Coverage, eligibility and access to health care
Coverage
Within the limits provided in this document, CAF members and other eligible persons will be:
- provided comprehensive coverage, whether serving in Canada or abroad, including:
- hospitalization and physician services;
- supplemental health benefits including drugs and health practitioner's benefits;
- occupational health services; and
- dental services.
- excluded from any deductible fees or co-payments for care and services provided by or authorized by the CAF, except where otherwise specified;
- provided emergency health services from the nearest appropriate military or civilian treatment facility; and
- responsible for all costs related to health care services not authorized, or for services from sources other than those designated and authorized by the senior Health Services authority. In addition, payment will not be made for treatments or therapies if they are deemed to be:
- controversial;
- not scientifically founded or proven;
- not medically beneficial; or
- provided solely for cosmetic purposes.
Note: Consideration will be given for cost recovery for the fees that result from missed appointments.
Limitation: Health services outside Canada
Eligible persons residing in Canada will not be entitled to routine health services outside Canada.
Emergency Out-of-Country medical services
Emergency out-of-country medical services are fully covered under the Spectrum of Care, including during non-duty related travel.
Prior Approval Out of Country Medical Services
Out-of-Country (OOC) hospital and medical services may be authorized for coverage under the SoC, subject to the following eligibility criteria.
Prior Approval/Application
All OOC must have prior approval through the Directorate of Medical Policy - Spectrum of Care thru the following process:
- CAF health care provider (HCP) assesses the member’s healthcare requirements and determines the need for OOC health services.
- A referral to an appropriate specialist is completed. The specialist must provide a consultation report indicating that all regulatory criteria are met and the healthcare service is unavailable in Canada. If possible, identify a specific OOC referral hospital or specialist. The specialist must send a full consultation report, along with any investigation results, to be included in the member’s medical records within the Canadian Forces Health Information System (CFHIS); and,
- The CAF HCP submits a request IAW HS Grp Instruction 5000-03 Requesting an Exception to CAF Spectrum of Care or items/services under Compensation and Benefits Instruction 211 or Quality of Life to the D Med Pol SoC team for adjudication via our electronic medical record, CFHIS.
Eligibility
- The medical treatment is performed at a hospital or licensed medical facility with a similar standard of care as Canadian facilities.
- The medical treatment is not experimental, for research or for purely cosmetic purposes; and,
- The medical treatment is accepted in Canada as appropriate in the same medical circumstances and not performed by an identical or equal procedure in Canada but a delay in services would: result in death; or medically significant irreversible tissue damage.
Approval and Coverage
Upon approval, the Base/Wing Surgeon will receive:
- Confirmation of the approved service(s);
- Identification of the designated medical facility; and,
- Details outlining any limitations, inclusions, or exclusions related to funding.
Eligibility
All Regular Force personnel are covered by the Spectrum of Care from the time of enrolment to the effective date of release from the CAF. Reserve Force personnel are covered only during specified periods of eligibility based on their duty status and the relatedness of their illness or injury to military service (QR&O 34.07).
From time-to-time, other persons may be authorized for specific services or for specified periods of time. Some examples are: visiting military forces, foreign military exchange personnel and their dependants, CAF recruit applicants and civilian food handlers.
Accessing health care
Access to Health Care will, by necessity, be slightly different from base to base and dependent on: the base role, the size of the military population, the base location, the type and size of facilities available and the number and type of military and civilian Health Care personnel available. The local HCC and Dental Detachment Commander will be responsible to clearly publish any changes to the procedures and routines for accessing both regular and emergency health care.
Access to private medical clinic could be appropriate if there is either a clinical or operational requirement and the process is described in the Enhanced Access Health Care Services.