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 1 (EBUC) provisions of the Act, respectively. The Minister is required to make dollar-for-dollar deductions to a province’s or territory’s (PT’s) CHT payments when EBUC are permitted. The intent of the CHA with respect to deductions is to encourage compliance with the Act and its objective of ensuring Canadians’ access to health care services on uniform terms and conditions and without financial barriers.

At the time the CHA came into force, many jurisdictions had legal frameworks for public health insurance which either explicitly allowed EBUC to be levied on patients, or, by convention, had permitted such fees to become entrenched in their health care systems. In view of these factors, it was acknowledged that it would take time for PTs to align their systems with the values and requirements of the CHA. The Act, therefore, included a provision for the first three years (1984-1987) which, in effect, provided refunds of amounts deducted from federal transfers for EBUC violations once the PT succeeded in eliminating EBUC. 

PTs adopted legislation governing their public health insurance systems which mirrored, and in most cases went well beyond, the requirements of the CHA. As a result, over $244 million was refunded to seven PTs in respect of patient charges levied in the 1984-1987 period. The advent of the CHA, including the refund provision, helped eliminate EBUC for a considerable period of time in most parts of the country and in most care settings.

Time for a New Reimbursement Policy

Despite provisions discouraging or prohibiting EBUC in both federal and PT legislation, there are still instances of patients paying for access to insured health care services in some jurisdictions. As was the case in 1984, these charges put at risk the fundamental value of universal access to health care.
Some jurisdictions have been active in investigating allegations of patient charges, adopting legislative and regulatory measures to deter EBUC, ensuring that patients are reimbursed and that providers or institutions who contravene PT law (and the CHA) are disciplined. These governments are to be commended for their vigilance on behalf of patients.

Given the success of the original refund provision of the CHA in eliminating EBUC, the federal government is implementing a new Reimbursement Policy for Provinces and Territories Subject to Deductions under the Canada Health Act (the Reimbursement Policy). Under this new policy, if a province or territory is subject to a deduction, the federal Minister of Health has the discretion to provide a reimbursement if the PT comes into compliance with the Act by the end of the calendar year.

Current Process

Under the CHA’s Extra-billing and User Charges Information Regulations (the Regulations), PTs are obligated to report to Health Canada on EBUC occurring within their jurisdiction. This takes the form of a financial statement submitted each year, by December 16, which describes any EBUC activity occurring in the fiscal year two years previous. If the Minister does not receive a statement, or believes the information was not provided in accordance with the Regulations, the Act obligates the Minister to estimate an amount after consultation with the PT. The CHT payments to the jurisdiction are then reduced by a corresponding amount in March of the following year.

Working Together to Eliminate Patient Charges

The objective of the Reimbursement Policy is to work collaboratively with PTs subject to a CHT deduction to ultimately eliminate these patient charges.  When a PT is informed it will be subject to a CHT deduction for EBUC (typically in January/February), the conditions for reimbursement will also be outlined.  In instances where the PT has already eliminated patient charges and a sufficient period of time has elapsed to assure Health Canada that the circumstances that led to these charges have been addressed, reimbursement may be made immediately.  Where such charges are ongoing, Health Canada will work with PT officials on the elements of an action plan to meet the conditions for reimbursement. Action plans, and PT progress on meeting them, will be published in the Canada Health Act Annual Report.

To be considered for reimbursement, the jurisdiction would need to demonstrate it has followed through on the agreed upon action plan within the specified time period – typically 12 months but no more than two years following the initial deduction.  Because the circumstances leading to deductions will vary from province to province, so will the action plans. Nonetheless, it is expected that all action plans will require the PT to submit the following documents to Health Canada in the January following the deduction:

  • A financial statement of any EBUC levied in the jurisdiction since the deduction
  • A report on the steps the jurisdiction has taken to eliminate EBUC, and how these charges have been addressed
  • An attestation as to the completeness and accuracy of the information submitted

Upon review of the jurisdiction’s report, if the Minister is satisfied that the elements of the action plan have been fulfilled, the PT would receive a reimbursement. However, if the Minister is not satisfied that the conditions were fulfilled, no reimbursement would occur and the deduction amount would be forfeited. Following an initial deduction and reimbursement cycle, if the Minister remains satisfied that appropriate action has been taken, the Reimbursement Policy would allow for the immediate reimbursement of subsequent CHT deductions.

In order to qualify for continued consideration under the Reimbursement Policy, a PT must also comply with the regular reporting requirements set out in the Regulations and submit an accurate EBUC financial statement to Health Canada in the December following the CHT deduction and commit to doing so on an annual basis going forward.

Footnote 1

Extra-billing is a charge by a physician to an insured person for an insured health service in addition to the amount normally paid by the P/T health insurance plan.  User charges are all other charges related to the provision of insured health services (e.g., facility fees related to a surgical procedure at a private clinic).

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