right size’ approach, scaling the complexity of decision making to be appropriate to the size of the NWT health and social services system.  Public consultation is readily available through Regional Wellness Councils.

3.0 Universality

3.1 Eligibility

The Medical Care Act and the Hospital Insurance and Health and Social Services Administration Act define eligibility for the Northwest Territories (NWT) Health Care Plan. The NWT uses guidelines that are consistent with the legislation and Interprovincial Agreement on Eligibility and Portability to determine eligibility in order to fulfill obligations of section 10 in the Canada Health Act.

Every resident is, on the first day of the third month after becoming a resident, eligible for and entitled to payment of benefits in respect of insured services rendered to the resident in accordance with the Medical Care Act and Medical Care Regulations.

According to the Medical Care Act, a resident is a person lawfully entitled to be or to remain in Canada, who makes their home and is ordinarily present in the NWT, but does not include a tourist, transient, or visitor to the NWT. There were no amendments to the Medical Care Act regarding eligibility made in 2019-2020.

In order to register for the NWT Health Care Plan, residents fill out an application form and provide relevant supporting documentation (e.g., visa, immigration papers, and proof of residency). Residents may register prior to the date they become eligible. Registration is directly linked to eligibility for coverage and claims are only paid if the client has registered.

Coverage begins when a signed application has been approved.

Residents can opt out of the NWT Health Care Plan if they choose not to register. There is nothing in the Medical Care Act that requires a resident to register for the NWT Health Care Plan. At any time, a resident may advise the NWT Health Care Plan administrator of a wish to opt out of the Plan.

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 period. For persons moving back to Canada, eligibility is restored when permanent residency is established.

In accordance with the Interprovincial Agreement on Eligibility and Portability of Hospital and Medical Care Insurance, residents who have been federal inmates become eligible upon release to the NWT; permanent residents become eligible upon establishment of permanent residency. Returning Canadians are eligible on the first day of arrival in NWT and permanent residents are also eligible on the first day, provided that the NWT is the first jurisdiction they are residing in upon arriving in or returning to Canada.

If an application for an NWT Health Care Card is denied, coverage is denied for a procedure, or if a person is appealing the decision to cancel their NWT Health Care Card, individuals may appeal to the Director of Medical Insurance. Second level and final appeals may be directed to the Deputy Minister of Health and Social Services.

As of March 31, 2020, there were 42,501 individuals registered with the NWT Health Care Plan.

3.2 Other Categories of Individuals

Holders of employment visas, student visas and, in some cases, visitor visas are covered if they meet the provisions of the Eligibility and Portability Agreement and guidelines for NWT Health Care Plan coverage.

Babies born to NWT residents outside of Canada are automatically covered effective on the date of birth, if:

Foreign students and workers are eligible for coverage if they hold study or work permits valid for a period of 12 months or longer. Those holding permits of less than 12 months are not eligible for coverage.

Permanent residents (landed immigrants) and returning permanent residents, including those with expired residency, are covered on the first day of arrival in the NWT provided the NWT is their first place of residence in Canada, and they intend to reside in the NWT.

Convention refugees are covered, provided they provide appropriate documentation.

The following are not eligible for an NWT Health Care Card as they are not considered residents:

4.0 Portability

4.1 Minimum Waiting Period

Waiting periods for persons moving to the Northwest Territories (NWT) are consistent with the Interprovincial Agreement on Eligibility and Portability. The waiting period ends the first day of the third month of residency for those moving permanently to the NWT.

4.2 Coverage during Temporary Absences in Canada

Section 4(2) of the Medical Care Act provides NWT residents with access to insured health coverage while temporarily out of the NWT but still in Canada, consistent with section 11(1) (b)(i) of the Canada Health Act. The Department of Health and Social Services (the Department) adheres to the Interprovincial Agreement on Eligibility and Portability. No amendments were made in 2019-2020 to the Medical Care Act.

NWT residents may be covered for up to one year of temporary absence for work, travel or holidays. Full-time students attending post-secondary school are covered as well. The full cost of insured services is paid for all services received in other Canadian jurisdictions. The criterion for Temporary Absence is that the individual must be physically present in the NWT for a period of 153 days in a calendar year to maintain residency.

When a valid NWT Health Care Card is produced, most doctor visits and hospital services are billed directly to the Department. During the reporting period, approximately 28.6 million dollars were paid out for hospital in-patient and out-patient services in other provinces and territories. Reimbursement guidelines exist for patients having to pay up front for medically necessary services.

The NWT participates in both the Hospital Reciprocal Billing Agreement and the Medical Reciprocal Billing Agreement with other jurisdictions (except Quebec).

4.3 Coverage during Temporary Absences Outside Canada

As per section 4(3) of the Medical Care Act and section 11(1)(b) (ii) of the Canada Health Act, the NWT provides reimbursement for NWT residents who require medically necessary services while temporarily outside Canada. No amendments were made in 2019-2020 to the Medical Care Act.

Individuals are required to pay up front and seek reimbursement upon their return to the NWT. Costs for eligible services, including in-patient services, out-patient services, and haemodialysis rendered outside Canada, will be reimbursed up to the amounts payable in the NWT. Residents temporarily out of Canada may receive coverage for up to one year; however, prior approval as well as documentation proving the NWT will be the individual's permanent residence upon return is required. Returning Canadians are covered on the first day of arrival in the NWT. Documentation is required to validate the first day of arrival. Permanent residents (Landed immigrants) are covered on the first day of arrival in the NWT, with appropriate documentation from Immigration Canada, provided the NWT is their first place of residence in Canada and they intend to reside here. Foreign workers holding a valid closed work permit are eligible for coverage on the first day they are present in the NWT. Live-in care givers with a work permit that lists NWT as the location of employment are eligible for first day coverage.

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.
First level appeals of decisions may be sent to the Director of Medical Insurance. Second level appeals are considered by the Deputy Minister of Health and Social Services. The decision of the Deputy Minister is final.

5.0 Accessibility

5.1 Access to Insured Health Services

The Government of the Northwest Territories (NWT) Medical Travel Policy provides NWT residents with assistance to access medically necessary insured services not available in their home community or in the NWT, consistent with section 12(1)(a) of the Canada Health Act.Footnote 18

Extra-billing is not permitted in the NWT, in adherence to section 18 of the Canada Health Act and section 14(1) of the Medical Care Act. The only exception is if a medical practitioner opts out of the NWT Medical Care Plan and collects his or her own fees. Extra-billing did not occur in 2019-2020.

User charges are also not permitted under section 14(2) of the Medical Care Act unless the medical practitioner has opted-out of the NWT Medical Care Plan, collects his or her own fees, and gives reasonable notice of the intention to collect fees.

The Medical Care Act includes a provision to allow the Minister of Health and Social Services (the Minister) to establish a Benefits Appeal Committee that could address any matter referred to it by the Minister, including complaints where a physician engaged in extra-billing and charged user fees. At present, there has been no need to establish this committee, because almost all physicians are compensated through contractual agreements with the Government of the NWT.

Complaints of extra-billing or user charges can be made to:

The Health Services Administration Office, Health and Social Services
Bag#9, Inuvik
NT, X0E OTO
by phone at: 1-800-661-0830 or 1-867-777-7400
or by Fax at: 1-867-777-3197

In 2019-2020, the Northwest Territories Health and Social Services Authority (Territorial Authority) launched the Primary Health Care Reform initiative aimed at improving primary care models, support relationship-building between clients and our system, and contribute to the best health, best care, and a better future for NWT residents. As part of this reform initiative, a demonstration project was initiated called Expanded Same Day Access. This project implemented expanded hours at the medical clinics in Yellowknife and a walk-in appointment option for clients.

5.2 Physician Compensation

The Department of Health and Social Services (the Department), in close consultation with the NWT Medical Association, sets physician compensation. Generally, family and specialist practitioners are compensated through contractual agreements with the Government of NWT, while the remaining practitioners are compensated on a fee-for-service basis. Fee-for-service rates in the NWT are itemized in the Insured Services Tariff approved by the Minister in accordance with the Medical Care Act.

Under the Medical Care Act, the Minister may appoint medical and financial inspectors who shall, under the direction of the Director, inspect, examine, and audit books, accounts, reports, and medical records maintained in hospitals, health facilities, offices of medical practitioners, and other health care facilities respecting patients who are receiving or who have received insured services. The Director may reassess an account for insured services submitted by a medical practitioner and make any appropriate adjustment in the amount paid to the medical practitioner in respect of the insured services.

Although physicians may charge for uninsured services in accordance with the Service Fee Policy, there is no ability to charge block fees.

5.3 Payments to Hospitals

Contribution agreements between the Department and the Boards of Management dictate payments made to hospitals. Government budgets, resources, and levels of services offered determine the allocated amounts.

Payments for the provision of insured hospital services are governed under the Hospital Insurance and Health and Social Services Administration Act and the Financial Administration Act. A comprehensive budget is used to fund hospitals in the NWT.

6.0 Recognition Given to Federal Transfers

Federal funding from the Canada Health Transfer has been recognized and reported by the Government of the Northwest Territories (GNWT) through the follow documents: GNWT, Public Accounts 2018-2019 (published December 10, 2019); and the GNWT, Main Estimates, 2020-2021 (published February 25, 2020).

The Public Accounts contain the consolidated financial statements of the GNWT, audited by the Auditor General of Canada, and are presented annually to the Legislative Assembly. The Main Estimates are also presented annually to the Legislative Assembly.

Registered Persons
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
1. Number as of March 31st (#) 43,430 42,780 43,632 43,324 42,501
Insured Hospital Services Within Own Province or Territory
Public Facilities 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
2. Number (#)  23 23 23 23 23
3. Payments for insured health services ($)Northwest Territories table 2 Footnote 1 72,824,873 74,482,130 75,767,548 81,773,467 97,113,884
Private For-Profit Facilities 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
4. Number of private for-profit facilities providing insured health services (#) 0 0 0 0 0
5. Payments to private for-profit facilities for insured health services($) Not applicable Not applicable Not applicable Not applicable Not applicable
Northwest Territories table 2 Footnote 1

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

Northwest Territories table 2 Return to footnote 1 referrer
Insured Hospital Services Provided to Residents in Another Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
6. Total number of claims, in-patient (#) 1,316 1,278 1,291 1,393 1,423
7. Total payments, in-patient ($) 21,899,702 22,181,729 19,458,993 25,785,734 21,495,046
8. Total number of claims, out-patient (#) 12,641 13,444 13,894 15,565 14,387
9. Total payments, out-patient ($) 4,804,337 5,684,108 6,269,596 7,602,454 7,055,604
Insured Hospital Services Provided Outside CanadaNorthwest Territories table 4 Footnote 1
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
10. Total number of claims, pre-approved in-patient Not available Not available Not available 0 0
11. Total payments, pre-approved in-patient ($) Not available Not available Not available 0 0
12. Total number of claims, pre-approved out-patient Not available Not available Not available 1 2
13. Total payments, pre-approved out-patient ($) Not available Not available Not available 320 5,253
14. Total number of claims, non pre-approved in-patient 14 9 13 11 7
15. Total payments, non pre-approved in-patient ($) 216,539 97,456 316,373 32,727 17,522
16. Total number of claims, non pre-approved out-patient 45 44 31 50 24
17. Total payments, non pre-approved out-patient ($) 39,388 52,643 19,719 26,157 9,029
Northwest Territories table 4 Footnote 1

2018-19 is the first year Health Canada required reporting preapproved versus non pre-approved claims and expenditures. Prior to 2018-19 all out of Canada claims are included in the non pre-approved category.

Northwest Territories table 4 Return to footnote 1 referrer
Insured Physician Services Within Own Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
18. Number of participating physicians (#)Northwest Territories table 5 Footnote 1 326 350 360 372 411
19. Number of opted-out physicians (#) 0 0 0 0 0
20. Number of not participating physicians (#) 0 0 0 0 0
21. Total payments for services provided by physicians paid through all payment methods ($)Northwest Territories table 5 Footnote 2 53,732,241 55,291,846 56,505,139 57,405,424 59,311,914
22. Total payments for services provided by physicians paid through fee-for-service ($) 1,635,526 1,259,330 1,201,976 1,183,680 1,325,187
Northwest Territories table 5 Footnote 1

Estimate based on total active physicians for each fiscal year.

Northwest Territories table 5 Return to footnote 1 referrer

Northwest Territories table 5 Footnote 2

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

Northwest Territories table 5 Return to footnote 2 referrer
Insured Physician Services Provided to Residents in Another Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
23. Number of services (#) 55,149 63,012 62,833 65,030 63,575
24. Total payments ($) 6,434,942 6,944,788 6,947,348 7,339,664 7,075,008
Insured Physician Services Provided Outside CanadaNorthwest Territories table 7 Footnote 1
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
25. Number of pre-approved services Not available Not available Not available 1 0
26. Total pre-approved payments ($) Not available Not available Not available 2,603 0
27. Number of non pre-approved services 200 101 115 73 47
28. Total non pre-approved payments ($) 171,104 7,471 18,383 6,532 14,038
Northwest Territories table 7 Footnote 1

2018-19 is the first year Health Canada required reporting preapproved versus non pre-approved claims and expenditures. Prior to 2018-19 all out of Canada claims are included in the non pre-approved category.

Northwest Territories table 7 Return to footnote 1 referrer
Insured Surgical-Dental Services Within Own Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
29. Number of participating dentists (#) Not available Not available Not available Not available Not available
30. Number of opted-out dentists (#)Northwest Territories table 8 Footnote 1 Not applicable Not applicable Not applicable Not applicable Not applicable
31. Number of non-participating dentists (#)Northwest Territories table 8 Footnote 1 Not applicable Not applicable Not applicable Not applicable Not applicable
32. Number of services provided (#) Not available Not available Not available Not available Not available
33. Total payments ($) Not available Not available Not available Not available Not available
Northwest Territories table 8 Footnote 1

Health Canada requested this data as of the 2016-2017 report, but did not require provinces or territories to report on previous years.

Northwest Territories table 8 Return to footnote 1 referrer

Nunavut

The Department of Health (the Department) faces many unique challenges when providing for the health and well-being of Nunavummiut. Of a total population of 38,780Footnote 19 approximately one third of the population is under the age of 15 years (12,348 people). The territory is made up of 25 communities located across three time zones and divided into three regions: the Qikiqtani (or Baffin), the Kivalliq and the Kitikmeot.

The Government of Nunavut incorporates Inuit Societal Values into program and policy development, as well as into service design and delivery. The delivery of health services in Nunavut is based on a primary health care model. Nunavut's primary health care providers are family physicians, nurse practitioners, midwives, community health nurses, and other allied health professionals.

In 2019–2020, the territorial operations and maintenance budget for the Department was $480,999,000 including supplementary appropriationsFootnote 20. One third of the Department's total operational budget was spent on costs associated with medical travel and treatment provided in out-of-territory facilities. Nunavut is a vast territory with a low population density and limited health infrastructure, therefore, access to a range of hospital and specialist services often requires that residents be sent out-of-territory for care.

In 2019–2020, a total of $35,650,000 was allocated to the Department for capital projectsFootnote 21. The Department's 2019–2020 capital projects include the construction of the new community health centres in Sanikiluaq and Kinngait.

COVID-19 Measures

Upon recommendation from the Chief Public Health Officer, a public health emergency was declared in Nunavut by the Minister of Health on March 18, 2020. During the 2019-2020 reporting period (March 18 – March 31, 2020) several public health measures were initiated as part of the Department's COVID-19 response plan to ensure the health and safety of Nunavummiut during the pandemic. During the reporting period, there were no confirmed or probable cases of COVID-19 in the territory.

Ongoing Health Services:

Adjusted Services:

1.0 Public Administration

1.1 Health Care Insurance Plan and Public Authority

The Health Care Insurance Plans of Nunavut, including physician and hospital services, are administered by the Department of Health (the Department) on a non-profit basis.

The Medical Care Act (NWT, 1988 and as duplicated for Nunavut by section 29 of the Nunavut Act, 1999) governs the entitlement to and payment of benefits for insured medical services.

The Hospital Insurance and Health and Social Services Administration Act (NWT, 1988 and as duplicated for Nunavut by section 29 of the Nunavut Act, 1999) enables the establishment of hospital and other health services.

The Department is responsible for delivering health care services to Nunavummiut, including the operation of community health centres, regional health centres, and a hospital. There are three regional offices that manage the delivery of health services at a regional level. Iqaluit operations are administered separately. The Government of Nunavut opted for decentralization to regional offices to support front-line workers and community-based delivery of a wide range of health programs and services.

1.2 Reporting Relationship

Legislation governing the administration of health services in Nunavut was carried over from the Northwest Territories (as Nunavut statutes) pursuant to the Nunavut Act. The Medical Care Act governs who is covered by the Nunavut Health Care Plan and the payment of benefits for insured medical services. Section 23(1) of the Medical Care Act requires the Minister responsible for the Act to appoint a Director of Medical Insurance.

The Director is responsible for the administration of the Act and its Regulations. Section 24 requires the Director to submit an annual report on the operation of the Nunavut Health Care Plan to the Minister for tabling in the Legislative Assembly. The 2018-2019 Annual Report on the Operation of the Medical Care Plan from the Director of Medical Insurance was submitted and is available on the Department's website.

1.3 Audit of Accounts

The Auditor General of Canada is the auditor of the Government of Nunavut in accordance with section 30.1 of the Financial Administration Act (Nunavut, 1999). The Auditor General is required to conduct an annual audit of the consolidated financial statements of the Government of Nunavut. The most recent audit of the Government of Nunavut's public accounts was completed on October 24, 2019, for the fiscal year 2018–2019Footnote 22. The Independent Auditor's Report to Nunavut's Legislative Assembly can be found on page 37 of the Government of Nunavut's Report of Public Accounts.

2.0 Comprehensiveness

2.1 Insured Hospital Services

Insured hospital services are provided in Nunavut under the authority of the Hospital Insurance and Health and Social Services Administration Act and Regulations, sections 2 to 4. No amendments were made to the Act or Regulations in 2019–2020.

In 2019–2020, insured hospital services were delivered in 28 facilities across Nunavut including:

The QGH is currently the only acute care facility in Nunavut, accredited by Accreditation Canada, providing a range of in-and out-patient hospital services as defined by the Canada Health Act. QGH offers 24-hour emergency services, in-patient care (including obstetrics, pediatrics and palliative care), surgical services, laboratory services, diagnostic imaging, respiratory therapy, rehabilitation services, and health information management services.

Currently, Rankin Inlet is providing 24-hour care for in-patients; out-patients receive care by on-call staff. Cambridge Bay is providing daily clinic hours, and emergency care is available, on-call, 24-hours a day. There are also a limited number of birthing beds at both facilities.

Other community health centres provide public health services, out-patient services and urgent treatment services.

Public health services are provided at public health clinics located in Rankin Inlet and Iqaluit. Public health programing is provided in the remaining communities through the local health centre. The Department of Health (the Department) also operates a Family Practice Clinic in Iqaluit. This clinic operates as part of the primary care program at QGH.

The Department is responsible for authorizing, licensing, inspecting and supervising all health facilities in the territory.

Insured in-patient hospital services include:

Out-patient services include:

The Department makes the determination to add insured hospital services based on the availability of appropriate resources, equipment and overall feasibility in accordance with financial guidelines set by the Department and with the approval of the Financial Management Board. No new services were added in 2019–2020 to the list of insured hospital services.

2.2 Insured Physician Services

The Medical Care Act, section 3(1), and Medical Care Regulations, section 3, provide for insured physician services in Nunavut. No amendments were made to the Act or Regulation in 2019–2020. The Nursing Act allows for licensure of nurse practitioners in Nunavut; this permits nurses to deliver insured services in Nunavut.

Upon initial registration physicians must be in good standing with a College of Physicians and Surgeons from a Canadian jurisdiction, and be licensed to practice in Nunavut. The Government of Nunavut's Medical Registration Committee currently manages this process for Nunavut physicians. Nunavut recruits and contracts its own family physicians, and accesses specialist services primarily from its main referral centres in Ottawa, Edmonton, Winnipeg, and Yellowknife. Recruitment of full-time family physicians has improved significantly; there are 39 family physician positions, covered by a combination of locums and full-time physicians, funded through the Department. In 2019-2020, physicians provided over 8,439 days of service across the territory.

Of the 39 full-time family physician positions in Nunavut, 24 are in the Qikiqtaaluk region; 10 in the Kivalliq region; and five in the Kitikmeot region. There are also two and a half general surgeon positions, two anaesthetist positions, and four pediatrician positions at the QGH. Visiting specialists, general practitioners, and locums also provide insured physician services; these arrangements are made by each of the Department's three regions.

Physicians can elect to collect fees other than those under the Medical Care Plan in accordance with section 12(2) (a) or (b) of the Medical Care Act by notifying the Director of Medical Insurance (the Director) in writing. An election can be revoked the first day of the following month after a letter to that effect is delivered to the Director. In 2019–2020, no physicians provided written notice of this election. All physicians practicing in Nunavut are under contract with the Department. In 2019–2020, 170 physicians provided service in Nunavut.

Insured physician services refer to all services rendered by medical practitioners that are medically required. Where insured services are unavailable in some places in Nunavut, the patient is referred to another jurisdiction to obtain the insured service. Nunavut has health service agreements with medical and treatment centres in Ottawa, Winnipeg, Churchill, Yellowknife and Edmonton. These are the out-of-territory sites to which Nunavut mainly refers its patients to access medical services not available within the territory.

The following is a list of common insured categories as per Nunavut's Medical Care Regulations. Services provided under these categories are considered insured if the medically required diagnosis and/or treatment is provided in-territory or out-of-territory.

The addition or deletion of insured physician services requires government approval. For this, the Director of Medical Insurance would become involved in negotiations with a collective group of physicians to discuss the service. Then the decision of the group would be presented to Cabinet for approval. No insured physician services were added or removed in 2019–2020.

2.3 Insured Surgical-Dental Services

Dentists providing insured surgical-dental services under the Nunavut Health Care Plan must be licensed pursuant to the Dental Professions Act (NWT, 1988 and as duplicated for Nunavut by section 29 of the Nunavut Act, 1999). Billing numbers are provided for billing the Plan regarding the provision of insured dental services.

Insured dental services are limited to those dental-surgical procedures scheduled in the Regulations, requiring the unique capabilities of a hospital for their performance; for example, orthognathic surgery. The Department insures all dental-surgical services outlined in provincial/territorial reciprocal billing agreements. Oral surgeons are brought to Nunavut on a regular basis, but on rare occasions, for medically complicated situations, patients are flown out of the territory. Dentists travelling to Nunavut to deliver services are under contract with the Government of Nunavut and do not have the option to opt-out.

The addition of new surgical-dental services to the list of insured services requires government approval. No new services were added to the list in 2019–2020.

2.4 Uninsured Hospital, Physician and Surgical-Dental Services

Services provided under the Workers' Compensation Act (NWT, 1988 and as duplicated for Nunavut by section 29 of the Nunavut Act, 1999) or other acts of Canada, except the Canada Health Act, are excluded.

Services provided by physicians that are not insured include:

Services not covered in a hospital include:

In 2019–2020, the Qikiqtani General Hospital charged a $2,638 per diem rate for services provided for non-Canadian resident stays. The in-patient rate charged in Rankin Inlet and Cambridge Bay was $1,482 per day.

When residents are sent out-of-territory for services, the Department relies on the policies and procedures guiding that particular jurisdiction when they provide services to Nunavut residents that could result in additional costs, only to the extent that these costs are covered by Nunavut's Medical Insurance Plan (see section 4.2 below). Any query or complaint is handled on an individual basis with the jurisdiction involved.

The Department also administers the Non-Insured Health Benefits (NIHB) Program, on behalf of Indigenous Services Canada, for Inuit and First Nations residents in Nunavut. NIHB covers a co-payment for medical travel, accommodations and meals at boarding homes (in Ottawa, Winnipeg, Churchill, Edmonton, Yellowknife and Iqaluit), prescription drugs, dental treatment, vision care, medical supplies and prostheses, and a number of other incidental services.

3.0 Universality

3.1 Eligibility

Eligibility for the Nunavut Health Care Plan is briefly defined under sections 3(1), (2), and (3) of the Medical Care Act. The Department of Health (the Department) also adheres to the Interprovincial Agreement on Eligibility and Portability, as well as internal guidelines. No amendments were made to the Act or Regulations in 2019–2020.

Subject to these provisions, every Nunavut resident is eligible for and entitled to insured health services on uniform terms and conditions. A resident means a person lawfully entitled to be in or to remain in Canada, who makes their home and is ordinarily present in Nunavut, but does not include a tourist, transient or visitor to Nunavut. Eligible residents receive a health card with a unique health care number.

Registration requirements include a completed application form and supporting documentation. A health care card is issued to each resident. To streamline document processing, a staggered renewal process is used. No premiums exist. Coverage under the Nunavut Medical Insurance Plan is linked to verification of registration, although every effort is made to ensure registration occurs when a coverage issue arises for an eligible resident. For non-residents, a valid health care card from their home province or territory is required.

Coverage generally begins the first day of the third month after arrival in Nunavut, but first-day coverage is provided under a number of circumstances, for example, newborns whose mothers or fathers are eligible for coverage. Permanent residents (landed immigrants), returning Canadians, repatriated Canadians, returning permanent residents, and non-Canadians who have been issued an employment visa for a period of 12 months or more, are also granted first-day coverage.

Members of the Canadian Armed Forces and inmates of a federal penitentiary are not eligible for registration. These groups are granted first-day coverage under the Nunavut Health Care Plan upon discharge.

Pursuant to section 7 of the Interprovincial Agreement on Eligibility and Portability, individuals in Nunavut who are temporarily absent from their home province or territory and who are not establishing residency in Nunavut remain covered by their home provincial or territorial health insurance plans for up to one year.

On March 31, 2020, 38,997 individuals were registered with the Nunavut Health Care Plan, an increase of 173 from the previous year. There are no formal provisions for Nunavut residents to opt-out of the Nunavut Health Care Plan, and no legislated appeals process or policy related to appeals of residency or coverage decisions.

3.2 Other Categories of Individuals

Categories of individuals not eligible for coverage include:

Children born out-of-country to Canadian citizens are covered only when they return to Nunavut. Returning residents (whose residency has expired) would be covered if proof of residency is provided.

When unique circumstances occur, assessments are done on an individual basis. This is consistent with section 15 of the Northwest Territories' Guidelines for Health Care Plan Registration, which was adopted by Nunavut in 1999.

4.0 Portability

4.1 Minimum Waiting Period

Consistent with section 3 of the Interprovincial Agreement on Eligibility and Portability, the waiting period before coverage begins for individuals moving within Canada is three months, or the first day of the third month following the establishment of residency in a new province or territory, or the first day of the third month when an individual, who has been temporarily absent from his or her home province, decides to take up permanent residency in Nunavut.

4.2 Coverage during Temporary Absences in Canada

The Medical Care Act, section 4(2), prescribes the benefits payable where insured medical services are provided outside Nunavut, but within Canada. The Hospital Insurance and Health and Social Services Administration Act, sections 5(d) and 28(1)(j)(o), provide the authority for the Minister of Health to enter into agreements with other jurisdictions to provide health services to Nunavut residents, and the terms and conditions of payment. No legislative or regulatory changes were made in 2019–2020 with respect to coverage outside Nunavut.

Students studying outside Nunavut must notify the Department of Health (the Department) and provide proof of enrollment to ensure continuing coverage. Requests for extensions must be renewed yearly and are subject to approval by the Director of Medical Insurance (the Director). Temporary absences for work, vacation or other reasons for up to one year are approved by the Director upon receipt of a written request from the insured person. The Director may approve absences in excess of 12 continuous months upon receiving a written request from the insured individual.

The provisions regarding coverage during temporary absences in Canada fully comply with the terms and conditions of the Interprovincial Agreement on Eligibility and Portability. Nunavut participates in physician and hospital reciprocal billing. As well, special bilateral agreements are in place with Ontario, Manitoba, Alberta, and the Northwest Territories. The Hospital Reciprocal Billing Agreements provide payment of in-patient and out-patient hospital services to eligible Nunavut residents receiving insured services out-of-territory. High-cost procedure rates, newborn rates, and out-patient rates are based on those established by the Interprovincial Health Insurance Agreements Coordinating Committee. The Physician Reciprocal Billing Agreements provide payment of insured physician services on behalf of eligible Nunavut residents receiving insured services out-of-territory. Payment is made to the host province or territory at the rates established by that province or territory.

4.3 Coverage during Temporary Absences outside Canada

The Medical Care Act, section 4(3), prescribes the benefits payable where insured medical services are provided outside Canada. The Hospital Insurance and Health and Social Services Administration Act, section 28(1)(j)(o), provides the authority for the Minister to set the terms and conditions of payment for services provided to Nunavut residents outside Canada. No amendments were made in 2019-2020 to either Act respectively. Nunavut residents are granted coverage for up to one year if they are temporarily out of the country for any reason, although they must give prior notice in writing. No exceptions are made to this process for specific categories of individuals as all cases are addressed individually. For services provided to residents who have been referred out-of-country for highly specialized procedures unavailable in Nunavut and Canada, Nunavut will pay the full cost. For non-referred or emergency services, the payment for hospital services is $2,638 per day and for out-patient care it is $359 per day.

Insured physician services provided to eligible residents temporarily outside the country are paid at rates equivalent to those paid had that service been provided in the territory. Reimbursement is made to the insured individual or directly to the provider of the insured service.

4.4 Prior Approval Requirement

Prior approval is required to receive reimbursement for elective services provided in private facilities in Canada or in any facility outside the country. There are no processes related to pre-approval appeals for out-of-jurisdiction coverage.

5.0 Accessibility

5.1 Access to Insured Health Services

The Medical Care Act, section 14, prohibits extra-billing by physicians unless the medical practitioner has made an election that is still in effect. Access to insured services is provided on uniform terms and conditions. To break down the barrier posed by distance and cost of travel, the Government of Nunavut provides medical travel assistance. Interpretation services in Inuktut are also provided to patients. The Department of Health (the Department) does not have a specific complaints office solely for extra-billing. However, the Department has other mechanisms for Nunavummiut to register concerns regarding their health care service and can be reached at:

NHIP@gov.nu.ca
Nunavut Health Insurance Programs Office Department of Health
Box 889
Rankin Inlet, NU X0C 0G0 Toll Free: 1 (800) 661-0833

Concerns raised regarding extra-billing that have occurred within Nunavut are fully investigated and addressed with disciplinary action if warranted. If extra-billing has occurred out-of-territory, it is up to the jurisdiction where it has occurred to investigate and address.

The Qikiqtani General Hospital, a site of Iqaluit Health Services is currently the only acute care hospital facility in Nunavut. The hospital has a total of 20 beds available for acute, medical, surgical, pediatric, rehabilitative, palliative and chronic care services. There are also four birthing rooms and four day surgery beds. The facility provides in-patient, out-patient and 24-hour emergency services. On-site physicians provide emergency services on rotation. Medical services provided include: an ambulatory care/out-patient clinic emergency stabilization services, pediatric services, and general medical, maternity and palliative care. Surgical services provided include ophthalmology, urology, orthopedics, gynaecology, pediatrics, general surgery, emergency trauma, otolaryngology and dental surgery under general anaesthesia and conscious sedation. Patients requiring specialized surgeries are sent to other jurisdictions. Diagnostic services include: radiology, laboratory, electrocardiogram and CT scans.

Outside of Iqaluit, out-patient and 24-hour emergency nursing services are provided by local health centres in Nunavut’s 24 other communities.

Nunavut has three continuing care centres located in Gjoa Haven, Igloolik and Cambridge Bay. These facilities provide full-time nursing and personal care to adults. The Gjoa Haven and Igloolik facilities have 10 beds each, and the Cambridge Bay facility has 8 beds.

Nunavut has agreements in place with a number of out-of-territory regional health authorities and specific facilities to provide medical specialists and other visiting health practitioner services. The following specialist services were provided in Nunavut during 2019–2020 under the visiting specialists program: ophthalmology, orthopedics, internal medicine, otolaryngology, neurology, rheumatology, dermatology, pediatrics, obstetrics/gynecology, urology, respirology, cardiology, total joint assessment clinic (TJAC), sleep study, oral surgery, and allergist. Visiting specialist clinics are scheduled in advance, and are offered on specific weeks throughout the year.

Nunavut’s Telehealth network, linking all 25 communities, allows for the delivery of a broad range of services over distances including specialist consultation services such as dermatology, psychiatry and internal medicine; rehabilitation services; regularly scheduled counseling sessions; family visitation; and continuing medical education. The long-term goal is to integrate Telehealth into the primary care delivery system, enabling residents of Nunavut greater access to a broader range of service options, and allowing service providers and communities to use existing resources more effectively.

For services and equipment unavailable in Nunavut, patients are referred to other jurisdictions.

 5.2 Physician Compensation

All full-time physicians in Nunavut work under contract with the Department. The Medical Care Act S.5.1(1) states “the Director, In accordance with this Act and the regulations, may enter into agreements, as the Director considers necessary, for services, including insured services, provided on an other than fee-for-service basis. The terms of the contracts are set by the Department. Visiting consultants are paid a daily contract rate for their professional services. Rates vary based on services rendered. The Department complies with the Financial Administration Act and Financial Administration Manual in monitoring or auditing remuneration.

5.3 Payments to Hospitals

Funding for the Qikiqtani General Hospital, regional health facilities and community health centres is provided through the Government of Nunavut’s budget process.

6.0 Recognition Given to Federal Transfers

Nunavummiut are aware of ongoing federal contributions through press releases and media coverage. The Government of Nunavut has also recognized the federal contribution provided through the Canada Health Transfer in various published documents. For fiscal year 2019–2020, they included the 2019–2020 Fiscal and Economic Indicators and the 2019–2022 Government of Nunavut and Territorial Corporations Business Plan.

Registered Persons
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
1. Number as of March 31stNunavut table 1 Footnote 1 37,764 38,662 39,293 38,824 38,997
Nunavut table 1 Footnote 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.

Return to footnote 1 referrer
Insured Hospital Services Within Own Province or Territory
Public Facilities 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
2. Number 28 28 28 28 28
3. Payments for insured health services ($)
 Not available Not available Not available Not available Not available
Private For-Profit Facilities 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
4. Number of private for-profit facilities providing insured health services 0 0 0 0 0
5. Payments to private for-profit facilities for insured health services ($)  0 0 0 0 0
Insured Hospital Services Provided to Residents in Another Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
6. Total number of claims, in-patient 3,324 3,616 3,791 3,976 4,139
7. Total payments, in-patient ($) 38,830,531 40,804,893 44,156,008 44,160,583 48,802,196
8. Total number of claims, out-patient 24,853 26,790 27,480 26,493 28,096
9. Total payments, out-patient ($) 9,638,408 11,369,138 12,178,482 12,337,509 12,961,710
Insured Hospital Services Provided Outside CanadaNunavut table 4 Footnote 1
Pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
10. Total number of claims, in-patient Not available Not available Not available Not available Not available
11. Total payments, pre-approved  ($) Not available Not available Not available Not available Not available
12. Total number of claims, out-patient Not available Not available Not available Not available Not available
13. Total payments, out-patient ($) Not available Not available Not available Not available Not available
Non pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
14. Total number of claims, in-patient Not available Not available Not available Not available Not available
15. Total payments, in-patient ($) Not available Not available Not available Not available Not available
16. Total number of claims, out-patient Not available Not available Not available Not available Not available
17. Total payments, out-patient ($) Not available Not available Not available Not available Not available
Nunavut table 4 Footnote 1

Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report, but did not require provinces or territories to report on previous years.

Nunavut table 4 Return to footnote 1 referrer
Insured Physician Services Within Own Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
18. Number of participating physicians 278 155 139 137 177Nunavut table 5 Footnote 1
19. Number of opted-out physicians 0 0 0 0 0
20. Number of non-participating physicians 0 0 0 0 0
21. Total payments for services provided by physicians paid through all payment methods ($) Not available Not available Not available Not available Not available
22. Total payments for services provided by physicians paid through fee-for-service ($)Nunavut table 5 Footnote 2 152,815 502,572 565,111 574,179 870,135
Nunavut table 5 Footnote 1

This figure captures the number of general practitioners providing services in Nunavut. The total does not include specialist services.

Nunavut table 5 Return to footnote 1 referrer

Nunavut table 5 Footnote 2

Typically, Nunavut does not pay its physicians through fee-for-service. Instead, the majority of physicians are compensated through contracted salaries.

Nunavut table 5 Return to footnote 2 referrer
Insured Physician Services Provided to Residents in Another Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
23. Number of services 93,365 99,539 107,416 121,456 128,069
24. Total payments ($) 8,088,273 8,694,011 9,162,104 9,899,822Nunavut table 6 Footnote 1 10,208,947
Nunavut table 6 Footnote 1

This figure captures the number of general practitioners providing services in Nunavut. The total does not include specialist services.

Nunavut table 6 Return to footnote 1 referrer
Insured Physician Services Provided Outside CanadaNunavut table 7 Footnote 1
Pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
25. Number of services Not applicable Not applicable Not applicable Not applicable Not applicable
26. Total payments ($) Not applicable Not applicable Not applicable Not applicable Not applicable
Non pre-approved 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
27. Number of services Not applicable Not applicable Not applicable 7 9
28. Total payments ($) Not applicable Not applicable Not applicable 530 496
Nunavut table 7 Footnote 1

Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report, but did not require provinces or territories to report on previous years.

Nunavut table 7 Return to footnote 1 referrer
Insured Surgical-Dental Services Within Own Province or Territory
  2015-2016 2016-2017 2017-2018 2018-2019 2019-2020
29. Number of participating dentists Not available Not available Not available Not available Not available
30. Number of opted-out dentistsNunavut table 8 Footnote 1 Not available Not available Not available Not available Not available
31. Number of non-participating dentistsNunavut table 8 Footnote 1 Not available Not available Not available Not available Not available
32. Number of services provided Not available Not available Not available Not available Not available
33. Total payments ($) Not available Not available Not available Not available Not available
Nunavut table 8 Footnote 1

Health Canada requested this data as of the 2016-2017 report, but did not require provinces or territories to report data for 2015-16.

Nunavut table 8 Return to footnote 1 referrer

Annex A - Canada Health Act and Extra-Billing and User Charges Information Regulations

This annex provides the reader with an office consolidation of the Canada Health Act and the Extra-billing and User Charges Information Regulations. An office consolidation is a rendering of the original Act, which includes any amendments that have been made since the Act's passage. The only regulations in force under the Act are the Extra-billing and User Charges Information Regulations. These Regulations require the provinces and territories to provide estimates of extra-billing and user charges prior to the beginning of each fiscal year so that appropriate penalties can be levied, as well as financial statements showing the amounts actually charged so that reconciliations with any estimated charges can be made. These Regulations are also presented in an office consolidation format. This unofficial consolidation is not necessarily current and is provided for the convenience of the reader only. For the official text of the Canada Health Act, please contact Justice Canada.

Links to Canada Health Act and Regulations:

Annex B - Policy Interpretation Letters

There are three key policy statements that clarify the federal position on the Canada Health Act. These statements were made in the form of ministerial letters from former federal Health Ministers to their provincial and territorial counterparts.

[Following is the text of the letter sent on June 18, 1985, to all provincial and territorial Ministers of Health by the Honourable Jake Epp, federal Minister of Health and Welfare. (Note: Minister Epp sent the French equivalent of this letter to Quebec on July 15, 1985.) ]

June 18, 1985

OTTAWA, K1A 0K9

Dear Minister:

Having consulted with all provincial and territorial Ministers of Health over the past several months, both individually and at the meeting in Winnipeg on May 16 and 17, I would like to confirm for you my intentions regarding the interpretation and implementation of the Canada Health Act. I would particularly appreciate if you could provide me with a written indication of your views on the attached proposals for regulations in order that I may act to have these officially put in place as soon as conveniently possible. Also, I will write to you further with regard to the material I will need to prepare the required annual report to Parliament.

As indicated at our meeting in Winnipeg, I intend to honour and respect provincial jurisdiction and authority in matters pertaining to health and the provision of health care services. I am persuaded, by conviction and experience, that more can be achieved through harmony and collaboration than through discord and confrontation.

With regard to the Canada Health Act, I can only conclude from our discussions that we together share a public trust and are mutually and equally committed to the maintenance and improvement of a universal, comprehensive, accessible and portable health insurance system, operated under public auspices for the benefit of all residents of Canada.

Our discussions have reinforced my belief that you require sufficient flexibility and administrative versatility to operate and administer your health care insurance plans. You know far better than I ever can, the needs and priorities of your residents, in light of geographic and economic considerations. Moreover, it is essential that provinces have the freedom to exercise their primary responsibility for the provision of personal health care services.

At the same time, I have come away from our discussions sensing a desire to sustain a positive federal involvement and role—both financial and otherwise—to support and assist provinces in their efforts dedicated to the fundamental objectives of the health care system: protecting, promoting and restoring the physical and mental well-being of Canadians. As a group, provincial/territorial Health Ministers accept a co-operative partnership with the federal government based primarily on the contributions it authorizes for purposes of providing insured and extended health care services.

I might also say that the Canada Health Act does not respond to challenges facing the health care system. I look forward to working collaboratively with you as we address challenges such as rapidly advancing medical technology and an aging population and strive to develop health promotion strategies and health care delivery alternatives.

Returning to the immediate challenge of implementing the Canada Health Act, I want to set forth some reasonably comprehensive statements of federal policy intent, beginning with each of the criteria contained in the Act.

Public Administration

This criterion is generally accepted. The intent is that the provincial health care insurance plans be administered by a public authority, accountable to the provincial government for decision-making on benefit levels and services, and whose records and accounts are publicly audited.

Comprehensiveness

The intent of the Canada Health Act is neither to expand nor contract the range of insured services covered under previous federal legislation. The range of insured services encompasses medically necessary hospital care, physician services and surgical-dental services which require a hospital for their proper performance. Hospital plans are expected to cover in-patient and out-patient hospital services associated with the provision of acute, rehabilitative and chronic care. As regards physician services, the range of insured services generally encompasses medically required services rendered by licensed medical practitioners as well as surgical-dental procedures that require a hospital for proper performance. Services rendered by other health care practitioners, except those required to provide necessary hospital services, are not subject to the Act's criteria.

Within these broad parameters, provinces, along with medical professionals, have the prerogative and responsibility for interpreting what physician services are medically necessary. As well, provinces determine which hospitals and hospital services are required to provide acute, rehabilitative or chronic care.

Universality

The intent of the Canada Health Act is to ensure that all bonafide residents of all provinces be entitled to coverage and to the benefits under one of the twelve provincial/territorial health care insurance plans. However, eligible residents do have the option not to participate under a provincial plan should they elect to do so.

The Agreement on Eligibility and Portability provides some helpful guidelines with respect to the determination of residency status and arrangements for obtaining and maintaining coverage. Its provisions are compatible with the Canada Health Act.

I want to say a few words about premiums. Unquestionably, provinces have the right to levy taxes and the Canada Health Act does not infringe upon that right. A premium scheme per se is not precluded by the Act, provided that the provincial health care insurance plan is operated and administered in a manner that does not deny coverage or preclude access to necessary hospital and physician services to bonafide residents of a province. Administrative arrangements should be such that residents are not precluded from or do not forego coverage by reason of an inability to pay premiums.

I am acutely aware of problems faced by some provinces in regard to tourists and visitors who may require health services while travelling in Canada. I will be undertaking a review of the current practices and procedures with my Cabinet colleagues, the Minister of External Affairs, and the Minister of Employment and Immigration, to ensure all reasonable means are taken to inform prospective visitors to Canada of the need to protect themselves with adequate health insurance coverage before entering the country.

In summary, I believe all of us as Ministers of Health are committed to the objective of ensuring that all duly qualified residents of a province obtain and retain entitlement to insured health services on uniform terms and conditions.

Portability

The intent of the portability provisions of the Canada Health Act is to provide insured persons continuing protection under their provincial health care insurance plan when they are temporarily absent from their province of residence or when moving from province to province. While temporarily in another province of Canada, bonafide residents should not be subject to out-of-pocket costs or charges for necessary hospital and physician services. Providers should be assured of reasonable levels of payment in respect of the cost of those services.

Insofar as insured services received while outside of Canada are concerned, the intent is to assure reasonable indemnification in respect of the cost of necessary emergency hospital or physician services or for referred services not available in a province or in neighbouring provinces. Generally speaking, payment formulae tied to what would have been paid for similar services in a province would be acceptable for purposes of the Canada Health Act.

In my discussions with provincial/territorial Ministers, I detected a desire to achieve these portability objectives and to minimize the difficulties that Canadians may encounter when moving or travelling about in Canada. In order that Canadians may maintain their health insurance coverage and obtain benefits or services without undue impediment, I believe that all provincial/territorial Health Ministers are interested in seeing these services provided more efficiently and economically.

Significant progress has been made over the past few years by way of reciprocal arrangements which contribute to the achievement of the in-Canada portability objectives of the Canada Health Act. These arrangements do not interfere with the rights and prerogatives of provinces to determine and provide the coverage for services rendered in another province. Likewise, they do not deter provinces from exercising reasonable controls through prior approval mechanisms for elective procedures. I recognize that work remains to be done respecting interprovincial payment arrangements to achieve this objective, especially as it pertains to physician services.

I appreciate that all difficulties cannot be resolved overnight and that provincial plans will require sufficient time to meet the objective of ensuring no direct charges to patients for necessary hospital and physician services provided in other provinces.

For necessary services provided out-of-Canada, I am confident that we can establish acceptable standards of indemnification for essential physician and hospital services. The legislation does not define a particular formula and I would be pleased to have your views.

In order that our efforts can progress in a coordinated manner, I would propose that the Federal-Provincial Advisory Committee on Institutional and Medical Services be charged with examining various options and recommending arrangements to achieve the objectives within one year.

Reasonable Accessibility

The Act is fairly clear with respect to certain aspects of accessibility. The Act seeks to discourage all point-of-service charges for insured services provided to insured persons and to prevent adverse discrimination against any population group with respect to charges for, or necessary use of, insured services. At the same time, the Act accents a partnership between the providers of insured services and provincial plans, requiring that provincial plans have in place reasonable systems of payment or compensation for their medical practitioners in order to ensure reasonable access to users. I want to emphasize my intention to respect provincial prerogatives regarding the organization, licensing, supply, distribution of health manpower, as well as the resource allocation and priorities for health services. I want to assure you that the reasonable access provision will not be used to intervene or interfere directly in matters such as the physical and geographic availability of services or provincial governance of the institutions and professions that provide insured services. Inevitably, major issues or concerns regarding access to health care services will come to my attention. I want to assure you that my Ministry will work through and with provincial/territorial Ministers in addressing such matters.

My aim in communicating my intentions with respect to the criteria in the Canada Health Act is to allow us to work together in developing our national health insurance scheme. Through continuing dialogue, open and willing exchange of information and mutually understood rules of the road, I believe that we can implement the Canada Health Act without acrimony and conflict. It is my preference that provincial/territorial Ministers themselves be given an opportunity to interpret and apply the criteria of the Canada Health Act to their respective health care insurance plans. At the same time, I believe that all provincial/territorial Health Ministers understand and respect my accountability to the Parliament of Canada, including an annual report on the operation of provincial health care insurance plans with regard to these fundamental criteria.

Conditions

This leads me to the conditions related to the recognition of federal contributions and to the provision of information, both of which may be specified in regulations. In these matters, I will be guided by the following principles:

  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, comprehensiveness, universality, portability and accessibility) continue to enjoy the support of all provincial and territorial governments. This support is shared by the vast majority of Canadians. At a time when there is concern about the potential erosion of the publicly funded and publicly administered health care system, it is vital to safeguard these principles.

As was evident and a concern to many of us at the recent Halifax meeting, a trend toward divergent interpretations of the Act is developing. While I will deal with other issues at the end of this letter, my primary concern is with private clinics and facility fees. The issue of private clinics is not new to us as Ministers of Health; it formed an important part of our discussions in Halifax last year. For reasons I will set out below, I am convinced that the growth of a second tier of health care facilities providing medically necessary services that operate, totally or in large part, outside the publicly funded and publicly administered system, presents a serious threat to Canada's health care system.

Specifically, and most immediately, I believe the facility fees charged by private clinics for medically necessary services are a major problem which must be dealt with firmly. It is my position that such fees constitute user charges and, as such, contravene the principle of accessibility set out in the Canada Health Act.

While there is no definition of facility fees in federal or most provincial legislation, the term, generally speaking, refers to amounts charged for non-physician (or "hospital") services provided at clinics and not reimbursed by the province. Where these fees are charged for medically necessary services in clinics which receive funding for these services under a provincial health insurance plan, they constitute a financial barrier to access. As a result, they violate the user charge provision of the Act (section 19).

Facility fees are objectionable because they impede access to medically necessary services. Moreover, when clinics which receive public funds for medically necessary services also charge facility fees, people who can afford the fees are being directly subsidized by all other Canadians. This subsidization of two-tier health care is unacceptable.

The formal basis for my position on facility fees is twofold. The first is a matter of policy. In the context of contemporary health care delivery, an interpretation which permits facility fees for medically necessary services so long as the provincial health insurance plan covers physician fees runs counter to the spirit and intent of the Act. While the appropriate pro-vision of many physician services at one time required an overnight stay in a hospital, advances in medical technology and the trend toward providing medical services in more accessible settings has made it possible to offer a wide range of medical procedures on an out-patient basis or outside of full-service hospitals. The accessibility criterion in the Act, of which the user charge provision is just a specific example, was clearly intended to ensure that Canadian residents receive all medically necessary care without financial or other barriers and regardless of venue. It must continue to mean that as the nature of medical practice evolves.

Second, as a matter of legal interpretation, the definition of "hospital" set out in the Act includes any facility which provides acute, rehabilitative or chronic care. This definition covers those health care facilities known as "clinics". As a matter of both policy and legal interpretation, therefore, where a provincial plan pays the physician fee for a medically necessary service delivered at a clinic, it must also pay for the related hospital services provided or face deductions for user charges.

I recognize that this interpretation will necessitate some changes in provinces where clinics currently charge facility fees for medically necessary services. As I do not wish to cause undue hardship to those provinces, I will commence enforcement of this interpretation as of October 15, 1995. This will allow the provinces the time to put into place the necessary legislative or regulatory framework. As of October 15, 1995, I will proceed to deduct from transfer payments any amounts charged for facility fees in respect of medically necessary services, as mandated by section 20 of the Canada Health Act. I believe this provides a reasonable transition period, given that all provinces have been aware of my concerns with respect to private clinics for some time, and given the promising headway already made by the Federal/Provincial/Territorial Advisory Committee on Health Services, which has been working for some time now on the issue of private clinics.

I want to make it clear that my intent is not to preclude the use of clinics to provide medically necessary services. I realize that in many situations they are a cost-effective way to deliver services, often in a technologically advanced manner. However, it is my intention to ensure that medically necessary services are provided on uniform terms and conditions, wherever they are offered. The principles of the Canada Health Act are supple enough to accommodate the evolution of medical science and of health care delivery. This evolution must not lead, however, to a two-tier system of health care.

I indicated earlier in this letter that, while user charges for medically necessary services are my most immediate concern, I am also concerned about the more general issues raised by the proliferation of private clinics. In particular, I am concerned about their potential to restrict access by Canadian residents to medically necessary services by eroding our publicly funded system. These concerns were reflected in the policy statement which resulted from the Halifax meeting. Ministers of Health present, with the exception of the Alberta Minister, agreed to:

take whatever steps are required to regulate the development of private clinics in Canada, and to maintain a high quality, publicly funded medicare system.

Private clinics raise several concerns for the federal government, concerns which provinces share. These relate to:

The only way to deal effectively with these concerns is to regulate the operation of private clinics.

I now call on Ministers in provinces which have not already done so to introduce regulatory frameworks to govern the operation of private clinics. I would emphasize that, while my immediate concern is the elimination of user charges, it is equally important that these regulatory frameworks be put in place to ensure reasonable access to medically necessary services and to support the viability of the publicly funded and administered system in the future. I do not feel the implementation of such frameworks should be long delayed.

I welcome any questions you may have with respect to my position on private clinics and facility fees. My officials are willing to meet with yours at any time to discuss these matters. I believe that our officials need to focus their attention, in the coming weeks, on the broader concerns about private clinics referred to above.

As I mentioned at the beginning of this letter, divergent interpretations of the Canada Health Act apply to a number of other practices. It is always my preference that matters of interpretation of the Act be resolved by finding a Federal/Provincial/Territorial consensus consistent with its fundamental principles. I have therefore encouraged F/P/T consultations in all cases where there are disagreements. In situations such as out-of-province or out-of-country coverage, I remain committed to following through on these consultative processes as long as they continue to promise a satisfactory conclusion in a reasonable time.

In closing, I would like to quote Mr. Justice Emmett M. Hall. In 1980, he reminded us:

"we, as a society, are aware that the trauma of illness, the pain of surgery, the slow decline to death, are burdens enough for the human being to bear without the added burden of medical or hospital bills penalizing the patient at the moment of vulnerability."

I trust that, mindful of these words, we will continue to work together to ensure the survival, and renewal, of what is perhaps our finest social project.

As the issues addressed in this letter are of great concern to Canadians, I intend to make this letter publicly available once all provincial Health Ministers have received it.

Yours sincerely,

Diane Marleau
Minister of Health

[Following is the text of the letter sent on August 8, 2018, to all provincial and territorial Ministers of Health by the federal Minister of Health, the Honourable Ginette Petitpas Taylor.]

Dear Minister,

It was a pleasure to see you recently at our Federal/Provincial/Territorial Health Ministers' Meeting in Winnipeg.  As I have explained, when I was appointed as federal Health Minister, the Prime Minister tasked me with promoting and defending the Canada Health Act and quite specifically with eliminating patient charges for services that should be publicly insured.  As you are aware, I have taken this responsibility seriously. 

Following our conversations earlier this year, I was pleased to hear that all provinces and territories participated in officials' level discussions convened by Health Canada this Spring.  We fine-tuned our approach based on the feedback provided in a series of multi- and bilateral meetings. 

The purpose of this letter is to formally advise that I am proceeding with the three Canada Health Act initiatives I discussed with you.  Taken together, the Diagnostic Services Policy, the Reimbursement Policy, and strengthened reporting, will provide me with tools to effectively administer the Act in the interest of all Canadians.

Diagnostic Services Policy

One of the overarching objectives of the Canada Health Act is to ensure that Canadians have access to medically necessary care based on their health needs and not their ability or willingness to pay.  However, in many jurisdictions patients are charged for medically necessary diagnostic services provided at private clinics.  Since the inception of the Canada Health Act, the federal position has always been that all medically necessary physician and hospital services – including diagnostic services – must be covered by provincial and territorial health insurance plans.

If an authorized provider has referred a patient for a medically necessary diagnostic test, the status of the procedure as a publicly insured service should not change simply because the service is delivered in a private clinic rather than in a hospital.  I do not accept the premise that since some patients are willing to pay for expedited access to medically necessary services, they should be provided with a venue to do so.  This practice results in patients jumping the queue twice – first, for the diagnostic service itself and then for any follow-up care that may be required.  Simply put, this is not fair and goes against the fundamental principle of Canadian health care – that is, that access should be based on health need, not on the ability or willingness, to pay.

The Canada Health Act does not preclude the private delivery of insured services.  Many insured health services are provided to Canadians in private clinics and are paid for by the provincial or territorial health insurance plan.  As long as there are no patient charges, provinces and territories can provide insured services as they best see fit.  However, my clarification of the status of medically necessary diagnostic services through this letter means, in effect, that any charges to patients for these services will be considered to be in contravention of the Canada Health Act.

I fully appreciate that it may take time in some jurisdictions to align provincial and territorial systems with the Diagnostic Services Policy.  As I indicated in Winnipeg, the policy will not take effect until April 1, 2020 and reporting on any patient charges for diagnostic services will begin in December 2022 (for the fiscal year 2020-21).  That would mean, in accordance with the Canada Health Act, that any Canada Health Transfer deductions would only be made in March 2023.  If, in the interim, a jurisdiction has eliminated patient charges for diagnostic services, that jurisdiction would be eligible for reimbursement of deducted funds through the new Reimbursement Policy.

Reimbursement Policy

The Canada Health Act was enacted to eliminate the unfair practice of patient charges. The Act is clear – when a province allows patient charges, mandatory deductions to federal transfer payments must be made.  During the first three years of the Canada Health Act, a provision in the Act allowed deductions to be refunded if the jurisdiction took the necessary steps to eliminate patient charges for services which should be publicly insured.  This proved effective, and by 1987, patient charges were eliminated for most hospital and physician services across Canada. However, when this refund provision expired, the incentive structure under the Act went from a positive one, to a purely negative one.  I believe this needs to change.

With the aim of emulating the success of the original refund provision, I am introducing a new Reimbursement Policy. Going forward, provinces and territories would be eligible to be reimbursed for deductions taken in respect of patient charges, should they demonstrate they have taken action to remove these barriers to access.  The attached document provides details on the scope and application of the Policy.  Any deductions made starting from March 2018 will be eligible for reimbursement under this Policy.

Strengthened Reporting

Finally, in order to ensure that I have the information needed to administer the Act in an even-handed manner and in order to report to Canadians on the state of their publicly funded health care insurance system, reporting from provinces and territories to Health Canada and from Health Canada to Canadians will be strengthened and standardized.  Details, which were discussed with your officials this past Spring, will be communicated by my Deputy in the coming weeks.  Again, respecting that a new approach cannot be instituted overnight, we will phase in the new reporting measures.

Canadians are rightfully proud of their health care system and have high expectations that their governments will work together to protect their access to it.  I am confident these initiatives will help us meet that challenge and will safeguard our universal health care system for future generations.

I have appreciated our discussions to date and look forward to ongoing collaboration.

Yours sincerely,The Honourable Ginette Petitpas Taylor, P.C., M.P.

Reimbursement Policy for Provinces and Territories- Subject to Deductions under the Canada Health Act (the Reimbursement Policy)

Background

A fundamental premise of the Canadian health care system is that Canadians should have access to medically necessary physician and hospital services unimpeded by financial or other barriers. The Canada Health Act (CHA) was enacted in response to a growing concern that access to publicly insured health care services was increasingly undermined by point of service charges to patients.

The CHA established the conditions and criteria provinces must meet in order to qualify for their full cash contribution under the Canada Health Transfer (CHT). The Act also established discretionary and mandatory deductions for violations of the CHA principles and the extra-billing and user chargesFootnote 5 (EBUC) provisions of the Act, respectively. The Minister is required to make dollar-for-dollar deductions to a province's or territory's (PT's) CHT payments when EBUC are permitted. The intent of the CHA with respect to deductions is to encourage compliance with the Act and its objective of ensuring Canadians' access to health care services on uniform terms and conditions and without financial barriers.

At the time the CHA came into force, many jurisdictions had legal frameworks for public health insurance which either explicitly allowed EBUC to be levied on patients, or, by convention, had permitted such fees to become entrenched in their health care systems. In view of these factors, it was acknowledged that it would take time for PTs to align their systems with the values and requirements of the CHA. The Act, therefore, included a provision for the first three years (1984-1987) which, in effect, provided refunds of amounts deducted from federal transfers for EBUC violations once the PT succeeded in eliminating EBUC.

PTs adopted legislation governing their public health insurance systems which mirrored, and in most cases went well beyond, the requirements of the CHA. As a result, over $244 million was refunded to seven PTs in respect of patient charges levied in the 1984-1987 period. The advent of the CHA, including the refund provision, helped eliminate EBUC for a considerable period of time in most parts of the country and in most care settings.

Time for a New Reimbursement Policy

Despite provisions discouraging or prohibiting EBUC in both federal and PT legislation, there are still instances of patients paying for access to insured health care services in some jurisdictions. As was the case in 1984, these charges put at risk the fundamental value of universal access to health care.

Some jurisdictions have been active in investigating allegations of patient charges, adopting legislative and regulatory measures to deter EBUC, ensuring that patients are reimbursed and that providers or institutions who contravene PT law (and the CHA) are disciplined. These governments are to be commended for their vigilance on behalf of patients.

Given the success of the original refund provision of the CHA in eliminating EBUC, the federal government is implementing a new Reimbursement Policy for Provinces and Territories Subject to Deductions under the Canada Health Act (the Reimbursement Policy). Under this new policy, if a province or territory is subject to a deduction, the federal Minister of Health has the discretion to provide a reimbursement if the PT comes into compliance with the Act by the end of the calendar year.

Current Process

Under the CHA's Extra-billing and User Charges Information Regulations (the Regulations), PTs are obligated to report to Health Canada on EBUC occurring within their jurisdiction. This takes the form of a financial statement submitted each year, by December 16, which describes any EBUC activity occurring in the fiscal year two years previous. If the Minister does not receive a statement, or believes the information was not provided in accordance with the Regulations, the Act obligates the Minister to estimate an amount after consultation with the PT. The CHT payments to the jurisdiction are then reduced by a corresponding amount in March of the following year.

Working Together to Eliminate Patient Charges

The objective of the Reimbursement Policy is to work collaboratively with PTs subject to a CHT deduction to ultimately eliminate these patient charges. When a PT is informed it will be subject to a CHT deduction for EBUC (typically in January/February), the conditions for reimbursement will also be outlined. In instances where the PT has already eliminated patient charges and a sufficient period of time has elapsed to assure Health Canada that the circumstances that led to these charges have been addressed, reimbursement may be made immediately. Where such charges are ongoing, Health Canada will work with PT officials on the elements of an action plan to meet the conditions for reimbursement. Action plans, and PT progress on meeting them, will be published in the Canada Health Act Annual Report.

To be considered for reimbursement, the jurisdiction would need to demonstrate it has followed through on the agreed upon action plan within the specified time period – typically 12 months but no more than two years following the initial deduction. Because the circumstances leading to deductions will vary from province to province, so will the action plans. Nonetheless, it is expected that all action plans will require the PT to submit the following documents to Health Canada in the January following the deduction:

Upon review of the jurisdiction's report, if the Minister is satisfied that the elements of the action plan have been fulfilled, the PT would receive a reimbursement. However, if the Minister is not satisfied that the conditions were fulfilled, no reimbursement would occur and the deduction amount would be forfeited. Following an initial deduction and reimbursement cycle, if the Minister remains satisfied that appropriate action has been taken, the Reimbursement Policy would allow for the immediate reimbursement of subsequent CHT deductions.

In order to qualify for continued consideration under the Reimbursement Policy, a PT must also comply with the regular reporting requirements set out in the Regulations and submit an accurate EBUC financial statement to Health Canada in the December following the CHT deduction and commit to doing so on an annual basis going forward.

Annex C- Dispute Avoidance and Resolution Process under the Canada Health Act

In April 2002, the Honourable A. Anne McLellan outlined in a letter to her provincial and territorial counterparts a Canada Health Act Dispute Avoidance and Resolution process, which was agreed to by provinces and territories, except Quebec. The process meets federal and provincial/territorial interests of avoiding disputes related to the interpretation of the criteria of the Canada Health Act, and when this is not possible, resolving disputes in a fair, transparent and timely manner.

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

Where dispute avoidance activities prove unsuccessful, dispute resolution activities may be initiated, beginning with government- to-government fact-finding and negotiations. If these are unsuccessful, either Minister of Health involved may refer the issues to a third party panel to undertake fact-finding and provide advice and recommendations.

The federal Minister of Health has the final authority to interpret and enforce the Canada Health Act. In deciding whether to invoke the non-compliance provisions of the Act, the Minister will take the panel's report into consideration.
In September 2004, the agreement reached between the provinces and territories in 2002 was formalized by First Ministers, thereby reaffirming their commitment to use the Canada Health Act Dispute Avoidance and Resolution process to deal with Canada Health Act interpretation issues.

On the following pages you will find the full text of Minister McLellan's Letter to the Honourable Gary Mar, as well as a fact sheet on the Canada Health Act Dispute Avoidance and Resolution Process.

April 2, 2002

The Honourable Gary Mar, M.L.A.
Minister of Health and Wellness
Province of Alberta
Room 323, Legislature Building
Edmonton, Alberta
T5K 2B6

Dear Mr. Mar:

I am writing in fulfilment of my commitment to move forward on dispute avoidance and resolution as it applies to the interpretation of the principles of the Canada Health Act.

I understand the importance provincial and territorial governments attach to having a third party provide advice and recommendations when differences occur regarding the interpretation of the Canada Health Act. This feature has been incorporated in the approach to the Canada Health Act Dispute Avoidance and Resolution process set out 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:

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 Act Dispute Avoidance and Resolution Process

Scope

The provisions described apply to the interpretation of the principles of the Canada Health Act.

Dispute Avoidance

To avoid and prevent disputes, governments will continue to:

Health Canada commits to provide advance assessments to any province or territory upon request.

Dispute Resolution

Where the dispute avoidance activities between the federal government and a provincial or territorial government prove unsuccessful, either Minister of Health involved may initiate dispute resolution by writing to his or her counterpart. Such a letter would describe the issue in dispute. If initiated, dispute resolution will precede any action taken under the non-compliance provisions of the Act.

As a first step, governments involved in the dispute will, within 60 days of the date of the letter initiating the process, jointly:

If however, there is no agreement on the facts, or if negotiations fail to resolve the issue, any Minister of Health involved in the dispute may initiate the process to refer the issue to a third party panel by writing to his or her counterpart.

The Minister of Health for Canada has the final authority to interpret and enforce the Canada Health Act. In deciding whether to invoke the non-compliance provisions of the Act, the Minister of Health for Canada will take the panel's report into consideration.

Public Reporting

Governments will report publicly on Canada Health Act dispute avoidance and resolution activities, including any panel report.

Review

Should adjustments be necessary in the future, the Minister of Health for Canada commits to review the process with Provincial and Territorial Ministers of Health.

Annex D - Financial Statements of Actual Amounts of Extra-Billing and User Charges for the Period April 1, 2017 to March 31, 2018

The Canada Health Act and Extra-billing and User Charges Information Regulations require provinces/territories to report annually to the federal Minister of Health. This report takes the form of a financial statement of actual amounts of extra-billing and user charges levied in the province/territory for the fiscal year in question, along with an explanation regarding the method used to determine the reported amount as indicated in below.

The information reported in the financial statements may be used to determine amounts deducted from the Canada Health Transfer payments of a province/territory where extra-billing and user charges are occurring. However, pursuant to Section 20 of the Act, the federal Minister of Health may estimate amounts of extra-billing and user charges levied, if there is evidence that the information reported in the financial statement does not accurately reflect amounts actually charged to patients in the province or territory.

Under the Act, Extra-billing is defined as a charge by an enrolled physician or dentist to an insured person for an insured service in addition to the amount paid by the provincial/territorial health insurance plan.

Under the Act, A user charge is defined as any charge for an insured health service, other than extra-billing. This includes any charge levied for insured hospital services, or any non-physician related services provided in conjunction with an insured physician service at a non-hospital facility (e.g., private clinic or private practice).

While Quebec did not submit a financial statement in the standard form provided, amounts of extra-billing and user charges levied in the province during 2017-2018 were confirmed in the form of two letters, which are reproduced in this annex.

Newfoundland and Labrador

Canada Health Act

Financial Statement of actual amounts of extra-billing and user charges

For the period April 1, 2017 to March 31, 2018

1. Amounts of extra-billing

Extra-billing is defined as a charge by an enrolled physician or dentist to an insured person for an insured service in addition to the amount paid by the provincial/territorial health insurance plan.

Amount of extra-billing levied by enrolled physicians and dentists for insured health services: $0

2. Amounts of user charges

A user charge is defined as any charge for an insured health service, other than extra-billing. This includes any charge levied for insured hospital services, or any non-physician related services provided in conjunction with an insured physician service at a non-hospital facility (e.g., private clinic or private practice).

Amount of user charges levied for insured services: $ 70,819.35

N.B.  Charges may be levied for accommodation and meal costs related to a patient who, in the opinion of the attending physician, is a permanent resident in a hospital or other chronic care institution as per the limitation of Section 19 (2).  Charges related to this limitation should not be included in the financial statement.

Total for extra-billing and user charges $ 70,819.35

3. Description of method used to determine amounts of extra-billing and user charges

The following information should be included in description of the method used to determine the amounts of extra-billing and user charges (EBUC) reported, including if a NIL amount is submitted: 

a) Name of applicable pieces of PT legislation that prohibit extra-billing and user charges (including facility fees).

Please use as much space needed below or add extra pages as necessary.

In Newfoundland and Labrador, HCS administers the Medical Care Insurance Plan. Subsection 7(1) of the Medical Care and Hospital Insurance Act, states that a practitioner shall not charge or collect from a beneficiary a fee for those insured services in excess of the amount payable under this Act and the regulations. Administration of the Medical Care Insurance Plan, including deterrence of extra-billing, is in accordance with the Act and the associated regulations. Of particular note are the Medical Care Insurance Insured Services Regulations, NLR 21/96 (the "Regulations").

b) Details about the process used to investigate extra-billing and user charges (e.g., proactive regular audits of provider billings; reactive investigations triggered by patient complaints, media reports or other sources).

Please use as much space needed below or add extra pages as necessary.

HCS conducts regular audits of provider billings. No instances of extra-billing or user charges (EBUC) were identified during the relevant period through the regular auditing process.

Cases of extra-billing and user charges may be identified through the audit process described under section 21 of the Medical Care and Hospital Insurance Act or may be reported from beneficiaries. These instances may be discovered when beneficiaries submit claims to the Department of Health and Community Services (the Department) for reimbursement.

Complaints from beneficiaries regarding charges for insured health services are managed by the Department. Depending on the circumstance, the Department may investigate or refer the matter to the College of Physicians and Surgeons of Newfoundland and Labrador, the regulatory body for physicians in the province, for potential disciplinary action. Beneficiaries may also contact the College directly if they feel that they have been subject to improper billing by their physician.

Regarding repayment, section 25 of the Medical Care and Hospital Insurance Act provides the Minister with powers to recover overpayments and interest that were discovered via audit. The Minister of Health and Community Services may do this by entering into an agreement with the practitioner or their professional corporation or the Minister may order the practitioner to pay to the Minister the overpaid amount plus interest.

Beneficiaries wishing to file a complaint regarding medical care that they have received are encouraged to call or email the Complaints Coordinator at the College (1-709-726-8546 or complaints@cpsnl.ca) or call the Medical Care Plan general inquiries line (Avalon area: 1-866-449-4459; all other regions:1-800-563-1557).

c) A summary of any extra-billing and user charges investigations during the fiscal year including:

Please use as much space needed bellow or add extra pages as necessary.

In 2017-2018, HCS received six complaints from beneficiaries of direct billing for cataract surgery. HCS issued a Public Service Announcement on February 7, 2018 inviting individuals to contact HCS with suspected instances of EBUC related to cataract surgery. The phone line received over six hundred calls. There were one hundred and five (105) known instances of user charges related to cataract surgery affecting sixty-one patients for the applicable reporting period indicated. In other words, sixty-one patients paid out-of-pocket expenses for cataract surgery on one or both eyes during this timeframe.

The insured portion of the cataract surgeries amounts to $674.47 for professional fees and the basic lens.

Table 1
  Cost of item when covered by provincial plan Is This An Insured Service?
Professional fees for cataract surgery $574.47 Yes
Basic soft foldable lens $100.00 No. At the time, this lens was considered an upgrade. As of January 1, 2019, the soft or foldable lens was accepted as standard of care and patients no longer pay out of pocket for this item.
Total user charges per eye $674.47 -

Examination of documents obtained from callers to the phone line relevant to this reporting period showed a base fee of $1,195 for a "bronze" or "standard" surgical package. Itemized invoices were not available for examination for all patients. On examination of documents where available, the base fee generally included the following services for non-insured "advanced diagnostics":

Table 2 - Services paid by beneficiary that are not covered
Invoiced Item Amount Charged to Patient Per Eye Is This An Insured Service?
Optical coherence biometry and auto-refraction $195.00 No
Corneal vector analysis and astigmatism planning $400.00 No
Optical coherence tomography (OCT) of anterior segment $150.00 MCP does not insure this test when performed for cataract surgery. OCT is an insured service in the hospital or clinic only when specific clinical indications are met.
No
Total amount of non-insured diagnostic charges to patient $895.00 -

Higher cost surgical packages included all of the above non-insured diagnostics with the addition of more advanced lens implant options, which also represent non-insured services. In addition to these non-insured diagnostic charges, patients were offered the option to pay an additional $1000 per eye for the use of Femto laser technology. This type of technology is not payable in addition to existing insured professional fees for cataract surgery. The Medical Care Plan (MCP) Medical Payment Schedule specifies that fees for cataract surgery include cataract extraction "by any procedure". As such, any costs for Femto laser technology would already be included in professional fees paid by MCP.

As there were 105 "eyes" which incurred direct charges for cataract surgery during the time indicated, the total amount of user charges identified for this reporting period is 105 eyes multiplied by $674.47, which is equal to $70,819,35.

d) Details on mechanisms to deter patient extra-billing and user charges (e.g., provider fines; plan payment withholding; provider/patient education initiatives; loss of facility accreditation).

Please use as much space needed below or add extra pages as necessary.

Section 7 of the Medical Care and Hospital Insurance Act outlines that a practitioner who provides insured services, whether or not he or she has made an election to opt out of participation in the MCP, shall not charge or collect from a beneficiary a fee for those insured services in excess of the amount payable under the Act and the regulations. A practitioner or other person who contravenes this is guilty of an offence and liable on summary conviction to a fine of up to but not more than $20,000 for each contravention.

The Medical Care and Hospital Insurance Act authorizes the Minister to appoint auditors to audit the accounts and claims for payment submitted by physicians and dentists. The Act prescribes the power and duties of auditors, sets out the remedies available and details the processes to be followed. The Act also details the review and appeal processes available to practitioners. Individual providers are randomly selected on a bi-weekly basis for audit.

Prince Edward Island

Canada Health Act

Financial Statement of actual amounts of extra-billing and user charges

For the period April 1, 2017 to March 31, 2018

1. Amounts of extra-billing

Extra-billing is defined as a charge by an enrolled physician or dentist to an insured person for an insured service in addition to the amount paid by the provincial/territorial health insurance plan.

Amount of extra-billing levied by enrolled physicians and dentists for insured health services: $ NIL

2. Amounts of user charges

A user charge is defined as any charge for an insured health service, other than extra-billing. This includes any charge levied for insured hospital services, or any non-physician related services provided in conjunction with an insured physician service at a non-hospital facility (e.g., private clinic or private practice).

Amount of user charges levied for insured services: $ NIL

N.B.  Charges may be levied for accommodation and meal costs related to a patient who, in the opinion of the attending physician, is a permanent resident in a hospital or other chronic care institution as per the limitation of Section 19 (2).  Charges related to this limitation should not be included in the financial statement.

Total for extra-billing and user charges $ NIL

3. Description of method used to determine amounts of extra-billing and user charges

The following information should be included in description of the method used to determine the amounts of extra-billing and user charges (EBUC) reported, including if a NIL amount is submitted: 

a) Name of applicable pieces of PT legislation that prohibit extra-billing and user charges (including facility fees).

Please use as much space needed below or add extra pages as necessary.

Extra billing is not permitted, as per the Province of Prince Edward Island’s Health Services Payment Act.

PEI's Hospital and Diagnostic Services Insurance Act (HDSIA) does not explicitly prohibit user charges for insured health services. However, there are a number of sections in the HDSIA Regulations that infer that user charges would be prohibited, as described below.

Section 1.1(l): "insured services" means, subject to subsection (2), the in-patient and out-patient hospital services available to an entitled person without charge, as determined by the Minister but does not include any services to which a person is entitled, and for which a person is eligible, under any law mentioned in Schedule C"

Section 6.1: An approved hospital shall make a direct charge in respect of the patient who is an entitled person for the difference between the per diem cost of providing insured services and the hospital charges approved by the Minister for private or semi-private accommodation and for any other services which are not insured services requested by or on behalf of the patient.

b) Details about the process used to investigate extra-billing and user charges (e.g., proactive regular audits of provider billings; reactive investigations triggered by patient complaints, media reports or other sources).

Please use as much space needed below add extra pages as necessary.

Health PEI administers a system of internal controls when reviewing physician billings, and investigates irregularities in billing. Physicians are subject to internal audit of billing practices to ensure all amounts billed to Health PEI are appropriate.

Annual financial results for Health PEI are reviewed to identify irregularities and significant variances. This includes a review of revenues to identify any new revenue items (ie. user charges). These revenues are also subject to review by the Auditor General.

The Province of Prince Edward Island offers several avenues for patients and the general public to provide feedback and complaints, including a “Compliments and Complaints” link on the Health PEI website. The Minister of Health and Wellness, the CEO of Health PEI and staff can also be contacted by anyone who may have been subject to any extra billing or user charges. Health PEI follows up on any complaints, including those around billing practices.

c) A summary of any extra-billing and user charges investigations during the fiscal year including:

Please use as much space needed bellow or add extra pages as necessary.

Health PEI conducts physician billing audits on the appropriateness of amounts billed to Health PEI by physicians for insured services. Health PEI does not have access to physicians’ financial records to determine whether any insured services were billed separately to individuals or third parties other than Health PEI. No incidences of extra billing or user charges were noted during these audits.

d) Details on mechanisms to deter patient extra-billing and user charges (e.g., provider fines; plan payment withholding; provider/patient education initiatives; loss of facility accreditation).

Please use as much space needed below or add extra pages as necessary.

Potential new revenue sources for Health PEI are subject to evaluation and approval by Finance and executive leadership, where user charges for insured services would be noted and rejected.

Nova Scotia

Canada Health Act

Financial Statement of actual amounts of extra-billing and user charges

For the period April 1, 2017 to March 31, 2018           

1. Amounts of extra-billing

Extra-billing is defined as a charge by an enrolled physician or dentist to an insured person for an insured service in addition to the amount paid by the provincial/territorial health insurance plan.

Amount of extra-billing levied by enrolled physicians and dentists for insured health services: $ 0

2. Amounts of user charges

A user charge is defined as any charge for an insured health service, other than extra-billing. This includes any charge levied for insured hospital services, or any non-physician related services provided in conjunction with an insured physician service at a non-hospital facility (e.g., private clinic or private practice).

Amount of user charges levied for insured services: $ 0

N.B.  Charges may be levied for accommodation and meal costs related to a patient who, in the opinion of the attending physician, is a permanent resident in a hospital or other chronic care institution as per the limitation of Section 19 (2).  Charges related to this limitation should not be included in the financial statement.

Total for extra-billing and user charges $ 0

3. Description of method used to determine amounts of extra-billing and user charges

The following information should be included in the description of the method used to determine the amounts of extra-billing and user charges (EBUC) reported, including if a NIL amount is submitted: 

a) Name of applicable pieces of PT legislation that prohibit extra-billing and user charges (including facility fees).

Please use as much space needed below or add extra pages as necessary.

b) Details about the process used to investigate extra-billing and user charges (e.g., proactive regular audits of provider billings; reactive investigations triggered by patient complaints, media reports or other sources).

Please use as much space as needed below.

Nova Scotia relies on a complaints-based system whereby concerns are brought to the attention of the Minister on a case by case basis

c) A summary of any extra-billing and user charges investigations during the fiscal year including:

Please use as much space as needed bellow.

There were no investigations in 2017-2018 fiscal year.

d) Details on mechanisms to deter patient extra-billing and user charges (e.g., provider fines; plan payment withholding; provider/patient education initiatives; loss of facility accreditation).

Please use as much space as needed below.

New Brunswick

Canada Health Act

Financial Statement of actual amounts of extra-billing and user charges

For the period April 1, 2017 to March 31, 2018           

1. Amounts of extra-billing

Extra-billing is defined as a charge by an enrolled physician or dentist to an insured person for an insured service in addition to the amount paid by the provincial/territorial health insurance plan.

Amount of extra-billing levied by enrolled physicians and dentists for insured health services: $ 0

2. Amounts of user charges

A user charge is defined as any charge for an insured health service, other than extra-billing. This includes any charge levied for insured hospital services, or any non-physician related services provided in conjunction with an insured physician service at a non-hospital facility (e.g., private clinic or private practice).

Amount of user charges levied for insured services: $ 0

N.B.  Charges may be levied for accommodation and meal costs related to a patient who, in the opinion of the attending physician, is a permanent resident in a hospital or other chronic care institution as per the limitation of Section 19 (2).  Charges related to this limitation should not be included in the financial statement.

Total for extra-billing and user charges $ 0

3. Description of method used to determine amounts of extra-billing and user charges

The following information should be included in descriptions of the method used to determine the amounts of extra-billing and user charges (EBUC) reported, including if a NIL amount is submitted: 

1. Name of applicable pieces of PT legislation that prohibit extra-billing and user charges (including facility fees).

Please use as much space needed below or add extra pages as necessary.

New Brunswick’s Medical Services Payment Act and its Regulations (MSPA) describe mechanisms creating a health system which is Publicly Administered, Comprehensive, Universally available to its beneficiaries, Portable, and Accessible.  It defines who may receive or provide an entitled service and how fee schedules are determined, and prohibits extra-billing or user charges for any such service remunerated through the Medicare Branch.

Some providers may choose to practise outside the MSPA. The MSPA establishes a wall between the publicly funded system (which meets the principles outlined above) and entrepreneurial private business, prohibiting any practitioner payments which exceed the established fee schedules, and payments to private hospitals. It also establishes a private practitioner’s duty to inform prospective patients.

2. Details about the process used to investigate extra-billing and user charges (e.g., proactive regular audits of provider billings; reactive investigations triggered by patient complaints, media reports or other sources).

Please use as much space needed below or add extra pages as necessary.

New Brunswick uses a robust “comment based” approach to identifying individual citizens’ concerns on a wide range of health issues. In a typical month in the 2017-2018 fiscal year the Department of Health received, logged, and responded to 100-150 concerns from individual New Brunswickers on issues including access to primary or specialized care, pharmaceutical approvals, access to services in a citizen’s language of choice, wait times for specific services, the structure of specific programs, etc. The Department’s web page provides several mechanisms to make such comments, including mailing addresses, e-mail addresses, telephone numbers, and a web-based message service. No concerns respecting extra-billing and user charges were received in the 2017-2018 fiscal year.

3. A summary of any extra-billing and user charges investigations during the fiscal year including:

Please use as much space as needed bellow.

4. Details on mechanisms to deter patient extra-billing and user charges (e.g., provider fines; plan payment withholding; provider/patient education initiatives; loss of facility accreditation).

Please use as much space needed below or add extra pages as necessary.

New Brunswick’s Medical Services Payment Act and its Regulations (MSPA) describe mechanisms creating a health system which is Publicly Administered, Comprehensive, Universally available to its beneficiaries, Portable, and Accessible. It defines who may receive or provide an entitled service and how fee schedules are determined, and prohibits extra-billing or user charges for any such service remunerated through the Medicare Branch. • Schedule 2 of the Regulation describes services which are ineligible for payment under the Act; paragraph (n.l ) specifically prohibits payments to practitioners within New Brunswick whose fee exceeds the amount payable under the Regulation.

Quebec

Direction générale de la coordination, de la planification, de la performance et de la qualité
[Coordination, planning, performance and quality assurance branch]

BY EMAIL

Québec, December 16, 2019

Gigi Mandy
Executive Director
Canada Health Act Division
Strategic Policy Branch
Health Canada
Brooke Claxton Building, Floor 8
70 Colombine Driveway, Tunney's Pasture
Postal locator 0908C
Ottawa, Ontario  K1A 0K9

Dear Ms. Mandy,

This is further to the letter to the Deputy Minister of Health and Social Services, Yvan Gendron, dated November 22. The letter requested the aggregate amount of extra-billing and user fees for 2017-2018.

In Quebec, the health insurance plan is regulated by the Health Insurance Act. This Act does not allow user fees to be imposed. It also prohibits any person from demanding or receiving any payment from a person for incidental fees related to an insured service, except in cases prescribed by regulation or provided for in an agreement and the conditions mentioned therein.

In order to provide further clarification about this prohibition, the Government of Quebec has approved a draft regulation expressly prohibiting any fees related to services insured by Quebec's health insurance plan as well as all accessory fees provided for in compensation agreements with physicians. This regulation has been in effect since January 2017. Of course, in the event of actions, whatever they may be, that are contrary to Quebec's statutes and regulations, the Régie de l'assurance maladie du Québec will take the appropriate measures to rectify the situation.

As you are no doubt aware, health and social services are within the exclusive jurisdiction of the provinces. As such, Quebec intends to remain responsible for the management, organization and planning of care and services on its territory.

Moreover, the government is accountable to the National Assembly and to the people of Quebec with respect to how its healthcare system is run. Thus, Quebec shall continue to fulfill this responsibility to Quebec's citizens, who are the ultimate arbiters as to the quality and accessibility of the services provided to them by our healthcare system.

You may consult, for your information, the Ministère de la Santé et des Services Sociaux's (MSSS) 2017-2018 annual management report tabled in the National Assembly, which provides an accounting of how Quebec manages its healthcare system. The report is available in the Publications section of the MSSS website.

Sincerely,

Valérie Fontaine, Director
International and Intergovernmental Affairs Directorate
Our ref: 19-CP-0041

Ontario

Canada Health Act

Financial Statement of actual amounts of extra-billing and user charges

For the period April 1, 2017 to March 31, 2018           

1. Amounts of extra-billing

Extra-billing is defined as a charge by an enrolled physician or dentist to an insured person for an insured service in addition to the amount paid by the provincial/territorial health insurance plan.

Amount of extra-billing levied by enrolled physicians and dentists for insured health services: $ NIL

2. Amounts of user charges

A user charge is defined as any charge for an insured health service, other than extra-billing. This includes any charge levied for insured hospital services, or any non-physician related services provided in conjunction with an insured physician service at a non-hospital facility (e.g., private clinic or private practice).

Amount of user charges levied for insured services: $ NIL

N.B.  Charges may be levied for accommodation and meal costs related to a patient who, in the opinion of the attending physician, is a permanent resident in a hospital or other chronic care institution as per the limitation of Section 19 (2).  Charges related to this limitation should not be included in the financial statement.

Total for extra-billing and user charges $ NIL

3. Description of method used to determine amounts of extra-billing and user charges

The following information should be included in the description of the method used to determine the amounts of extra-billing and user charges (EBUC) reported, including if a NIL amount is submitted: 

Name of applicable pieces of PT legislation that prohibit extra-billing and user charges (including facility fees).

Please use as much space needed below or add extra pages as necessary.

The Ontario Health Insurance Plan (OHIP) and all insured services are set out under the Health Insurance Act (HIA) and Regulations.

In Ontario, a combination of two pieces of legislation prohibits any person or entity from charging for all or part of an OHIP-insured service rendered to an insured person (i.e. EBUC, including illegal facility fees). These statutes are as follows:

  1. The Commitment to the Future of Medicare Act (CFMA) prohibits any person or entity from charging unauthorized payments for all or part of an OHIP-insured service rendered to an insured person. Such charges include extra-billing (i.e. charges to insured persons for insured physician and dental-surgical services) and user charges (i.e. charges to insured persons for non-physician/dental-surgical services provided in conjunction with insured services at a hospital).

    The CFMA also prohibits providers and other entities from providing preferred access to an insured service conditional on the payment of a fee, which is called queue-jumping, and from making the provision of an insured service conditional on paying a block fee for uninsured services.

    The CFMA applies regardless of the type of facility or setting in which a service is rendered.

  2. For services rendered outside of a hospital, the Independent Health Facilities Act (IHFA) prohibits any person from charging for the cost of any premises, equipment, supplies and personnel that support, assist and/or provide a necessary adjunct to certain OHIP-insured services (i.e. facility fees).

    Regardless of whether a service is provided in an IHF or any other non-hospital setting, a charge for a service that is a necessary adjunct to an insured service, but is not part of the insured service, is an illegal facility fee under the IHFA.

Through a dedicated program (CFMA Program), the Ontario Ministry of Health (the ministry) reviews all possible cases of EBUC brought to its attention according to the process set out under the CFMA. Charging facility fees contrary to the IHFA may also have implications under the CFMA, and therefore, the ministry's CFMA Program also reviews allegations of illegal facility fees under the IHFA in conjunction with the ministry's IHF program.

If, as a result of a review, it is determined that a patient has paid an unauthorized payment (i.e. extra-billing) and/or user charge, the ministry ensures that the full amount is reimbursed to the patient.

a) Details about the process used to investigate extra-billing and user charges (e.g., proactive regular audits of provider billings; reactive investigations triggered by patient complaints, media reports or other sources).

Please use as much space needed below or add extra pages as necessary.

The ministry reviews all possible instances of EBUC that come to its attention. Patient complaints regarding possible EBUC and questions from the public are received via a dedicated toll-free number and email address. Information regarding possible EBUC arises primarily from patient complaints; however, the ministry may also review possible violations that are brought to its attention by other sources such as Health Canada, regulatory colleges, MPPs, the media, advertisements, etc.

All inquiries from patients and other sources regarding out-of-pocket charges for health care services are responded to and are assessed to determine whether or not a CFMA review is opened (i.e., was the service charged for clearly uninsured or is further review required?). If it is determined that EBUC may have occurred, according to CFMA Program policy, patients are asked to complete a CFMA Program form providing their consent for the ministry to open a review and contact the provider or entity on their behalf.

Reviews regarding EBUC follow a process outlined in legislation (CFMA). At the onset of a review, there is normally insufficient information to determine whether or not EBUC has occurred. Therefore, in most cases, the ministry requests relevant records and/or information from providers under authority of the CFMA (e.g. medical and/or hospital/facility records related to the service the patient was charged for, copies of all invoices and receipts, a breakdown of any patient charges, etc.). Once the requested information has been received, it is reviewed by CFMA Program staff in order to determine whether a specific service provided to a patient was insured. In almost all cases, ministry medical advisors are consulted for assistance in interpreting medical records. Staff may also consult with other areas of the ministry, including legal services and other branches.

The ministry can and does review possible EBUC on a proactive basis (i.e. without receiving a complaint). However, as noted above, reviews often require examinations of specific patient records to determine whether a specific service provided to a patient was insured, and therefore, without a specific patient complaint, the ministry primarily seeks information regarding general practices and does not review patient medical records.

If the ministry finds through a CFMA review that a patient has paid an illegal extra-billing fee or user charge, the ministry ensures that the full amount is reimbursed to the patient. Although not required under the Act, it is the ministry's policy that if a provider or entity has been determined to have received an unauthorized payment, they are given an opportunity to repay the patient directly. If the provider or entity declines to repay the patient, the ministry will repay the patient directly and the provider or entity will become indebted to OHIP for the amount of the unauthorized payment plus an administrative charge of $150.00 for each payment made by OHIP to the patient.Footnote 23

Most providers and entities who are notified of the ministry's determination that they have received an unauthorized payment agree to reimburse the patient directly. However, on rare occasions, the CFMA Program has initiated direct recoveries from providers or entities.

As required, the CFMA contains provincial offence provisions, where individuals and corporations in violation of the CFMA are subject to fines if convicted of an offence under the Provincial Offences Act (POA). Additionally, when a CFMA review identifies possible inappropriate OHIP billing or fraud, the matter is referred to either the ministry's Payment Accountability Unit or to the Ontario Provincial Police Health Fraud Investigation Unit.

b) A summary of any extra-billing and user charges investigations during the fiscal year including:

Please use as much space as needed bellow.

For each review that took place in FY 2017-18 in which the ministry determined that an unauthorized payment was received for extra-billing and/or user charges, the patient was reimbursed the full amount by either the person or entity that received the payment or by the ministry directly. Therefore, the total extra-billing amount reported above ($ NIL) represents the net amount of unauthorized payments for insured physician and dental-surgical services levied in Ontario in FY 2017-18.

In FY 2017-18, the ministry conducted 84 reviews of potential EBUC as follows:

49 reviews resulted in a determination that a patient was not charged for an insured service as per Ontario legislation and Regulation:

# of Reviews Nature of Review
43 Patient-Initiated
6 Non-Patient Specific and Initiated by Other Sources (e.g. Abortion Education Group, Regulatory College, Concerned Citizen, etc.)

35 reviews resulted in a determination that a patient was charged for an insured service as per Ontario Legislation and Regulation. In each of these cases, patients were reimbursed the total  amount they paid:

# of Reviews Nature of Reviews # of Patients Reimbursed Charge Type Charge Per Service Total Amount Charged Total Amount Reimbursed
26 Patient Initiated 26 Extra-Billing $25.00-$2,651.25 $16,160.91 $16,160.91
8 Patient Initiated 8 User Charges $25.98-$1,410.99 $3,325.17 $3,325.17
1 MPP Referred 1 User Charges $672.88 $672.88 $672.88
35 Total # of Reviews Involving Confirmed EBUC (Including Facility Fees) Total Amount Charges and Reimbursed for Confirmed Reviews $20,158.96 $20,158.96

In his letter dated November 20, 2019 to Ontario Deputy Minister of Health Helen Angus, Federal Deputy Minister of Health Stephen Lucas specifically referenced concerns that patients may be required to pay fees in order to access insured abortion services in Ontario. As noted above, under the authority of the CFMA, the ministry reviews all possible instances of EBUC for insured services that come to its attention. In FY 2017-18, five investigative reviews were undertaken by the ministry in relation to potential patient charges by non-hospital clinics in association with insured abortion services. The clinics reviewed included the Brampton Woman's Clinic, the Mississauga Women's Clinic, and the Bloor West Village Women's Clinic. These clinics are the same as those referenced in letters from the former federal Minister of Health Ginette Petitpas-Taylor to the Ontario Minister of Health Christine Elliott and from the Executive Director of Health Canada's Canada Health Act Division to Ontario's Health Services Branch in the summer of 2019. No CFMA and/or IHFA violations were identified as a result of those reviews. It was determined in all cases that no OHIP-insured persons had been charged for an insured abortion service (or part thereof) or for access to an insured abortion service. Therefore, no reimbursements for extra-billing or user charges were made by the ministry in FY 2017/18 in relation to insured abortion services.

c) Details on mechanisms to deter patient extra-billing and user charges (e.g., provider fines; plan payment withholding; provider/patient education initiatives; loss of facility accreditation).

Please use as much space needed below or add extra pages as necessary.

The ministry takes steps to prevent EBUC by maintaining a webpage which provides public information regarding the CFMA, including what is prohibited under the Act (i.e., extra-billing, queue-jumping, illegal block fees), how to determine if they have been charged for an insured service or for access to an insured service, and how to contact the ministry via a dedicated toll free number and email address in order to open an review or ask a question regarding a possible CFMA violation.

The ministry also regularly undertakes proactive CFMA review(s) that are not tied to a specific patient complaint but are instead initiated by the ministry to target providers in high-risk areas of practice known to have frequent instances of EBUC. In many cases, these investigations are done for the purposes of provider education, in order for the ministry to communicate the provider's obligations under the Canada Health Act (CHA) and CFMA, and to ensure that their billing practices are amended as appropriate to comply with Ontario legislation. The ministry has also in the past undertaken patient education initiatives to increase awareness among members of the general public about the protections under the CFMA and to encourage filing complaints to the CFMA program so that reviews can be initiated.

In rare but serious cases where the person or entity fails comply with a CFMA review without just cause (e.g., if a provider or entity fails to provide the ministry with requested information relevant to the determination of whether or not EBUC has occurred), the Act authorizes the ministry to suspend all OHIP payments to the person or entity pending receipt of the requested information, as per the review process set out under the Act

As noted above, the CFMA also contains provincial offence provisions, where individuals and corporations in violation to the CFMA are subject to fines if convicted of an offence under the POA. Additionally, when a CFMA review identifies possible inappropriate OHIP billing or fraud, the matter is referred to either the ministry's Payment Accountability Unit or to the Ontario Provincial Police for more serious cases.

Manitoba

Canada Health Act

Financial Statement of actual amounts of extra-billing and user charges

For the period April 1, 2017 to March 31, 2018

1. Amounts of extra-billing

Extra-billing is defined as a charge by an enrolled physician or dentist to an insured person for an insured service in addition to the amount paid by the provincial/territorial health insurance plan.

Amount of extra-billing levied by enrolled physicians and dentists for insured health services: $ 0

2. Amounts of user charges

A user charge is defined as any charge for an insured health service, other than extra-billing. This includes any charge levied for insured hospital services, or any non-physician related services provided in conjunction with an insured physician service at a non-hospital facility (e.g., private clinic or private practice).

Amount of user charges levied for insured services: $ 0

N.B.  Charges may be levied for accommodation and meal costs related to a patient who, in the opinion of the attending physician, is a permanent resident in a hospital or other chronic care institution as per the limitation of Section 19 (2).  Charges related to this limitation should not be included in the financial statement.

Total for extra-billing and user charges $ 0

3. Description of method used to determine amounts of extra-billing and user charges

The following information should be included in description of the method used to determine the amounts of extra-billing and user charges (EBUC) reported, including if a NIL amount is submitted: 

a) Name of applicable pieces of PT legislation that prohibit extra-billing and user charges (including facility fees).

Please use as much space needed below or add extra pages as necessary.

b) Details about the process used to investigate extra-billing and user charges (e.g., proactive regular audits of provider billings; reactive investigations triggered by patient complaints, media reports or other sources).

Please use as much space needed below or add extra pages as necessary.

c) A summary of any extra-billing and user charges investigations during the fiscal year including:

Please use as much space needed bellow or add extra pages as necessary.

There were no formal investigations conducted in 2017-2018 on the basis of complaints from residents of Manitoba. There were no confirmed cases of extra-billing or user charges.

d) Details on mechanisms to deter patient extra-billing and user charges (e.g., provider fines; plan payment withholding; provider/patient education initiatives; loss of facility accreditation).

Please use as much space needed below or add extra pages as necessary.

Saskatchewan

Canada Health Act

Financial Statement of actual amounts of extra-billing and user charges

For the period April 1, 2017 to March 31, 2018

1. Amounts of extra-billing

Extra-billing is defined as a charge by an enrolled physician or dentist to an insured person for an insured service in addition to the amount paid by the provincial/territorial health insurance plan.

Amount of extra-billing levied by enrolled physicians and dentists for insured health services: $ 0

2. Amounts of user charges

A user charge is defined as any charge for an insured health service, other than extra-billing. This includes any charge levied for insured hospital services, or any non-physician related services provided in conjunction with an insured physician service at a non-hospital facility (e.g., private clinic or private practice).

Amount of user charges levied for insured services: $ 0

N.B.  Charges may be levied for accommodation and meal costs related to a patient who, in the opinion of the attending physician, is a permanent resident in a hospital or other chronic care institution as per the limitation of Section 19 (2).  Charges related to this limitation should not be included in the financial statement.

Total for extra-billing and user charges $ 0

3. Description of method used to determine amounts of extra-billing and user charges

The following information should be included in description of the method used to determine the amounts of extra-billing and user charges (EBUC) reported, including if a NIL amount is submitted: 

a) Name of applicable pieces of PT legislation that prohibit extra-billing and user charges (including facility fees).

Please use as much space needed below or add extra pages as necessary.

The Saskatchewan Medical Care Insurance Act precludes physicians/dentists who provide insured services from charging patients more than the amount paid for that service under the Act, unless the physician/dentist has opted out entirely from receiving payments under the Act. Notice must also be given to the province where a physician/dentist opts out. No notices have been received for the reporting period.

The Saskatchewan Medical Care Insurance Act includes provisions which indicate that any amount that a physician who provides insured services requires a beneficiary to pay or to have paid as a condition of receiving an insured service which exceeds the amount to be paid for that service under the Act, is considered to be a charge.

The Health Facilities Licensing Act precludes any licensee from charging or permitting any other person to charge any fee to any beneficiary for any insured health service performed at the health facility.

b) Details about the process used to investigate extra-billing and user charges (e.g., proactive regular audits of provider billings; reactive investigations triggered by patient complaints, media reports or other sources).

Please use as much space needed below or add extra pages as necessary.

With regard to extra-billing compliance is monitored through consultations with the provincial health authority, physicians and dentists, as well as complaints from members of the public. When requests are made by a beneficiary seeking reimbursement of monies paid directly to a physician for insured physician services that are extra-billing charges, correspondence is sent to the beneficiary (copying the physician) advising them of Section 18 (1.1) of the Saskatchewan Medical Care Insurance Payment Act that a physician must accept the negotiated rate as payment in full for insured services provided to a beneficiary. Once the physician has received payment from Medical Services for the eligible service(s), reimbursement for any difference in the amount charged by the practitioner and the amount paid by Medical Services should be collected directly from the practitioner. If a further complaint is made, the beneficiary is directed to address complaints to the Saskatchewan College of Physicians and Surgeons.

Persons who have a complaint of an extra-billing charge may raise the concern with the College of Physicians and Surgeons of Saskatchewan. Section 7.1 (Code of Ethics) in the College's bylaws notes the following:

With regard to user charges, compliance is monitored through consultations with the provincial health authority, physicians and dentists, as well as complaints from members of the public.

Persons who have a complaint of user charges may raise the concern with the College of Physicians and Surgeons of Saskatchewan. Section 7.1 (Code of Ethics) in the College's bylaws notes the following:

c) A summary of any extra-billing and user charges investigations during the fiscal year including:

Please use as much space needed bellow or add extra pages as necessary.

For the 2017-2018 fiscal year Saskatchewan is reporting $0 in extra-billing. Saskatchewan has no information that extra-billing charges have been levied during the reporting period.

For the 2017-2018 fiscal year Saskatchewan is reporting $0 in User Charges. Saskatchewan has no information that user charges have been levied during the reporting period. Saskatchewan is not aware of charges being levied for insured services provided in a hospital. Nor is Saskatchewan aware of any additional charges for insured services being levied in a physician clinic as defined in the federal private clinics policy.

d) Details on mechanisms to deter patient extra-billing and user charges (e.g., provider fines; plan payment withholding; provider/patient education initiatives; loss of facility accreditation).

Please use as much space needed below or add extra pages as necessary.

The Saskatchewan Medical Care Insurance Act and the Health Facilities Licensing Act stipulate monetary penalties for individuals guilty of contravening the Act(s), including extra-billing and user charges of insured health services.

Alberta

Canada Health Act

Financial Statement of actual amounts of extra-billing and user charges

For the period April 1, 2017 to March 31, 2018

1. Amounts of extra-billing

Extra-billing is defined as a charge by an enrolled physician or dentist to an insured person for an insured service in addition to the amount paid by the provincial/territorial health insurance plan.

Amount of extra-billing levied by enrolled physicians and dentists for insured health services: $ 0

2. Amounts of user charges

A user charge is defined as any charge for an insured health service, other than extra-billing. This includes any charge levied for insured hospital services, or any non-physician related services provided in conjunction with an insured physician service at a non-hospital facility (e.g., private clinic or private practice).

Amount of user charges levied for insured services: $ 0

N.B.  Charges may be levied for accommodation and meal costs related to a patient who, in the opinion of the attending physician, is a permanent resident in a hospital or other chronic care institution as per the limitation of Section 19 (2).  Charges related to this limitation should not be included in the financial statement.

Total for extra-billing and user charges $ 0

3. Description of method used to determine amounts of extra-billing and user charges

The following information should be included in description of the method used to determine the amounts of extra-billing and user charges (EBUC) reported, including if a NIL amount is submitted: 

a) Name of applicable pieces of PT legislation that prohibit extra-billing and user charges (including facility fees).

Please use as much space needed below or add extra pages as necessary.

b) Details about the process used to investigate extra-billing and user charges (e.g., proactive regular audits of provider billings; reactive investigations triggered by patient complaints, media reports or other sources).

Please use as much space needed below or add extra pages as necessary.

Alberta Health has reviewed the Canada Health Act form Financial Statement of Actual Amounts of Extra-Billing and User Charges for the Period April 1, 2017 to March 31, 2018 and reporting guidelines.

Alberta Health uses the following processes to determine and investigate EBUC:

  1. Alberta Health has conducted audits and compliance reviews in accordance with the authority and the provisions of the Alberta Health Care Insurance Act (AHCIA) that mirrors the fundamental principles of the Canada Health Act.
  2. Alberta Health uses a proactive risk based planning process to identify potential areas of inappropriate billing under the AHCIA, which includes provisions to address non-compliance with regard to extra-billing and prohibited fees by any person. Based on this process, high risk subjects for audit and/or compliance review are selected. The scope of work includes all physicians and other practitioners receiving compensation through the Plan on a fee-for-service basis or through Clinical Alternative Relationship Plans. Payments to hospitals, which Alberta Health Services operates and funds, are not in scope.
  3. If patients in Alberta have questions or concerns regarding potential extra-billing or user charges they can direct their inquiries to Alberta Health.  The primary mechanisms of inquiry or complaint are:
    • Contacting the Alberta Health Care Insurance Plan (AHCIP) by phone, fax, mail, or email.
    • The Alberta Health TIPS line. Patients can call to express concerns and those that are physician or claims related will be directed to Claims Specialist Unit. 
    • Statement of Benefits Paid (SOBP).  The SOBP is a list of practitioner services a patient receives during a specified period that have been paid for by the AHCIP.  The statement lists dates, general types of service, physician names, and the amount paid to physicians.  Albertans who find health services on their SOBP that they do not recognize can outline the discrepancies and return the SOBP to Alberta Health for investigation.
  4. Alberta Health staff may investigate claims if billing irregularities are noticed as they are being processed.
  5. Once an inquiry or complaint is received Alberta Health personnel will enter the information on a tracking sheet, conduct a preliminary review, and consult further with the complainant, and the practitioner if needed, to gather additional information regarding the billing scenario and from there typically one of three things occur:   
    • The billing inquiry may be resolved with the patient and/or the health practitioner by clarifying coverage under the Alberta Health Care Insurance Plan. 
    • If a billing error has been identified the health practitioner will be notified and the claim will be reversed and, if needed, the patient reimbursed.
    • If the matter cannot be resolved with the health practitioner through communication or education, or if a trend of inappropriate billings is identified, the matter is escalated to a compliance review.
c) A summary of any extra-billing and user charges investigations during the fiscal year including:

Please use as much space needed bellow or add extra pages as necessary.

  1. Alberta Health does not report on audit and/or compliance reviews that are not yet concluded.
  2. In 2017-2018, Alberta Health investigated and resolved two cases of possible extra-billing based on inquiries received from Albertans.
d) Details on mechanisms to deter patient extra-billing and user charges (e.g., provider fines; plan payment withholding; provider/patient education initiatives; loss of facility accreditation).

Please use as much space needed below or add extra pages as necessary.

  1. In addition to the Alberta Health processes provided in answer b), the AHCIA prohibits EBUC in the following sections of legislation:
    • Section 9(1) of the AHCIA, Extra billing, prescribes that “No physician or dentist who is opted into the [Alberta Health Care Insurance Plan (the Plan)] who provides insured services to a person shall charge or collect from any person an amount in addition to the benefits payable by the Minister for those insured services.”
    • Section 11(1) of the AHCIA, Other prohibited fees, prescribes that “No person shall charge or collect from any person (a) an amount for any goods or services that are provided as a condition to receiving an insured service provided by a physician or dentist who is opted into the Plan, or (b) an amount the payment of which is a condition to receiving an insured service provided by a physician or dentist who is opted into the Plan where the amount is in addition to the benefits payable by the Minister for the insured service.”
    • Section 14 prescribes that a person who contravenes section 9, 11 or 12 is guilty of an offence and liable to a fine.
    • Section 26(1)(2)(3) prescribes that an insurer (carrier, employer, corporation or unincorporated group that administers a self-insurance plan) shall not enter into, issue, maintain in force or renew a contract or initiate or renew a self-insurance plan under which any resident or group of residents is provided with any prepaid basic health services or extended health services or indemnification for all or part of the cost of any basic health services or extended health services.
    • Sections 18 and 39 authorize Alberta Health to reassess claims and conduct audits and compliance reviews after the Minister has paid the claim.
    • Sections 9(2), 11(3)(4), 12(1), 13(3) and 14(a)(b) of the AHCIA prescribe that the Minister may send warnings to practitioners, refer contraventions to the practitioners’ professional regulators, opt practitioners out the Plan, recover benefits paid, recover and reimburse the amount charged or collected as other prohibited fees, not pay benefits for insured services if section 11 is contravened, and apply fines for offences.

Alberta Health issued Bulletin Med 184 on May 25, 2016 to provide information to physicians and billing staff about prohibited billing activities under sections 9 and 11 of the AHCIA. This bulletin is available on the Alberta Health website (https://open.alberta.ca/publications/bulletin-alberta-health-care-insurance-plan-medical-services) and is attached for your reference.

British Columbia

Canada Health Act

Financial Statement of actual amounts of extra-billing and user charges

For the period April 1, 2017 to March 31, 2018

1. Amounts of extra-billing

Extra-billing is defined as a charge by an enrolled physician or dentist to an insured person for an insured service in addition to the amount paid by the provincial/territorial health insurance plan.

Amount of extra-billing levied by enrolled physicians and dentists for insured health services:

2. Amounts of user charges

A user charge is defined as any charge for an insured health service, other than extra-billing. This includes any charge levied for insured hospital services, or any non-physician related services provided in conjunction with an insured physician service at a non-hospital facility (e.g., private clinic or private practice).

Amount of user charges levied for insured services: $ 332

N.B.  Charges may be levied for accommodation and meal costs related to a patient who, in the opinion of the attending physician, is a permanent resident in a hospital or other chronic care institution as per the limitation of Section 19 (2).  Charges related to this limitation should not be included in the financial statement.

Total for extra-billing and user charges $ 16,753,833

3. Description of method used to determine amounts of extra-billing and user charges

The following information should be included in description of the method used to determine the amounts of extra-billing and user charges (EBUC) reported, including if a NIL amount is submitted: 

a) Name of applicable pieces of PT legislation that prohibit extra-billing and user charges (including facility fees).

Please use as much space needed below or add extra pages as necessary.

The Medicare Protection Act (the Act) pays for insured medical services (also known as benefits) provided to residents of British Columbia. The Act establishes rules regarding billing for services provided by physicians who are enrolled with the Medical Service Plan (MSP). The Act also prohibits anyone from charging patients for “materials, consultations, procedures, use of an office, clinic, or for any other matters that relate to the rendering of a benefit” unless specifically permitted by the Medical Services Commission (MSC)

b) Details about the process used to investigate extra-billing and user charges (e.g., proactive regular audits of provider billings; reactive investigations triggered by patient complaints, media reports or other sources).

Please use as much space needed below or add extra pages as necessary.

c) A summary of any extra-billing and user charges investigations during the fiscal year including:

Please use as much space needed bellow or add extra pages as necessary.

d) Details on mechanisms to deter patient extra-billing and user charges (e.g., provider fines; plan payment withholding; provider/patient education initiatives; loss of facility accreditation).

Please use as much space needed below or add extra pages as necessary.

In the spring of 2018, BC’s Minister of Health announced, in part to bring BC in compliance with the Canada Health Act, that the Government would bring into force the remaining provisions of the 2003 Bill 92 to address the province’s ability to respond to and address extra billing. Most of these provisions came into force on October 1, 2018. The key changes include:

In addition to the above changes, Bill 92 includes a prohibition for charging in relation to diagnostic services (s. 18.1). This provision, previously scheduled to take effect on April 1, 2019, will come into force on March 31, 2020.

Bringing into force these provisions serves to strengthen enforcement against extra billing and reinforces the province’s commitment to universal public health care.

Impact of Litigation on Extra-billing Elimination Actions

The enforceability of the Bill 92 provisions has been challenged in Court in Cambie Surgeries Corporate v. British Columbia (Attorney General). On November 23, 2018, the BC Supreme Court issued an injunction enjoining the enforcement of the extra billing provisions (Sections 17, 18, and 45) in the MPA until June 1, 2019 or further order of the Court (the Court Order). BC’s application to appeal this injunction has been denied. This Court Order has required BC to reevaluate a number of its strategies for extra-billing elimination in order to be compliant with this judicial decision.

Physician/Clinic Notification

A letter serving notice of the changes was issued to all registered medical practitioners, accredited diagnostic facilities and private surgical clinics on September 10, 2018. These letters were sent via registered mail to ensure there is a record of them being delivered.

Partners/Stakeholders

Briefings were conducted prior to October 1, 2018, with various associations including: Doctors of BC, the BC College of Physicians and Surgeons, the Canadian Medical Protective Association and the Vice Presidents of Medicine for the Health Authorities, to ensure awareness around the legislative changes and new expectations.

Public Awareness

On April 4, 2018, the MoH issued a press release announcing the province would be bringing into force the remaining provisions of Bill 92, effective October 1, 2018. An additional press release was issued on September 7, 2018, providing an overall update on Bill 92 and reporting a six-month extension to April 1, 2019 of the Medicare Protection Act measures applicable to diagnostic services.

The MoH has taken a number of steps to enable an increased understanding of extra billing, updating a number of relevant sections of the BC government website aimed at the public that link patients directly, through multiple paths, to information concerning extra billing. These include:

On the BC government’s Health homepage, the language under Popular Topics has been amended to indicate that extra billing information is available under the MSP for BC Residents webpage. Additional links to extra billing information can be accessed from the homepage, under Health Care Complaints.

Applicable patient information on the changes to the Medicare Protection Act and the ability to seek reimbursement from the Medical Services Commission is profiled online.

The MoH will monitor ongoing patient inquiries and consider additional formats to make information available to the public, as required.

Health Authority Contracts

At present there are 15 private surgical clinics operating in British Columbia. As part of the province’s ongoing and focused efforts to address the requirements of the CHA Health Authorities have negotiated contracts with eight of the clinics, and negotiations are currently underway to establish a contract with one of the largest private clinics that has historically been a source of extra billing. When successfully concluded this will bring the total number of contracted clinics to nine, covering the vast majority of surgeries undertaken by the private surgical clinics, with the exception of the Cambie Surgery Centre, which is still before the courts.

The MoH issued a letter on September 13, 2018 notifying all Health Authorities of expectations about contracting between Health Authorities and private clinics for the provision of medical services. This included a requirement for all Health Authorities to amend their current surgical services contracts with private clinics to include termination provisions in the event of extra billing. As a requirement of the amended contracts, medical practitioners and clinics have been required to sign compliance statements. This letter of expectations was revised following the Court Order, as was the compliance statement – which is now referred to as a “notice to physician”.

With the move to contracting with private surgery clinics and ongoing engagement as part of Bill 92, the volume of extra billing continues to decline across the province. Health Authorities continue to engage with the smaller private surgical clinics to establish contracts with the clinics as part of the ongoing plan to reduce extra-billing.

Medical Services Commission – Compliance and Monitoring

The MoH has developed a series of operational processes to protect patients from extra billing, including protocols with the Medical Services Commission to adjudicate compliance. These processes include: processing complaints, investigating allegations and making a determination as to whether extra billing has taken place.

Due to the recent Court Order, the MoH has adjusted these processes. The MoH will continue to work closely with the Medical Services Commission to identify the most appropriate roles given its limited scope of action. Once the MoH is able to move forward, these processes will enable the Medical Services Commission to reimburse beneficiaries directly, assume debt on behalf of a beneficiary and recover the charge from the practitioner and/or clinic. In addition, once enforcement is no longer prohibited by the Court Order, extra billing offences may be referred to the MoH’s Audit and Investigations Branch and the Special Investigations Unit for the purpose of recommending charges and penalties, where appropriate.

Yukon

Canada Health Act

Financial Statement of actual amounts of extra-billing and user charges

For the period April 1, 2017 to March 31, 2018

1. Amounts of extra-billing

Extra-billing is defined as a charge by an enrolled physician or dentist to an insured person for an insured service in addition to the amount paid by the provincial/territorial health insurance plan.

Amount of extra-billing levied by enrolled physicians and dentists for insured health services: $ 0

2. Amounts of user charges

A user charge is defined as any charge for an insured health service, other than extra-billing. This includes any charge levied for insured hospital services, or any non-physician related services provided in conjunction with an insured physician service at a non-hospital facility (e.g., private clinic or private practice).

Amount of user charges levied for insured services: $ 0

N.B.  Charges may be levied for accommodation and meal costs related to a patient who, in the opinion of the attending physician, is a permanent resident in a hospital or other chronic care institution as per the limitation of Section 19 (2).  Charges related to this limitation should not be included in the financial statement.

Total for extra-billing and user charges $ 0

3. Description of method used to determine amounts of extra-billing and user charges

The following information should be included in description of the method used to determine the amounts of extra-billing and user charges (EBUC) reported, including if a NIL amount is submitted: 

a) Name of applicable pieces of PT legislation that prohibit extra-billing and user charges (including facility fees).

Please use as much space needed below or add extra pages as necessary.

There are no user fees or co-insurance charges for Insured Health Services under the Yukon Health Care Insurance Plan or the Yukon Hospital Insurance Services Plan. All services are provided on a uniform basis and are not impeded by financial or other barriers. There is no extra-billing in Yukon for any services covered by the Plan.

The Yukon Health Care Insurance Plan Act defines an Insured Health Services as: "those physician services, surgical-dental services, and other health services including the supply of drugs, medical and dental supplies, prosthesis, ..."

In FY 17-18 Yukon did not have any private for-profit health care facilities delivering insured health services. Information submitted excludes government operated continuing care facilities in Yukon.

b) Details about the process used to investigate extra-billing and user charges (e.g., proactive regular audits of provider billings; reactive investigations triggered by patient complaints, media reports or other sources).

Please use as much space needed below or add extra pages as necessary.

Regular audits of physician claims along with reactive investigations triggered by client and/or other physician complaints. Annual audit by the Auditor General.

If a patient has a complaint related to physician services including extra-billing or user charges they can contact the Yukon Medical Council.

c) A summary of any extra-billing and user charges investigations during the fiscal year including:

Please use as much space needed bellow or add extra pages as necessary.

d) Details on mechanisms to deter patient extra-billing and user charges (e.g., provider fines; plan payment withholding; provider/patient education initiatives; loss of facility accreditation).

Please use as much space needed below or add extra pages as necessary.

The preamble to the Yukon Physician Fee Guide contains the following:

"No fee above or in addition to this prescribed schedule may be charged to either Yukon Health Care Insurance Plan or to the patient in the case of insured services provided to insured persons."

Northwest Territories

Canada Health Act

Financial Statement of actual amounts of extra-billing and user charges

For the period April 1, 2017 to March 31, 2018           

1. Amounts of extra-billing

Extra-billing is defined as a charge by an enrolled physician or dentist to an insured person for an insured service in addition to the amount paid by the provincial/territorial health insurance plan.

Amount of extra-billing levied by enrolled physicians and dentists for insured health services: $ 0

2. Amounts of user charges

A user charge is defined as any charge for an insured health service, other than extra-billing. This includes any charge levied for insured hospital services, or any non-physician related services provided in conjunction with an insured physician service at a non-hospital facility (e.g., private clinic or private practice).

Amount of user charges levied for insured services: $ 0

N.B.  Charges may be levied for accommodation and meal costs related to a patient who, in the opinion of the attending physician, is a permanent resident in a hospital or other chronic care institution as per the limitation of Section 19 (2).  Charges related to this limitation should not be included in the financial statement.

Total for extra-billing and user charges $ 0

3. Description of method used to determine amounts of extra-billing and user charges

The following information should be included in description of the method used to determine the amounts of extra-billing and user charges (EBUC) reported, including if a NIL amount is submitted: 

a) Name of applicable pieces of PT legislation that prohibit extra-billing and user charges (including facility fees).

Please use as much space needed below or add extra pages as necessary.

There are two pieces of legislation in the Northwest Territories which prohibit extra billing and user charges. Section 14(1) of the Northwest Territories Medical Care Act states that: “No medical practitioner shall charge to or collect from an insured person a fee in excess of the benefit in respect of the insured service, unless the medical practitioner has made an election that is still in effect.” In addition, section 8(2) of the Hospital Insurance Regulations under the Hospital Insurance and Health and Social Services Administration Act also states that: “The rate payable to a hospital or federal hospital that is situated in a province or territory participating under the federal Act (i.e. Canada Health Act) shall not exceed the rate established for the hospital by that province or territory, less the authorized charge.” Therefore, residents of the NWT are protected from extra billing and charges when receiving insured services both within the territory, and when receiving insured services outside the territory under a reciprocal billing agreement.

b) Details about the process used to investigate extra-billing and user charges (e.g., proactive regular audits of provider billings; reactive investigations triggered by patient complaints, media reports or other sources).

Please use as much space needed below or add extra pages as necessary.

Medical Care Act 8.m (2) (3) (4)

8.(1) The Director may reassess an account for insured services submitted by a medical practitioner, where, as a result of an inspection under section 7, it appears to the Director that(a) all or part of the insured services were not in fact rendered;(b) all or part of the insured services were not medically necessary;(c) all or part of the insured services were not provided in accordance with accepted professional standards and practice; or(d) the nature of the insured services is misrepresented.

(2) Where the Director makes a reassessment under subsection (1),the Director may make any appropriate adjustment in the amount paid to the medical practitioner in respect of the insured services.

(3) If the amount paid to a medical practitioner for insured services was in excess of the benefit payable under the adjustment referred to in subsection(2),the difference between the amount paid and the adjusted amount constitutes a debt to the Government of the Northwest Territories and the Director may recover the amount from the medical practitioner(a) by withholding from benefits payable to the medical practitioner an amount equivalent to the difference between the amount paid and the adjusted amount;(b) by civil action; or(c) pursuant to an agreement between the Director and the medical practitioner providing for the payment of the amount.

(4) If the amount paid to a medical practitioner for insured services was less than the benefit payable under the adjustment referred to in subsection (2), the Director shall pay to the medical practitioner an amount equal to the difference between the amount paid and the adjusted amount.

The NWT has a “complaint-based" system in place, and takes steps to respond to concerns and improve care and services for NWT residents. When a resident has a concern or issue with the care they have received they are first encouraged to speak with their local health provider. If the issue is not resolved they are encouraged to contact their designated Patient Representative to help address the issue and file a formal complaint.

The Medical Care Act includes a provision to allow the Minister of Health and Social Services (the Minister) to establish a Benefits Appeal Committee that could address any matter referred to it by the Minister, including complaints where a physician engaged in extra-billing and charged user fees. At present, there has been no need to establish this committee, because almost all physicians are compensated through contractual agreements with the Government of the NWT.

No audits completed. Mostly salaried physicians All but two physicians in the NWT are on contract with the NT Health Authority and do not bill fee for service. The two NWT Fee for Service Physicians and all visiting specialist use the services of local NWT billing clerks who bill the appropriate fees according to the NWT fee tarif

c) A summary of any extra-billing and user charges investigations during the fiscal year including:

Please use as much space needed bellow or add extra pages as necessary

d) Details on mechanisms to deter patient extra-billing and user charges (e.g., provider fines; plan payment withholding; provider/patient education initiatives; loss of facility accreditation).

Please use as much space needed below or add extra pages as necessary.

Mostly salaried physicians

All but two physicians in the NWT are on contract with the NT Health Authority and do not bill fee for service. The two NWT Fee for Service Physicians and all visiting specialist use the services of local NWT billing clerks who bill the appropriate fees according to the NWT fee tariff

Nunavut

Canada Health Act

Financial Statement of actual amounts of extra-billing and user charges

For the period April 1, 2017 to March 31, 2018

1. Amounts of extra-billing

Extra-billing is defined as a charge by an enrolled physician or dentist to an insured person for an insured service in addition to the amount paid by the provincial/territorial health insurance plan.

Amount of extra-billing levied by enrolled physicians and dentists for insured health services: $ Nil

2. Amounts of user charges

A user charge is defined as any charge for an insured health service, other than extra-billing. This includes any charge levied for insured hospital services, or any non-physician related services provided in conjunction with an insured physician service at a non-hospital facility (e.g., private clinic or private practice).

Amount of user charges levied for insured services: $ Nil

N.B.  Charges may be levied for accommodation and meal costs related to a patient who, in the opinion of the attending physician, is a permanent resident in a hospital or other chronic care institution as per the limitation of Section 19 (2).  Charges related to this limitation should not be included in the financial statement.

Total for extra-billing and user charges $ Nil

3. Description of method used to determine amounts of extra-billing and user charges

The following information should be included in description of the method used to determine the amounts of extra-billing and user charges (EBUC) reported, including if a NIL amount is submitted: 

a) Name of applicable pieces of PT legislation that prohibit extra-billing and user charges (including facility fees).

Please use as much space needed below or add extra pages as necessary.

Not applicable - the Government of Nunavut contracts directly with physicians and dentists and has direct ownership of all health facilities - insured patients are not billed for insured services. The Medical Care Act, section 14, prohibits extra-billing by physicians unless the medical practitioner has made an election that is still in effect.

b) Details about the process used to investigate extra-billing and user charges (e.g., proactive regular audits of provider billings; reactive investigations triggered by patient complaints, media reports or other sources).

Please use as much space needed below or add extra pages as necessary.

Not needed - the Government of Nunavut contracts directly with physicians and dentists and has direct ownership of all health facilities - insured patients are not billed for insured services.

The Department does not have a specific complaints office solely for extra-billing. However, the Department has other mechanisms for Nunavummiut to register concerns regarding their health care service and can be reached at

NHIP@gov.nu.ca
Nunavut Health Insurance Programs Office
Department of Health
Box 889
Rankin Inlet, NU
XOC 0G0
Toll Free: (800) 661-0833

c) A summary of any extra-billing and user charges investigations during the fiscal year including:

Please use as much space needed bellow or add extra pages as necessary.

Not needed - the Government of Nunavut contracts directly with physicians and dentists and has direct ownership of all health facilities - insured patients are not billed for insured services.

d) Details on mechanisms to deter patient extra-billing and user charges (e.g., provider fines; plan payment withholding; provider/patient education initiatives; loss of facility accreditation).

Please use as much space needed below or add extra pages as necessary.

Not needed - the Government of Nunavut contracts directly with physicians and dentists and has direct ownership of all health facilities - insured patients are not billed for insured services.

Annex E - Reimbursement Action Plans & Progress Reports

Under the Reimbursement Policy, provinces and territories (PT) subject to a Canada Health Transfer (CHT) deduction as a result of patient charges are eligible for reimbursement should they demonstrate action has been taken to come into compliance with the Canada Health Act and the patient charges have been eliminated.

Following a CHT deduction as a result of patient charges, Health Canada officials work collaboratively with PT officials to reach a mutually agreed upon Action Plan. Given the circumstances leading to deductions will vary by jurisdiction, so too will the conditions for reimbursement, and the resulting Action Plans. However, the overarching objective of the Reimbursement Policy is the effective elimination of patient charges.

In addition to the Reimbursement Action Plan, PTs must submit annual progress reports to Health Canada that outline the degree to which the plan has been implemented. Upon review of the jurisdiction's report, if Health Canada is satisfied that key elements of the Action Plan have been fulfilled, the PT could receive a partial or full reimbursement. Following an initial deduction and reimbursement cycle, if Health Canada remains satisfied that patient charges have been eliminated, the Reimbursement Policy allows for the immediate reimbursement of subsequent CHT deductions.

Action plans, and PT progress reports on meeting their plans, are published on the following pages.

For further details on the Reimbursement Policy please refer to Annex B which includes the full text.

[Following is the text of the British Columbia Extra-Billing Elimination Action Plan and December 2020 Status Update]

British Columbia’s Extra Billing Elimination Action Plan

This report outlines British Columbia’s (BC) Action Plan to address extra-billing. Central to the plan is the implementation of Bill 92, the amendment to the BC Medicare Protection Act (Appendix A), which strengthens the province’s legislative provisions against extra billing.

Background

The Canada Health Act requires the Federal Government to impose financial penalties on provinces where extra billing has occurred. As a result, BC has been subject to reductions in the amount it receives under the Canada Health Transfer. Previous federal deductions reported by BC to Health Canada have been approximately $200,000 per year. In 2017-2018, the Ministry of Health (MoH) audited three private clinics. Based on the audits, Health Canada estimated that extra billing in BC for the 2015-2016 fiscal year was $15.9 million and as a result, BC’s federal health funding was reduced by that amount.

In the spring of 2018, BC’s Minister of Health announced, in part to bring BC in compliance with the Canada Health Act, that the Government would bring into force the remaining provisions of the 2003 Bill 92 to address the province’s ability to respond to and address extra billing. Most of these provisions came into force on October 1, 2018. The key changes include:

In addition to the above changes, Bill 92 includes a prohibition for charging in relation to diagnostic services (s. 18.1). This provision is scheduled to take effect on April 1, 2019.

Bringing into force these provisions serves to strengthen enforcement against extra billing and reinforces the province’s commitment to universal public health care.

The enforceability of the Bill 92 provisions has been challenged in Court in Cambie Surgeries Corporate v. British Columbia (Attorney General). On November 23, 2018, the BC Supreme Court issued an injunction enjoining the enforcement of the extra billing provisions in the Act until June 1, 2019 or further order of the Court (the Court Order). BC is appealing this decision.

Since BC’s announcement to bring into force Bill 92, a number of steps have been taken. The following provides a summary of the province’s approach to implementation.

Physician/Clinic Notification

A letter serving notice of the changes was issued to all registered medical practitioners, accredited diagnostic facilities and private surgical clinics on September 10, 2018 (Appendix B). These letters were sent via registered mail to ensure there is a record of them being delivered.

Sections of the BC government website aimed at medical practitioners – have been updated to articulate the changes that have been made. This includes an FAQ document for practitioners, as well as contact information for further questions (Appendix C).

Partners/Stakeholders

Briefings were conducted prior to October 1, 2018, with various associations including: Doctors of BC, the BC College of Physicians and Surgeons, the Canadian Medical Protective Association and the Vice Presidents of Medicine for the Health Authorities, to ensure awareness around the legislative changes and new expectations.

Public Awareness

On April 4, 2018, the MoH issued a press release announcing the province would be bringing into force the remaining provisions of Bill 92, effective October 1, 2018. An additional press release was issued on September 7, 2018, providing an overall update on Bill 92 and reporting a six-month extension to April 1, 2019 of the Medicare Protection Act measures applicable to diagnostic services.

A number of relevant sections of the BC government website aimed at the public have been updated to prominently feature alerts that will link patients directly, through multiple paths, to information concerning extra billing. These include:

The MoH will monitor ongoing patient inquiries and consider additional formats to make information available to the public, as required.

Health Authority Contracts

Currently, there are ten contracts between Health Authorities and private clinics for surgical services. The MoH issued a letter on September 13, 2018 notifying all Health Authorities of expectations about contracting between Health Authorities and private clinics for the provision of medical services (Appendix E). This included a requirement for all Health Authorities to amend their current surgical services contracts with private clinics to include termination provisions in the event of extra billing. As a requirement of the amended contracts, medical practitioners and clinics have been required to sign compliance statements (Appendix F). This letter of expectations was revised following the Court Order (Appendix G), as was the compliance statement – which is now referred to as a “notice to physician” (Appendix H).

Medical Services Commission – Compliance and Monitoring

The MoH has developed a series of operational processes to protect patients from extra billing. However, due to the recent Court Order, the Ministry is not able to implement these processes at this time. These processes include: processing complaints, investigating allegations and making a determination as to whether extra billing has taken place. Once the Ministry is able to move forward, these processes will enable the Medical Services Commission to reimburse beneficiaries directly, assume debt on behalf of a beneficiary and recover the charge from the practitioner and/or clinic. In addition, once enforcement is not prohibited by the Court Order, extra billing offences may be referred to the MoH’s Audit and Investigations Branch and the Special Investigations Unit for the purpose of recommending charges and penalties, where appropriate. As noted above, the Ministry is appealing the recent Court Order and will be seeking for the injunction to be overturned.

Diagnostic Imaging and Laboratory Services

On August 8, 2018, the Honourable Ginette Petitpas Taylor, Minister of Health Canada, wrote to BC Minister of Health, Adrian Dix, regarding the Federal Government’s Diagnostic Services Policy. In the letter, Minister Petitpas Taylor stated:

“I fully appreciate that it may take time in some jurisdictions to align provincial and territorial systems with the Diagnostic Services Policy. As I indicated in Winnipeg, the policy will not take effect until April 1, 2020, and reporting on any patient charges for diagnostic services will begin in December 2022 (for the fiscal year 2020-2021.) That would mean, in accordance with the Canada Health Act, that any Canada Health transfer deductions would only be made in March 2023. If in the interim, a jurisdiction has eliminated patient charges for diagnostic services, that jurisdiction would be eligible for reimbursement of deducted funds through the new Reimbursement Policy.”

Further, on September 20, 2018, Deputy Minister of Health Canada, Simon Kennedy emailed all of the provinces and territories on the issue of the diagnostic services. In his email, it stated:

“You will note the Minister has indicated that the Diagnostic Services Policy will take full effect from April 1, 2020. This policy is a clarification of the application of the CHA to diagnostic services. It confirms the federal position that medically necessary diagnostic services are insured services, regardless of the venue where the services are delivered. This means that provinces and territories not currently reporting to Health Canada on patient charges in respect of medically necessary diagnostic services will be required to do so as of December 2022 (for the fiscal year 2020-21). This extended phase-in period is to allow any jurisdiction where patient charges for diagnostic services are permitted to make the changes necessary to align with the Policy. Naturally, moving earlier than 2020-21 to eliminate such charges is strongly encouraged.”

BC is committed to addressing patient charges for diagnostic services. To that end, in March 2018, the BC Surgical and Diagnostic Imaging Strategy was announced which seeks to provide faster access and to reduce wait times for all medical imaging modalities within the province. The priority focus for 2018-2019 was providing faster access to magnetic resonance imaging (MRI), which included by performing 37,000 more MRI exams by the end of March 2019, establishing a centralized intake and pooled referrals approach (where appropriate) and to reduce wait times for high priority patients. To support these initiatives, $11 million in additional funding was made available to the Health Authorities.

  1. MRI Volumes
    • In 2018-2019, the target number of publicly-funded MRI exams performed is 225,000.
    • This is approximately 35,000 more MRI exams performed than in 2017-2018.
    • Year-to-Date (Period 6, up to September 20, 2018), BC has performed 103,683 MRI publicly-funded MRI exams, which is:
      • 971 above the 2018-2019 YTD Period 6 target; and
      • 25,607 more MRI exams performed compared to 2017-2018 YTD Period 6.
  2. MRI Inventory
    • There are 31 MRI units in the province operating over 800 hours per week.
    • There is an expected deployment of 9 net new MRI units over the next two years. There may be more net new MRI units as further business cases are approved by the Ministry.
    • The 9 net new MRI units include 2 private MRI clinics that were recently purchased by Fraser Health Authority and the new clinics will start seeing patients in early 2019.
    • There are no active contracts between Health Authorities and private clinics to perform MRI exams, but there are 7 contracts that are ready for demand if needed.
  3. HHR Recruitment and Retention
    • All Health Authorities, except Northern Health Authority, were able to recruit more MRI technologists to meet their needs. This includes the addition of 17 MRI technologists in the Lower Mainland.
    • The Northern Health Authority has had issues with recruiting and retaining MRI technologists. To secure MRI technologists coverage, they are contracting with an out-of-province agency for locums, aggressively recruiting for full-time FTEs (three positions currently posted), and investigating other options to overcome the shortage, such as working with other Health Authorities to share resources.

BC believes the above steps will address the demand for medically necessary MRIs in the province. In addition, as of April 1, 2019, BC will bring into effect Section 18.1 of the Medicare Protection Act, which will make it illegal for a medical practitioner to charge for diagnostic imaging. This will deter the private delivery of the service and provide greater protection to patients being charged for medically necessary diagnostic services.

With regard to the Laboratory Services Act, the Ministry plans to bring forward in the fall/winter of 2019-2020 a proposed series of consequential amendments for Cabinet to consider. These changes are not anticipated to be material in nature; rather, they are to ensure elements in the Laboratory Services Act are consistent with the updated Medicare Protection Act.

Audits of Private Clinics

The MoH has completed three audits of private clinics – False Creek Healthcare Centre, Seafield Surgical Centre, and Okanagan Health Surgical Centre. The results of these audits were shared with Health Canada in accordance with the agreement signed by our respective ministers in 2017.

The MoH has established an audit unit that is responsible for the ongoing audit of existing private surgical centers, and in the 2018-2019 fiscal year is aiming to complete a further three audits, subject to impediments due to the Court Order, bringing the total completed and underway to ten, including Cambie. The clinics are selected on a risk-based approach, taking into account factors such as complaints made by patients, types of services offered, number of physicians providing services and evidence from clinics’ websites that they extra bill.

The purpose of the audits is two-fold:

  1. To monitor and assess compliance with the Medicare Protection Act, and
  2. To help determine an accurate estimate of the extent of extra billing in the province.

Subject to clarification from the Court, the MoH is committed to full transparency and will continue to work with Health Canada in reviewing audit findings as the work is completed. Going forward, it is suggested that the monthly conference calls to discuss audit findings are re-established.

Reporting Requirements

BC commits to submitting a complete and accurate 2016-2017 extra billing and user charges financial statement to Health Canada in December 2018, per the reporting requirements set out in the Canada Health Act and Regulations.

As per the Reimbursement Policy, BC also commits to submitting a January 2019 report to Health Canada, assessing the degree to which the elements of the Action Plan have been completed. This report will include:

Conclusion:

In summary, BC’s MoH is appealing the Court Order to be able to use the Bill 92 provisions, and, if successful, will monitor and assess the impact of the implementation of Bill 92. BC’s MoH will also determine whether further changes to policy and/or legislation are warranted to address extra billing. By moving forward with the above noted actions, BC believes it has taken the necessary steps to address extra billing within the province and is seeking reimbursement from Health Canada for the 2018-2019 $15.9 million penalty.

Status Update: Implementation of BC’s Extra-billing Elimination Action Plan December 2020

Pursuant to sections 18 and 19 of the Canada Health Act (CHA), we submit the December 2020 status update to British Columbia’s Extra-billing Elimination Action Plan.

We believe that the status update below demonstrates BC’s ongoing commitment to upholding the principles of the CHA under challenging circumstances, and we reiterate the expectation that steps are taken under the Federal reimbursement policy to reimburse BC for all extra-billing penalties levied to date, including any penalty that may arise from the filing related to practices in effect in 2018-2019.

On September 10, 2020, the Honourable Mr. Justice Steeves delivered his reasons for judgement in the Cambie Surgeries Corporation v. British Columbia (Attorney General) trial. The decision ruled in the Province’s favour on all counts; all sections of the Medicare Protection Act (MPA) being challenged were upheld. Lawyers for Cambie Surgeries Corporation have applied to appeal the decision.

The Province is pleased to see a successful outcome in this litigation and while this year’s annual report on extra-billing and user charges is focused on the 2018-2019 reporting year, it is important to acknowledge that during the 2018-2019 reporting year, the Province took all actions reasonably within its power to enforce the provisions of the MPA and uphold the principles of the CHA given the various forms of injunction that were in place throughout that reporting year. A timeline of the various injunctions follows.

Given the success of the Province in the litigation, the expectation is that BC will receive the balance of $32.8 million of Canada Health Transfer funds previously withheld by the Federal Government and that future deductions are not applied.

Background

In October 2018, BC brought the remaining provisions of the 2003 Bill 92 into force to address the province’s ability to respond to extra-billing and to bring BC into compliance with the CHA.

The key changes to the MPA include the following:

Impact of Litigation

The following timeline covers the cumulative impact of Cambie Surgeries Corporate vs. British Columbia (Attorney General) on the implementation of Bill 92.

BC has committed significant resources and incurred significant expense to the successful conclusion of this trial as we work towards the appeal hearing next year, and will continue to exercise its legislative authority to ensure compliance with the MPA (within the legal parameters of the new injunction issued on December 8, 2020). The Ministry will focus ongoing enforcement across all potential operations at risk of extra-billing, including previously audited clinics if there are indicators that practices have not changed.

Physician/Clinic Notification

Sections of the BC government website aimed at medical practitioners have been updated and placed on the main landing page to raise awareness amongst physician about what is being communicated to patients regarding appropriate and inappropriate billing.

Public Awareness

The Ministry has provided patients with a description of benefits and a link to the description of extra-billing.

The Ministry also has a description of extra-billing along with the form for submitting a request for investigation for patients who believe themselves to have been extra billed.

Links to the description of extra-billing and the form are also available with the description of Services covered by the Medical Services Plan (MSP), and Services not covered by MSP.

Further to these webpages targeted at patients, the Ministry has also provided physicians with a link to the description of extra-billing so that they may better understand patient expectations for appropriate billing.

British Columbians have the right to expect that they will not be asked by physicians to pay out of pocket for insured services. The Ministry believes that its communication strategy has been effective at reducing those situations and remains committed to working towards their elimination. The Ministry will monitor ongoing patient inquiries and consider additional formats to make information available to the public, as required.

MSC – Compliance and Monitoring

The Ministry works closely with the MSC to ensure that operational processes are designed to protect patients from extra-billing. The Ministry processes patient complaints and investigates allegations of extra-billing to determines whether extra-billing has taken place. Where possible, throughout the investigation, the Ministry seeks to resolve the complaint by communication and education with the physician.

Throughout 2018-2019 the Ministry was subject to various court orders and injunctions related to enforcement of extra-billing which sometimes deterred the ability to investigate complaints.

In 2018-2019 there were a total of 13 patient complaints of which four were investigated. Of the four investigations, there were two investigations performed where extra-billing was determined to have likely occurred. There were two investigations where, based on information provided by the patient, no extra-billing was determined to have occurred.

There were nine patient complaints regarding charges in relation to cataract surgery. In these cases, no official investigation was performed for a variety of reasons (e.g. the Ministry requested additional information from patient and patient never followed up, patient was seeking general information only, or the Ministry was unable to assist further due to the various forms of injunctions that existed throughout 2018-2019).

The Ministry worked closely with the MSC and supporting medical and legal experts, to investigate these complaints in a timely fashion and ensure that both patients and practitioners receive clear expectations for appropriate action.

The Ministry will work with the MSC and the Attorney General to determine the impacts of the December 8, 2020 injunction on operational processes and the ability to proceed with using the powers brought into force by Bill 92. Modifications to operational processes that were being contemplated prior to receipt of the December 8, 2020 injunction included referring cases to the Ministry’s Audit and Investigations Branch and the Special Investigations Unit (SIU).

Health Authority (HA) Contracts

BC has seen successful in curbing extra-billing through government contracts with private clinics. BC is committed to curbing extra-billing and user charges in the province to enhance publicly funded health care.

In 2019-2020, there were 11 facilities which the HAs contracted with in compliance with the CHA to perform surgeries. The Ministry issued a letter on September 13, 2018 notifying all HAs of expectations (“letter of expectation”) about contracting between HAs and private clinics for the provision of medical services. This included a requirement for all HAs to amend their current surgical services contracts with private clinics to include termination provisions in the event of extra-billing. As a requirement of the amended contracts, medical practitioners and clinics have been required to sign compliance statements. Physicians can only provide contracted surgical services once the compliance statement is signed. The letter of expectation and compliance statements were revised following the November 23, 2018 BC Supreme Court injunction prohibiting the enforcement of the extra-billing provisions (s. 17, 18, and 45 of the MPA).

The compliance statement to physicians requires acknowledgement by physicians of the termination provisions in the contract between the HA and their clinic pertaining to extra-billing. These provisions apply to the physician’s service under contract (insured services) as well as services undertaken by the physician in clinics outside of the contract (the latter would be insured services provided at the clinic).

Currently, the regional HAs monitor the surgical contracts for compliance with all provisions. Since implementation in September 2018, the HAs have not terminated any contracts with private surgical clinics over performance or compliance issues. The Ministry is confident that the agreements are being followed by the physicians and HAs. Overall, the Ministry views this current productive dynamic between HAs and clinics (formerly providing private services) as demonstrative of the value of contractual arrangement to bring private surgical services back into the public system. This approach simultaneously eliminates extra-billing practices and enhances the capacity of the public health system to provide needed patient care. See the section ‘BC Surgical and Diagnostic Imaging Strategy’ for data on the number of surgeries performed under HA contracts with private clinics.

BC confirms that False Creek Healthcare Centre has entered into contracts with two HAs, the Vancouver Coastal Health Authority (VCHA), for the period May 1, 2020 to March 31, 2023, and the Fraser Health Authority (FHA), for the period March 3, 2020 to March 31, 2023. For fiscal year 2020-2021, the contract is valued at $6.18 million consisting of $2.84 million from the FHA and $3.34 million from the VCHA. False Creek Healthcare Centre was not under HA contract for the 2018-2019 reporting year. This contract should eliminate extra-billing at False Creek Healthcare Centre, which has been a significant source of extra-billing in previous years.

BC Surgical and Diagnostic Imaging Strategy

In March 2018, the BC Surgical and Diagnostic Imaging Strategy (the strategy) was announced. The strategy aims to fulfil the mandate given by the Premier to the Health Minister to work to reduce wait times and increase access to publicly funded surgeries and diagnostic imaging procedures to benefit people in communities throughout the province. The strategy received $100 million in targeted and ongoing funding in 2018-2019. In 2019-2020, the ongoing funding grew to $125 million.

In 2018-2019 there were 249,878 scheduled surgeries preformed in BC, a 5.7 percent increase over 2016-2017 when 236,491 scheduled surgeries were performed. The Ministry will be working with the HAs to quantify their increased public capacity so that we can better monitor in the future.

Key to achieving the mandate above is maximizing all the surgical capacity we have. In BC, as in other provinces, this includes private surgical centres. Contracting with these centres increases publicly funded access for patients whose surgical day procedures can be done safely and efficiently in the community, leaving our hospital capacity for more complex surgeries and procedures. BC has worked with the HAs and has now negotiated agreements valued at $67.9 million. Under contract arrangements with these clinics 11,706 surgeries were performed under contract in 2018-2019 - compared to 2017-2018 when 9,355 were performed. By negotiating contracts with private clinics to provide beneficiary services instead of extra-billing services BC has acted to prevent future extra-billing.

As an estimate of the impact, we would note that the Ministry has increased HA contracts, or extended additional contracts, to private surgical clinics found previously to be extra-billing. These contracts additions should eliminate an approximate equivalent in private billing. With these contracts, the HAs have moved from short term to multi-year terms of service (while maintaining termination clauses should extra-billing occur). The stability of these contract arrangements will keep former private capacity in the public system in a sustainable manner.

In addition to these steps, BC is also increasing public system capacity within HAs. This includes opening new operating rooms and extending the operating hours for others in our hospitals. In 2018-2019 operating rooms ran over 19,500 more hours than 2017-2018. Through this strategy BC demonstrates its continued commitment to addressing patient extra-billing, as defined under the CHA.

MRI Volumes

With respect to medical imaging, in 2018-2019, BC conducted 233,369 MRI exams compared to 173,678 MRI exams in 2016-2017 and 189,376 in 2017-2018. This is a 34.4 percent increase since 2016-2017.

This achievement was made by:

MRI Capacity

In 2017-2018 11 MRI units regularly operated for more than 112 hours per week each, of these only one unit was operating on a 24/7 rotation. By the end of 2018-2019, 18 MRI units are regularly operating above 112 hours per week, of these, 8 MRI units in growing urban areas are operating at a 24/7 staffing rotation. From the beginning of 2018-2019, MRI operating hours increased by more then 560 hours per week, with the 33 units operating over a combined 3,700 hours per week.

In 2018-2019 three net-new MRI units are operational in BC, including:

These two outpatient clinics were previously operating privately. The exams they perform are a direct reduction in the amount of private billing for diagnostic services in BC.

BC expects to make further gains in improving access through new MRI capacity that has been brought online. Since December 2018, seven net-new units are operational in BC, including:

At growing urban sites in Victoria and Surrey the new MRI units installed this past fiscal year are the latest technology, they are state-of-the-art 3T MRI units which can perform scans more quickly, with no reduction in image quality and allow for quicker patient turnaround times

These are the first 3T units within the province for adult populations. Three more net-new units are planned to be operationalized in the upcoming year.

Health Human Resources (HHR)

BC and HAs are working together to ensure the continuation of health services and supply of staff in key roles and occupations during the pandemic period, while continuing to develop and implement long-term plans for increased access.

The Ministry has developed and implemented A Commitment to Surgical Renewal in BC, which will ensure the province is positioned to handle both the backlog in surgeries and the needs of COVID-19 patients:

The Ministry is also continuing to implement other priority HHR initiatives through the pandemic period:

Certain priority occupations are also receiving additional support. The Ministry and AEST have taken the following action to support the capacity of occupational therapy and physiotherapy:

In addition to these steps, the Ministry and AEST have taken the following action to support the capacity of diagnostic services:

Finally, BC committed in July 2020 to a one-time investment of $4.4 million in for health profession-related education and training at BC post-secondary institutions:

Laboratory Services

Medically required laboratory services are publicly funded under the Laboratory Services Act (LSA). The Minister is responsible for all matters related to laboratory services including the facility approval process, governance, accountability and provision of benefits for all laboratory services in the province. The Agency for Pathology and Laboratory Medicine is now a program under the Provincial Health Services Authority (PHSA). The Agency's mandate is to provide laboratory system oversight and to ensure that clinical laboratory services are sustainable, quality driven, innovative, and support British Columbia's residents and clinicians with access to laboratory services. Since April 1, 2019 PHSA accepted accountability for operational functions assigned by the Ministry to support the LSA.

Since 2005, the Ministry has contracted with MAXIMUS Canada to deliver some of the administrative operations of MSP, PharmaCare and laboratory services (including responding to public inquiries, registering clients, and processing medical and pharmaceutical claims from health professionals). MAXIMUS Canada administers the province's medical and drug insurance plans under the Health Insurance BC program. Policy and decision-making functions remain with the Ministry.

Audits of Private Clinics

In 2017, Health Canada and the Ministry agreed upon a methodology to determine the extent and nature of patient extra-billing in BC, outlined in a Terms of Reference and Letter of Agreement. Since this agreement was put in place, the Ministry has completed six audits of private surgical clinics, bringing the total to seven, including Cambie. The results of these audits were shared with Health Canada in accordance with the agreement signed by our respective ministers in 2017.

In 2018-2019 further audits were put on hold in order to ensure the Ministry complies with the November 23, 2018 BC Supreme Court injunction prohibiting the enforcement of the extra- billing provisions (s. 17, 18, and 45 of the MPA)., but audits resumed in late 2020. As of November 2020, three of four on-sites audits have been conducted, with the fourth being delayed due to increased COVID-19 cases in the Vancouver Coastal Health Region. Although the fourth on-site audit was not conducted, financial information was received from all four clinics and this information formed the basis of our extra-billing estimates for these unaudited clinics.

The Ministry has established an audit unit that is responsible for the ongoing audit of existing private surgical centers, and in 2020-2021 is aiming to complete a further 4 audits bringing the total completed and underway to 11, including Cambie. The clinics are selected on a risk-based approach, considering factors such as complaints made by patients, types of services offered, number of physicians providing services and evidence from clinics’ websites that they extra bill.

The purpose of the audits is two-fold:

  1. To monitor and assess compliance with the MPA, and
  2. To help determine an accurate estimate of the extent of extra-billing in the province.

The Ministry will provide the final audit reports for individual clinics and/or providers to Health Canada subject to any redactions required to comply with the Freedom of Information and Personal Privacy Act (FOIPPA). The Ministry is working through concerns and legalities around posting summarized versions of audit reports online. The Ministry will be adding communication resources for this work and recruitment will be undertaken in the short term. Their first order of priority will be to make sure this is completed and posted in a timely manner.

Subject to clarification from the Court, the Ministry is committed to full transparency and will continue to work with Health Canada in reviewing audit findings as the work is completed.
Monthly conference calls to discuss extra-billing and other pertinent matters including audit findings have been re-established.

Reporting Requirements

BC submitted a complete and accurate 2018-2019 extra-billing and user charges financial statement to Health Canada as per the reporting requirements set out in the CHA and Regulations. BC reported a total of $13,949,979 in extra-billing charges occurred in 2018-2019 according to the agreed-on reporting methodology.

Conclusion

In summary, BC is continuing to monitor and assess the impact of the implementation of Bill 92 given the ongoing litigation (appeal) and injunction issued December 8, 2020. The Ministry will continue work to determine whether further changes to policy and/or legislation are warranted to address extra-billing. BC’s long-term goal is to strengthen the public health care system, eliminate extra-billing, and ensure full compliance with CHA. The specific steps and strategies to reach that goal will evolve to address changing circumstances, but BC’s multi-pronged and robust approach backed by significant resources will stay constant. By moving forward with the above noted actions, BC has taken the necessary steps to address extra-billing within the province and is seeking reimbursement from Health Canada for the 2018-2019 $13.9 million penalty.

The Province has made significant efforts and incurred substantial expense to stop extra-billing over recent years, all within the legal parameters of the ongoing litigation and various forms of injunction that BC has been subject to. Over the course of the Cambie litigation, the Province has spent considerable amount of money defending the public healthcare system.

Given the successful outcome of the Cambie litigation, ongoing efforts to educate and deter extra-billing, and a continued focus on audit and enforcement, we believe that this status update demonstrates BC’s robust commitment to upholding the principles of the Canada Health Act under challenging circumstances, and we expect steps to be taken under the authority of the Federal reimbursement policy to reimburse BC for all extra-billing penalties levied to date, including the balance of $32.8 million of Canada Health Transfer funds previously withheld by the Federal Government and any penalty that may arise from the filing related to practices in effect in 2018-2019.

Statement of Attestation

I attest that the above information captures the full extent of the Ministry of Health’s efforts to eliminate extra-billing and ensure full compliance with the CHA and its Regulations and applicable provincial/ territorial legislation.

January 28, 2021

Philip Twyford
Assistant Deputy Minister, Ministry of Health British Columbia

[Following is the text of the Newfoundland and Labrador Reimbursement Action Plan and Janary 2021 Status Update]

Newfoundland and Labrador Reimbursement Action Plan

Background

In the winter of 2017-2018, the Department of Health and Community Services (HCS) received phone calls from Medical Care Plan (MCP) beneficiaries complaining that they had paid out of pocket for cataract surgery.

Investigation

In February 2018, HCS issued a Public Service Announcement (PSA) in an effort to identify beneficiaries in the province who felt that they had been billed inappropriately for insured cataract surgery and created a hotline for reporting of such instances.

Corrective action through patient reimbursement and further investigation

HCS plans to reimburse patients for the excision of the cataract and intraocular lens replacement at a rate of $574.47 per eye when patients can produce documents verifying that they have paid for cataract surgery in a private clinic until June 15, 2018. The amount of $574.47 represents the professional fees billable for the excision of the cataract ($473.09) and insertion of the intraocular lens ($101.38). HCS is not reimbursing the costs of non-insured services associated with providing cataract surgery in a private clinic.

Legal Declaration

On March 28, 2018, in Jackman v. Newfoundland and Labrador, the Applicants filed an application for declaratory relief with the Supreme Court of Newfoundland and Labrador, General Division, on three matters:

  1. That there is no legislative prohibition to removing a cataractous lens in a private office.
  2. That the removal of a cataractous lens by an ophthalmologist in a private office is a non-insured service.
  3. That a supplementary list of services, when provided by an ophthalmologist in a private clinic, are non-insured services.

On March 6, 2019, Justice Goodridge declared that:

  1. Prior to June 15, 2018, there was no legislative prohibition to removing a cataractous lens in a private office.
  2. Prior to June 15, 2018, the removal of a cataractous lens by an ophthalmologist in a private clinic was an insured service.
  3. The supplementary list of services provided are non-insured services when provided in a private clinic.

Corrective action through legislative and policy amendments

Conclusion

This action plan was created as part of the Reimbursement Policy under the Canada Health Act and with the intention of eliminating patient charges for medically necessary cataract surgery. These efforts have been made in hopes of obtaining a reimbursement for Canada Health Transfer deductions in the amount of $1,349 taken in March 2019 for fiscal year 2016-2017, and in hopes of obtaining an immediate reimbursement for deductions resulting from the remaining patient charges that occurred in subsequent fiscal years.

January 2021 Status Report, Implementation of Newfoundland and Labrador’s Reimbursement Action Plan

Summary of Past Actions

Starting in late 2017, the Department of Health and Community Services (HCS) began receiving phone calls from Medical Care Plan (MCP) beneficiaries complaining about out-of-pocket charges being levied for cataract surgery. In February 2018, HCS issued a Public Service Announcement (PSA) and created a Cataract Surgery Information Line in an effort to identify beneficiaries who may have been billed inappropriately for insured cataract surgery.

On June 15, 2018, amendments to the Medical Care Insurance Insured Services Regulations were introduced to clarify that “the medically necessary removal and replacement of a cataractous lens by any procedure is an insured service and shall be performed in a hospital or a facility designated by the Lieutenant-Governor in Council”.

As of January 1, 2019, HSC adopted the aspheric lens as the new standard, ensuring that patients would no longer be billed for the basic lens associated with cataract surgery.

In January 2019, HCS announced that cataract surgery would be available in private offices throughout the province in the near future. In April 2019, an Amending Agreement to add Schedule “O” to the 2013-2017 Memorandum of Agreement was signed by HCS and the Newfoundland and Labrador Medical Association (NLMA).  Schedule “O” outlines an agreement between HCS and the NLMA with respect to service fees for cataract surgeries performed in designated facilities.

Corrective Action through Patient Reimbursement and Further Investigation

Following the 2018 PSA, HCS issued another PSA on the Reimbursement Process for Cataract Surgeries on February 20, 2020. As part of this process, HCS directly contacted 97 individuals who had previously reached out to HCS via the Cataract Surgery Information Line of 2018:

As part of the Reimbursement Process, HCS has reviewed information provided from an additional 83 new patients that had not previously contacted HCS. To date, the Reimbursement Process has identified 133 patients (230 eyes) for reimbursement and has denied 45 patients who did not meet the eligibility criteria established under the Reimbursement Process for Cataract Surgeries.

There were several reasons patients did not meet the eligibility criteria for reimbursement. For example, under the Reimbursement Process, June 15, 2018, was established as the cut-off date for reimbursement. This date coincided with the coming into force of the legislative amendments. As such, patients whose procedures were performed after June 15, 2018, were not eligible for reimbursement. In other instances, the documentation submitted by the patient may not have provided sufficient evidence that the service provided was an insured cataract procedure. For example, the invoice evidence may have shown that the service provided was an uninsured vision correction procedure.

The review process remains open to allow patients extra time to submit information to HCS for review. 

Proactive Action Through Policy for New Non-Hospital Designated Facilities

In 2020, HCS developed the Policy for the Provision of Cataract Surgery in Non-Hospital Designated Facilities, which outlines the requirements and expectations for these facilities. Section 14.1 of the policy specifically deals with expectations regarding extra-billing and user charges, which are prohibited. The ophthalmologist has a duty to make sure that the patient understands that all insured services are available without any charge (to the patient). Non-hospital designated facilities must provide an itemized list of services billed to ensure clarity between insured and billable non-insured services.
Non-hospital designated facilities must post a Patient Information Sheet in visible areas for public viewing in their offices. They must also provide a copy of this information sheet to all patients who are receiving cataract surgery in the designated facility to sign. HCS will investigate any patient complaints of suspected extra-billing or user charges. The Lieutenant-Governor in Council has the authority to suspend or cancel a non-hospital facility’s designation status if the non-hospital designated facility has failed to comply with the policy.

In January 2021, the Lieutenant-Governor in Council designated two non-hospital facilities to provide insured cataract surgery.

Contact Information

Contact information is provided below for residents who believe they may have been subject to inappropriate patient charges for insured health services.

Refer to Chapter 1 for key definitions under the Canada Health Act. For detailed information on what health services are insured under provincial or territorial health insurance plans, refer to section 2.0- Comprehensiveness, under each provincial and territorial section.

Newfoundland and Labrador

1-866-449-4459 (Avalon area)
1-800-563-1557 (all other regions)
1-709-726-8546 (Complaints Coordinator at the College of Physicians and Surgeons)
complaints@cpsnl.ca

Prince Edward Island

Prince Edward Island Department of Health and Wellness
P.O. Box 2000
Charlottetown, PEI
C1A 7N8
1-902-368-6414

Nova Scotia

Department of Health and Wellness
P.O.  Box 488
Halifax, NS
B3J 2R8

1-902-424-5818
1-800-387-6665 (toll-free in Nova Scotia)
1-800-670-8888 (TTY/TDD)

New Brunswick

Medicare Prescription Drug Plan

Quebec

Covered services accessory costs

Ontario

1-888-662-6613
protectpublichealthcare@ontario.ca

Manitoba

Manitoba Health Seniors and Active Living
300 Carlton Street
Winnipeg, MB
R3B 3M9
1-800-392-1207

Saskatchewan

Saskatchewan Ministry of Health
1-800-667-7766
info@health.gov.sk.ca

Alberta

Alberta Health
Attention: Alberta Health Care Insurance Plan
P.O.  Box 1360, Stn Main
Edmonton, AB
T5J 2N3
1-780-427-1432 (Edmonton)
1-310-0000 then 780-427-1432 (toll-free in Alberta)
780-422-0102 (fax)
health.ahcipmail@gov.ab.ca

British Columbia

Additional fees and charges

Yukon

Yukon Medical Council
1-867-667-3774
ymc@gov.yk.ca
Yukon Medical Council Complaint Process

Northwest Territories

Health Services Administration Office, Health and Social Services
Bag#9
Inuvik, NT
X0E OTO
1-800-661-0830
1-867-777-7400
1-867-777-3197 (fax)

Nunavut

Nunavut Health Insurance Programs Office
Department of Health
Box 889
Rankin Inlet, NU
X0C 0G0
1-800-661-0833 (toll free)
NHIP@gov.nu.ca

Footnotes

Footnote 1

https://www.health.gov.nl.ca/health/mcp/healthplancoverage.html

Return to footnote 1

Footnote 2

3(1)(b) surgical-dental treatment properly and adequately provided to a beneficiary and carried out in a hospital by a dentist if the treatment is of a type specified in the Schedule to the Medical Care Insurance Physicians and Fees Regulations ; https://www.assembly.nl.ca/Legislation/sr/Regulations/rc960021.htm#3_

Return to footnote 2

Footnote 3

https://www.health.gov.nl.ca/health/dentalservices/general_info.html#5

Return to footnote 3

Footnote 4

https://www.nlma.nl.ca/FileManager/Publications/Guides/nlma-physicians-guide-to-non-insured-service-june-2018.pdf

Return to footnote 4

Footnote 5

Services covered for recipients of last-resort financial assistance for 12 months or more.

Return to footnote 5

Footnote 6

On June 20, 2019, Ontario announced changes to its Cabinet that included the creation of the Ministry of Health and the Ministry of Long-Term Care. As such, the Ministry of Health and Long-Term Care will be referred to as the Ministry of Health (MOH) throughout this report.

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Footnote 7

BC Ministry of Health. (2020, March 17). Joint statement on Province of B.C.'s COVID-19 response, latest updates. Retrieved from https://news.gov.bc.ca/releases/2020HLTH0089-000505 .

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Footnote 8

BC Ministry of Health. (2020, March 18). Province declares state of emergency to support COVID-19 response. Retrieved from https://news.gov.bc.ca/releases/2020PSSG0017-000511 .

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Footnote 9

BC Ministry of Health. (2020, April 8). New measures support returning British Columbians, boost response to COVID-19. Retrieved from https://news.gov.bc.ca/releases/2020PREM0019-000657 .

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Footnote 10

BC Ministry of Health. (2020, July 21). BC's Restart Plan. Retrieved from https://www2.gov.bc.ca/gov/content/safety/emergency-preparedness-response-recovery/covid-19-provincial-support/bc-restart-plan

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Footnote 11

Ibid

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Footnote 12

BC Ministry of Health. (2020, August 21). Province introduces new measures to enforce COVID-19 public safety. Retrieved from https://news.gov.bc.ca/releases/2020PSSG0046-001568 .

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Footnote 13

BC Ministry of Health. (2020, September). Management of COVID-19: Health Sector Plan for Fall/Winter 2020/21. Retrieved from https://news.gov.bc.ca/files/COVID-19_fall-winter_preparation.pdf

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Footnote 14

A new Dentistry Master Agreement was executed in October 2020, that is, after the 2019-2020 Canada Health Act Annual Report reporting period.

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Footnote 15

https://www.hss.gov.nt.ca/sites/hss/files/resources/hss-annual-report-2019-20.pdf

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Footnote 16

https://www.hss.gov.nt.ca/en/services/d%C3%A9placement-pour-raisons-m%C3%A9dicales/medical-travel-policy

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Footnote 17

https://open.alberta.ca/dataset/schedule-of-dental-benefits.

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Footnote 18

Details on Medical Travel policy can be found here: https://www.hss.gov.nt.ca/en/services/d%C3%A9placement-pour-raisons-m%C3%A9dicales/medical-travel-policy

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Footnote 19

Nunavut Bureau of Statistics, Nunavut Population Estimates by Age Group, Region and Community, 2001 to 2019. Population estimates are based on the 2016 census counts adjusted for net census under coverage. Nunavut totals include unorganized areas and outpost camps.

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Footnote 20

Supplementary Appropriation (Operations and Maintenance), No. 3, 2019-2020, 2nd Session, 5th Assembly, Legislative Assembly of Nunavut.

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Footnote 21

2019–2020 Capital Estimates, Department of Finance, 2nd Session of the 5th Legislative Assembly.

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Footnote 22

Government of Nunavut, Public Accounts 2018-2019, Office of the Auditor General of Canada, Independent Auditor's Report to the Legislative Assembly of Canada 2018-19, page 37. https://gov.nu.ca/sites/default/files/2018-19_public_accounts_-_web_version.pdf

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Footnote 23

The amount of the administrative charge is $150.00 when the reimbursement is made under the CFMA, and $50 when the reimbursement is made under the IHFA.

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