Canada Health Act Annual Report 2010-2011

Table of Contents

• Acknowledgements
• Introduction
• Chapter 1 - Canada Health Act Overview
• Chapter 2 - Administration and Compliance
• Chapter 3 - Provincial and Territorial Health Care Insurance Plans in 2010-2011
  • Newfoundland and Labrador
  • Prince Edward Island
  • Nova Scotia
  • New Brunswick
  • Quebec
  • Ontario
  • Manitoba
  • Saskatchewan
  • Alberta
  • British Columbia
  • Yukon
  • Northwest Territories
  • Nunavut
• Annex A - Canada Health Act and Extra-Billing and User Charges Information Regulations
• Annex B - Policy Interpretation Letters
• Annex C - Dispute Avoidance and Resolution Process under the Canada Health Act
• Contact Information for Provincial and Territorial Departments of Health

Acknowledgements

Health Canada would like to acknowledge the work and effort that went into producing this Annual Report. It is through the dedication and timely commitment of the following departments of health and their staff that we are able to bring you this report on the administration and operation of the Canada Health Act:

• Newfoundland and Labrador Department of Health and Community Services
• Prince Edward Island Department of Health and Wellness
• Nova Scotia Department of Health and Wellness
• New Brunswick Department of Health
• Quebec Department of Health and Social Services
• Ontario Ministry of Health and Long-Term Care
• Manitoba Health
• Saskatchewan Health
• Alberta Health and Wellness
• British Columbia Ministry of Health
• Yukon Department of Health and Social Services
• Northwest Territories Department of Health and Social Services
• Nunavut Department of Health and Social Services

We also greatly appreciate the extensive work effort that was put into this report by our production team: the desktop publishing unit, the translators, editors and concordance experts, and staff of Health Canada at headquarters and in the regional offices.

Introduction

Canada has a predominantly publicly financed and administered health care system. The Canadian health insurance system is achieved through 13 interlocking provincial and territorial health insurance plans, and is designed to ensure that all eligible residents of Canadian provinces and territories have reasonable access to medically necessary hospital and physician services on a prepaid basis, without charges related to the pro­vision of insured health services.

The Canadian health insurance system evolved into its present form over more than five decades. Saskatchewan was the first province to establish universal, public hospital insurance in 1947 and, ten years later, the Government of Canada passed the Hospital Insurance and Diagnostic Services Act (1957) to share in the cost of these services with the provinces and territories. 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 cost share the provision of insured physician services with the provinces and territories. 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 fees 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 in 1984.

The Canada Health Act is Canada's federal health insurance legislation and defines the national principles that govern the Canadian health insurance system, namely, public administration, comprehensiveness, universality, portability and accessibility. These principles are symbols of the underlying Canadian values of equity and solidarity.

The roles and responsibilities for Canada's health care system are shared between the federal and provincial/territorial governments. The provincial and territorial governments have primary jurisdiction in the administration and delivery of health care services. This includes setting their own priorities, administering their health care budgets and managing their own resources. The federal government, under the Canada Health Act, sets out the criteria and conditions that must be satisfied by the provincial and territorial health insurance plans for provinces and territories to qualify for their full share of the cash contribution available to them under the federal Canada Health Transfer.

On an annual basis, the federal Minister of Health is required to report to Parliament on the administration and operation of the Canada Health Act, as set out in section 23 of the Act. The vehicle for so doing is the Canada Health Act Annual Report. While the principal and intended audience for the report is Parliamentarians, it is a public document that offers a comprehensive report on insured health services in each of the provinces and territories. The annual report is structured to address the mandated reporting requirements of the Act; as such, its scope does not extend to commenting on the status of the Canadian health care system as a whole.

Provincial and territorial health care insurance plans generally respect the criteria and conditions of the Canada Health Act. However, when instances of possible non-compliance with the Act arise, Health Canada's approach to the administration of the Act emphasizes transparency, consultation and dialogue with provincial and territorial health care ministries. The application of financial penalties through deductions under the Canada Health Transfer is considered only as a last resort when all other options to resolve an issue collaboratively have been exhausted. Pursuant to the commitment made by premiers under the 1999 Social Union Framework Agreement, federal, provincial and territorial governments (except Quebec) agreed through an exchange of letters, in April 2002, to a Canada Health Act Dispute Avoidance and Resolution (DAR) process. The DAR process was formalized in the First Ministers' 2004 Accord. Although the DAR process includes dispute resolution provisions, the federal Minister of Health retains the final authority to interpret and enforce the Canada Health Act.

In 2010-2011, the most prominent concerns with respect to compliance under the Canada Health Act remained patient charges and queue jumping for medically necessary health services at private clinics. Health Canada has made these concerns known to the provinces that allow these charges.

Chapter 1 - Canada Health Act Overview

This section describes the Canada Health Act, its requirements, key definitions, regulations and regulatory provisions, letters by former federal Ministers of Health Jake Epp and Diane Marleau to their provincial and territorial counterparts that are used in the interpretation and application of the Act, and from former federal Minister, Anne McLellan, to her provincial and territorial counterparts on the Canada Health Act Dispute Avoidance and Resolution process. A history of the evolution of federal health care transfers follows.

What is the Canada Health Act?

The Canada Health Act is Canada's federal legislation for publicly funded health care insurance. The 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).

The aim of the Act is to ensure that all eligible residents of Canada have reasonable access to medically necessary services on a prepaid basis, without direct charges related to the provision of insured health services.

Key Definitions Under the Canada Health Act

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."

Persons excluded under the Act include serving members of the Canadian Forces or Royal Canadian Mounted Police and inmates of federal penitentiaries.

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 procedure) provided to insured persons.

Insured hospital services are defined under the Act and include medically necessary in- and out-patient services such as accommodation and meals at the standard or public ward level and preferred accommodation if 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, but does not include services that are excluded by the regulations.

Insured physician services are defined under the Act as "medically required services rendered by medical practitioners." Medically required physician services are generally determined by physicians in conjunction with their provincial and territorial health insurance plans.

Insured surgical-dental services are services provided by a dentist in a hospital, where a hospital setting is required to properly perform the procedure.

Extended health care services as defined in the Act 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.

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:

• five program criteria that apply only to insured health services;
• two conditions that apply to insured health services and extended health care services; and
• extra-billing and user charges provisions that apply only to insured health services.

The Criteria

1. Public Administration (section 8)

The public administration criterion, set out in section 8 of the Canada Health Act, applies to provincial and territorial health care insurance plans. The intent of the public administration criterion is that the provincial and territorial health care insurance plans 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 administrative services necessary for the administration of the provincial and territorial health care insurance plans.

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

2. Comprehensiveness (section 9)

The comprehensiveness criterion of the Act requires that the health care insurance plan of a province or territory must cover all insured health services provided by hospitals, physicians or dentists (i.e., surgical-dental services that require a hospital setting) and, where the law of the province so permits, similar or additional services rendered by other health care practitioners.

3. Universality (section 10)

Under the universality criterion, all insured residents of a province or territory must be entitled to the insured health 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 plans to establish entitlement.

Newcomers to Canada, such as immigrants or Canadians returning from other countries to live in Canada, may be subject to a waiting period by a province or territory, not to exceed three months, before they are entitled to receive insured health services.

4. Portability (section 11)

Residents moving from one province or territory to another must continue to be covered for insured health services by the "home" jurisdiction during any waiting period imposed by the new province or territory of residence. The waiting period for eligibility to a provincial or territorial health care insurance plan must not exceed three months. After the waiting period, the new province or territory of residence assumes responsibility for health care coverage. However, 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.

Residents who are temporarily absent from their home province or territory or from Canada, must continue to be covered for insured health services during their absence. This allows individuals to travel or be absent from their home province or territory, within a prescribed duration, while retaining their health insurance coverage.

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 necessary services in relation to an urgent or emergent need when absent on a temporary basis, such as on business or vacation.

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.

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

5. 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 on uniform terms and conditions, unprecluded or unimpeded, either directly or indirectly, by charges (user charges or extra-billing) or other means (e.g., discrimination on the basis of age, health status or financial circumstances).

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

• reasonable compensation to physicians and dentists for all the insured health services they provide; and
• payment to hospitals to cover the cost of insured health services.

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" rule. Thus, residents of a province or territory are entitled to have access on uniform terms and conditions to insured health services at the setting "where" the services are provided and "as" the services are available in that setting.

The Conditions

1. Information (section 13(a))

The provincial and territorial governments shall provide information to the Minister of Health as may be reasonably required, in relation to insured health services and extended health care services, for the purposes of the Act.

2. Recognition (section 13(b))

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

Extra-billing and User Charges

The provisions of the Canada Health Act pertaining to extra-billing and user charges for insured health 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 deduction from the federal cash transfer to that province or territory is required under the Act. The amount of such a deduction for a fiscal year is determined by the federal Minister of Health based on information provided by the province or territory in accordance with the Extra-billing and User Charges Information Regulations (described below).

Extra-billing (section 18)

Under the Act, extra-billing is defined as the billing for an insured health service rendered to an insured person by a medical practitioner or a dentist (i.e., a dentist providing insured surgical-dental services in a hospital setting) in an amount in addition to any amount paid or to be paid for that service by the health care insurance plan of a province or territory. For example, if a physician was to charge a patient any amount for an office visit that is insured by the provincial or territorial health 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 contrary to the accessibility criterion.

User Charges (section 19)

The Act defines user charges as any charge for an insured health service other than extra-billing that is permitted by a provincial or territorial health care insurance plan and is not payable by the plan. For example, if patients were charged a facility fee for receiving an insured service at a hospital or clinic, 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.

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:

• defining the services included in the Act's definition of "extended health care services";
• prescribing which services to exclude from hospital services;
• prescribing the types of information that the federal Minister of Health may reasonably require, and the times at which and the manner in which that information may be provided; and
• prescribing how provinces and territories are required to recognize the CHT in their documents, advertising or promotional materials.

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 provide estimates of extra-billing and user charges before the beginning of a fiscal year so that appropriate penalties can be levied. They must also provide financial statements showing the amounts actually charged so that reconciliations with any estimated charges can be made. (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. In plain terms, this means that when it has been determined that a province or territory has allowed $500,000 in extra-billing by physicians, the federal cash contribution to that province or territory will be reduced by that same amount.

Discretionary Penalty Provisions

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 federal transfer payments under the CHT is based on the gravity of the default.

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 applied.

Excluded Services and Persons

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

• services that fall outside the definition of insured health services; and
• certain services and groups of persons are excluded from the definitions of insured services and insured persons.

These exclusions are discussed below.

Excluded Services

In addition to the medically necessary hospital and physician services covered by the Canada Health Act, provinces and territories also provide a range of other programs and services. These are provided at provincial and territorial discretion, on their own terms and conditions, and vary from one province or territory to another. Additional services that may be provided include pharmacare, ambulance services and optometric services.

The additional services provided by provinces and territories are often targeted to specific population groups (e.g., children, seniors or social assistance recipients), and may be partially or fully covered by provincial and territorial health insurance plans.

A number of services provided by hospitals and physicians are not considered medically necessary, and thus are not insured under provincial and territorial health insurance legislation. Uninsured hospital services for which patients may be charged include preferred hospital accommodation unless prescribed by a physician, private duty nursing services and the provision of telephones and televisions. Uninsured physician services for which patients may be charged include telephone advice, the provision of medical certificates required for work, school, insurance purposes and fitness clubs, testimony in court and cosmetic services.

In addition, the definition of "insured health services" excludes services to persons provided under any other Act of Parliament (e.g., refugees) or under the workers' compensation legislation of a province or territory.

Excluded Persons

The Canada Health Act definition of "insured person" excludes members of the Canadian Forces, persons appointed to a position of rank within the Royal Canadian Mounted Police and persons serving a term of imprisonment within a federal penitentiary. The Government of Canada provides coverage to these groups through separate federal programs.

As well, other categories of residents such as landed immigrants and Canadians returning from other countries to live in Canada may be subject to a waiting period by a province or territory. The Act stipulates that the waiting period cannot exceed three months.

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

There is a Frequently Asked Questions link on Health Canada's web-site to address common concerns that Canadians might have about Canada's publicly-insured health insurance plans. See: http://hc-sc.gc.ca/hcs-sss/medi-assur/faq-eng.php

Policy Interpretation Letters

There are two 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. Both letters are reproduced in Annex B of this report.

Epp Letter

In June 1985, approximately one year following the passage of the Canada Health Act in Parliament, then-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.

Minister Epp's letter followed several months of consultation with his provincial and territorial counterparts. The letter sets forth statements of federal policy intent that clarify the Act's criteria, conditions and regulatory provisions. These clarifications have been used by the federal government in assessing and interpreting compliance with the Act. The Epp letter remains an important reference for interpreting the Act.

Marleau Letter -- Federal Policy on Private Clinics

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

At the September 1994 federal/provincial/territorial meeting of health ministers in Halifax, all ministers of health present, 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/territorial health insurance plan pays the physician fee for a medically necessary service delivered at a private clinic, it must also pay the facility fee or face a deduction from federal transfer payments.

Dispute Avoidance and Resolution Process

In April 2002, then-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 and provincial/territorial interests of avoiding disputes related to the interpretation of the principles 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/territorial committees on Act-related 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.

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

Chapter 2 - Administration and Compliance

Administration

In administering the Canada Health Act, the federal Minister of Health is assisted by Health Canada staff at headquarters and in the regions, and by the Department of Justice.

Health Canada works with the provinces and territories to ensure that the principles of the Act are respected and always strives to resolve issues through consultation, collaboration and cooperation.

The Canada Health Act Division

The Canada Health Act Division at Health Canada is responsible for administering the Act. Members of the Division located in Ottawa and their colleagues in regional Health Canada offices fulfill the following ongoing functions:

• monitoring and analysing provincial and territorial health insurance plans for compliance with the criteria, conditions and extra-billing and user charges provisions of the Act;
• disseminating information on the Act and on publicly funded health care insurance programs in Canada;
• responding to inquiries about the Act and health insurance issues received by telephone, mail and the Internet, from the public, members of Parliament, government departments, stakeholder organizations and the media;
• developing and maintaining formal and informal partnerships with health officials in provincial and territorial governments for information sharing;
• developing and producing the Canada Health Act Annual Report on the administration and operation of the Act;
• conducting issue analysis and policy research to provide policy advice;
• collaborating with provincial and territorial health department representatives through the Interprovincial Health Insurance Agreements Coordinating Committee (see below);
• working in partnership with the provinces and territories to investigate and resolve compliance issues and pursue activities that encourage compliance with the Act; and
• informing the Minister of possible non-compliance and recommending appropriate action to resolve the issue.

Interprovincial Health Insurance Agreements Coordinating Committee (IHIACC)

The Canada Health Act Division chairs the Interprovincial Health Insurance Agreements Coordinating Committee and provides a secretariat for the Committee. The Committee was formed in 1991 to address issues affecting the interprovincial billing of hospital and medical services as well as issues related to registration and eligibility for health insurance coverage. It oversees the application of interprovincial health insurance agreements in accordance with the Canada Health Act.

The within-Canada portability provisions of the Act are implemented through a series of bilateral reciprocal billing agreements between provinces and territories for hospital and physician services. This generally means that a patient's health card will be accepted, in lieu of payment, when the patient receives 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. All provinces and territories participate in reciprocal hospital agreements and all, with the exception of Quebec, participate in reciprocal medical agreements. The intent of these agreements is to ensure that Canadian residents do not face point-of-service charges for medically required hospital and physician services when they travel in Canada. However, these agreements are interprovincial/territorial and are not required by the Act.

Compliance

Health Canada's approach to resolving possible compliance issues emphasizes transparency, consultation and dialogue with provincial and territorial health ministry officials. In most instances, issues are successfully resolved through consultation and discussion based on a thorough examination of the facts. To date, most disputes and issues related to administering and interpreting the Canada Health Act have been addressed and resolved without resorting to deductions. Deductions have only been applied when all options to resolve an issue have been exhausted.

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

Staff in the Compliance and Interpretation Unit, 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 may reveal issues that are not directly related to the Act, while others may pertain to the Act but are a result of misunderstanding or miscommunication, and are resolved quickly with provincial/territorial assistance, such as eligibility for health insurance coverage and portability of health services within and outside Canada.

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/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.

Compliance Issues

For the most part, provincial and territorial health care insurance plans meet the criteria and conditions of the Canada Health Act. However, on the basis of reports to Health Canada by their respective provincial health ministries, deductions were taken from the March 2011 CHT payments to British Columbia, in respect of extra-billing and patients charges at surgical clinics in the amount of $75,136, and Newfoundland and Labrador, in respect of extra-billing in the amount of $3,577, levied during fiscal year 2008-2009.

During 2010-2011, two potential compliance issues arose. First, media reports indicated that a private primary care clinic in Ottawa was planning to charge patients an annual fee to join. Health Canada had concerns that the payment of the fee might be a condition for receiving insured health services. Health Canada officials contacted officials at the Ontario Ministry of Health and Long-Term Care (MOHLTC) and requested that they investigate.

In the second instance, further to a media report, Health Canada raised concerns with the Ontario Ministry of Health and Long-Term Care about a Toronto hospital accepting payments for insured diagnostic services under the guise of a third-party payor arrangement.

In relation to both matters, the MOHLTC advised that they have taken decisive, corrective action pursuant to the requirements of the Ontario Commitment to the Future of Medicare Act. In order to satisfy the requirements of the Canada Health Act, Health Canada informed the MOHLTC that these measures must include reimbursement of extra-billing and user charges to insured Ontario residents, if such contraventions have occurred.

History of Deductions and Refunds Under the Canada Health Act

The Canada Health Act, which came into force April 1, 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.

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, which had extra-billing and user charges, had taken appropriate steps to eliminate them. Accordingly, by June 1987, a total of $244,732,000 in deductions were refunded to New Brunswick ($6,886,000), Quebec ($14,032,000), Ontario ($106,656,000), Manitoba ($1,270,000), Saskatchewan ($2,107,000), Alberta ($29,032,000) and British Columbia ($84,749,000).

Following the Canada Health Act's initial three-year transition period, under which refunds to provinces and territories for deductions were possible, penalties under the Act did not reoccur until fiscal year 1994-1995. Please refer to the table at the end of this section for a summary of deductions and refunds that have been made to provincial/territorial transfer payments since 1994-1995.

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 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 insurance plan. This higher amount constituted extra-billing under the Act. Including deduction adjustments for prior years, dating back to fiscal year 1992-1993, deductions began in May 1994 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 were deducted from British Columbia's cash contribution for extra-billing that occurred in the province between 1992-1993 and 1995-1996. These deductions were non-refundable, as were all subsequent deductions.

In January 1995, then 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 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 Canada Health 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.

From November 1995 to June 1996, total deductions of $3,585,000 were made 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 insurance plan.

Similarly, due to facility fees allowed at an abortion clinic, a total of $284,430 was deducted from Newfoundland and Labrador's cash contribution before these fees were eliminated, effective January 1, 1998.

From November 1995 to December 1998, deductions from Manitoba's Canada Health and Social Transfer (CHST) cash contribution amounted to $2,055,000, ending 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 $50,033 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 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.

With the closure of a private clinic in Halifax effective November 27, 2003, Nova Scotia was deemed to be in compliance with the Federal Policy on Private Clinics. 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 for 2002-2003 and one-time positive adjustment in the amount of $8,121 was made to Nova Scotia's March 2006 CHT 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.

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 during fiscal year 2000-2001, totalling $4,610. Accordingly, a deduction of $4,610 was made to the March 2003 CHST cash contribution.

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

Since 2005, the following deductions (and the fiscal year to which they pertained) have been taken to British Columbia's CHT payments^{Footnote 1} on the basis of charges reported by the province for extra-billing and patient charges: $72,464 in 2005 (2002-2003); $29,019 in 2006 (2003-2004); $114,850 in 2007 (2004-2005); $42,113 in 2008 (2005-2006); $66,195 in 2009 (2006-2007); and $73,925 in 2010 (2007-2008).

A deduction of $1,100 was taken from the March 2005 CHT payment to Newfoundland and Labrador as a result of patient charges for a magnetic resonance imaging scan in a hospital which occurred during 2002-2003. The March 2007 CHT payment to Nova Scotia was reduced by $9,460 in respect of extra-billing during fiscal year 2004-2005.

Since the passage of the Canada Health Act, from April 1984 to March 2011, deductions totalling $9,238,332 have been applied against provincial cash contributions in respect of the extra-billing and user charges provisions of the Act. This amount excludes deductions totalling $244,732,000 that were made between 1984 and 1987 and subsequently refunded to the provinces when extra-billing and user charges were eliminated.

Chapter 3 - Provincial and Territorial Health Care Insurance Plans in 2009-2010

The following chapter presents the 13 provincial and territorial health 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 2010-2011.

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:

• a narrative description of the provincial or territorial health care system relating to the criteria and conditions of the Act, which can be found following this chapter; and
• statistical information related to insured health services.

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

To help provinces and territories prepare their submissions to the annual report, Health Canada provided them with the document Canada Health Act Annual Report 2010-2011: A Guide for Updating Submissions (User's Guide). This guide is designed to help provinces and territories meet the reporting requirements of Health Canada. Annual revisions to the guide are based on Health Canada's analysis of health 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 2010-2011 was launched late spring 2011 with bilateral teleconferences with each jurisdiction. 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 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.

Provincial and Territorial Health Care Insurance Plan Statistics

In 2003-2004, the section of the annual report containing the statistical information submitted from the provinces and territories was simplified and streamlined following feedback received from provincial and territorial officials, and based on a review of data quality and availability. The format was further streamlined for the 2006-2007 report. In the 2009-2010 report, the tables were again streamlined to focus on total numbers of physicians and facilities. This format was retained in 2010-2011. The supplemental statistical information 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 federal Act.

The statistical tables contain resource and cost data for insured hospital, physician and surgical-dental by province and territory for five consecutive years ending on March 31, 2011. 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 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: Hospital services provided out of country represent 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: Physician services provided out of country represent 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

Introduction

The majority of publicly funded health services in Newfoundland and Labrador are delivered through four regional health authorities. They focus on the full continuum of care, including health promotion and protection, public health, community services, and acute and long-term care services.

In Newfoundland and Labrador, approximately 20,000 health care providers and administrators provide health services to approximately 520,000 residents (based on 2006 census).

There were significant investments in health and well­being in Budget 2010-2011. Investments of $2.7 billion were budgeted to improve health care throughout the province. Investments included $1.2 million to enhance surgical services at Western Memorial Hospital in Corner Brook, $1.1 million to decrease wait time for surgery by increasing the number of operating rooms in the Eastern Health region, and $797,700 for an expansion of the coverage for the current insulin pump therapy program, to include adults from the ages of 18 to 25 years old. An investment of approximately $7.2 million continued to ensure that those individuals who live with mental illness or addiction issues have treatment options available to them. An investment of $1.1 million will establish two new satellite dialysis units, one for Port aux Basques and the other for Labrador West. These units will help reduce the travel and improve the quality of life of patients who will be able to receive dialysis closer to home. As well, Newfoundland and Labrador made significant investments, including key investments to improve access to rural health care services, initiatives that support the health and wellness of children and youth, which includes $0.8 million to continue to fund the Human Papillomanvirus (HPV) immunization program for adolescent females, and to improve access to cancer care.

1.0 Public Administration

1.1 Health Care Insurance Plan and Public Authority

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

The Hospital Insurance Agreement Act is the legislation that enables the Hospital Insurance Plan. The Act gives the Minister of Health and Community Services the authority to make regulations for providing insured services on uniform terms and conditions to residents of the province under the conditions specified in the Canada Health Act and its regulations.

The Medical Care Insurance Act, 1999 empowers the Minister to administer a plan of medical care insurance for residents of the province. It provides for the development of regulations to ensure that the provisions of the statute meet the requirements of the Canada Health Act as it relates to administering the MCP.

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 MCP operates in accordance with the provisions of the Medical Care Insurance Act, 1999 and regulations, and in compliance with the Canada Health Act.

There were no legislative amendments to the Medical Care Insurance Act, 1999 or the Hospital Insurance Agreement Act in 2010-2011.

1.2 Reporting Relationship

The Department is mandated with administering the Hospital Insurance and Medical Care Plans. The Department reports on these plans through the regular legislative processes, e.g., Public Accounts and the Estimates 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 (2006), the Department of Health and Community Services and the eight (8) entities

that report to the Minister, including Regional Health Authorities, produce a strategic plan once every three years and report annually on performance. Plans and reports are tabled in the  House of Assembly and posted on the Department's web site (www.gov.nl.ca/health/publications). The Department's 2009-2010 Annual Report was tabled in the House of Assembly in September 2010.

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. The Auditor General has full and unrestricted access to MCP records.

The four regional health authorities are subject to financial statement audits, reviews, and compliance audits. Financial statement audits are performed by independent auditing firms that are selected by the health authorities under the terms of the Public Tender Act. Review engagements, compliance audits and physician audits were carried out by personnel from the Department under the authority of the Medical Care Insurance Act, 1999. Physician records and professional medical corporation records were reviewed to ensure that the records supported the services billed and that the services are insured under the MCP.

Beneficiary audits were performed by personnel from the Department under the Medical Care Insurance Act, 1999. Individual providers are randomly selected on a bi-weekly basis for audit.

2.0 Comprehensiveness

2.1 Insured Hospital Services

The Hospital Insurance Agreement Act and the Hospital Insurance Regulations made thereunder provide for insured hospital services in Newfoundland and Labrador.

Insured hospital services are provided for in- and out-patients in 15 hospitals, 22 community health centres and 14 community clinics. Insured services include: accommodations and meals at the standard ward level; nursing services; laboratory, radiology and other diagnostic procedures; drugs, biological and related preparations; medical and surgical supplies, operating room, case room and anaesthetic facilities; rehabilitative services (e.g., physiotherapy, occupational therapy, speech language pathology and audiology); out-patient and emergency visits; and day surgery.

The coverage policy for insured hospital services is linked to the coverage policy for insured medical services. The Department of Health and Community Services 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. There were no services added or de-listed in 2010-2011.

2.2 Insured Physician Services

The enabling legislation for insured physician services is the Medical Care Insurance Act, 1999 and the regulations made thereunder, which include:

• the Medical Care Insurance Insured Services Regulations;
• the Medical Care Insurance Beneficiaries and Inquiries Regulations; and
• the Physicians and Fee Regulations.

In 2010-2011, there were 1,096 physicians registered in the province.

An insured service is defined as one that is listed in section 3 of the Medical Care Insurance Insured Services Regulations; medically necessary; and/or recommended by the Department of Health and Community Services. There are no limitations on the services covered, subject to these criteria.

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

• all services properly and adequately provided by physicians to beneficiaries suffering from an illness requiring medical treatment or advice;
• group immunizations or inoculations carried out by physicians at the request of the appropriate authority; and
• diagnostic and therapeutic x-ray and laboratory services in facilities approved by the appropriate authority that are not provided under the Hospital Insurance Agreement Act and regulations made under the Act.

Physicians can choose not to participate in the health care insurance plan as outlined in section 12(1) of the Medical Care Insurance Act, 1999, namely:

• 12 (1) Where a physician providing insured services is not a participating physician, and the physician provides an insured service to a beneficiary, the physician is not subject to this Act or the regulations relating to the provision of insured services to beneficiaries or the payment to be made for the services except that he or she shall:
  • (a) before providing the insured service, if he or she wishes to reserve the right to charge the beneficiary for the service an amount in excess of that payable by the Minister under this Act, inform the beneficiary that he or she is not a participating physician and that the physician may so charge the beneficiary; and
  • (b) provide the beneficiary to whom the physician has provided the insured service with the information required by the Minister to enable payment to be made under this Act to the beneficiary in respect of the insured service.
• (2) Where a physician who is not a participating physician provides insured services through a professional medical corporation, the professional medical corporation is not, in relation to those services, subject to this Act or the regulations relating to the provision of insured services to beneficiaries or the payment to be made for the services and the professional medical corporation and the physician providing the insured services shall comply with subsection (1).

As of March 31, 2011, there were no physicians who had opted out of the Medical Care Plan (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, including the provincial medical association and the public. There were no services added or deleted during the 2010-2011 fiscal year to the list of insured physician services.

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 MCP if the treatment is specified in the Surgical-Dental Services Schedule.

Dentists may opt out of the MCP. These dentists must advise the patient of their opted-out status, stating the fees expected, and provide the patient with a written record of services and fees charged. There is currently one opted-out dentist.

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.

Addition of a surgical-dental service to the list of insured services must be approved by the Minister.

2.4 Uninsured Hospital, Physician and Surgical-Dental Services

Hospital services not covered by MCP include: preferred accommodation at the patient's request; cosmetic surgery and other services deemed to be medically unnecessary; ambulance or other patient transportation before admission or upon discharge; private duty nursing arranged by the patient; non-medically required x-rays or other services for employment or insurance purposes; drugs (except anti-rejection and AZT drugs) and appliances issued for use after discharge from hospital; bedside telephones, radios or television sets for personal, non-teaching use; fibreglass splints; services covered by the Workplace Health, Safety and Compensation Commission or by other federal or provincial legislation; and services relating to therapeutic abortions performed in non-accredited facilities or facilities not approved by the College of Physicians and Surgeons of Newfoundland and Labrador.

The use of the hospital setting for any services deemed not insured by the MCP are also uninsured under the Hospital Insurance Plan. For purposes of the Medical Care Insurance Act, 1999, the following is a list of non-insured physician services:

• any advice given by a physician to a beneficiary by telephone;
• the dispensing by a physician of medicines, drugs or medical appliances and the giving or writing of medical prescriptions;
• the preparation by a physician of records, reports or certificates for, or on behalf of, or any communication to, or relating to, a beneficiary;
• any services rendered by a physician to the spouse and children of the physician;
• any service to which a beneficiary is entitled under an Act of the Parliament of Canada, an Act of the Province of Newfoundland and Labrador, an Act of the legislature of any province of Canada, or any law of a country or part of a country;
• the time taken or expenses incurred in travelling to consult a beneficiary;
• ambulance service and other forms of patient transportation;
• acupuncture and all procedures and services related to acupuncture, excluding an initial assessment specifically related to diagnosing the illness proposed to be treated by acupuncture;
• examinations not necessitated by illness or at the request of a third party except as specified by the Department;
• plastic or other surgery for purely cosmetic purposes, unless medically indicated;
• testimony in a court;
• visits to optometrists, general practitioners and ophthalmologists solely for determining whether new or replacement glasses or contact lenses are required;
• the fees of a dentist, oral surgeon or general practitioner for routine dental extractions performed in hospital;
• fluoride dental treatment for children under four years of age;
• excision of xanthelasma;
• circumcision of newborns;
• hypnotherapy;
• medical examination for drivers;
• alcohol/drug treatment outside Canada;
• consultation required by hospital regulation;
• therapeutic abortions performed in the province at a facility not approved by the College of Physicians and Surgeons of Newfoundland and Labrador;
• sex reassignment surgery, when not recommended by the Clarke Institute of Psychiatry;
• in vitro fertilization and OSST (ovarian stimulation and sperm transfer);
• reversal of previous sterilization procedure;
• surgical, diagnostic or therapeutic procedures not provided in facilities as of January 1998 other than those listed in the Schedule to the Hospitals Act or approved by the appropriate authority under paragraph 3(d) of the Act; and
• other services not within the ambit of section 3 of the Act.

The majority of diagnostic 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.

Surgical-dental and other services not covered by the Surgical-Dental Program include the dentist's fee and the oral surgeon's or general practitioner's fees for routine dental extractions in a hospital.

The Medical Care Insurance Act, 1999 provides the Lieutenant-Governor in Council with the authority to make regulations prescribing which services are or are not insured services for the purpose of the Act.

3.0 Universality

3.1 Eligibility

There were 523,508 people registered with the program as of March 31, 2011. Residents of Newfoundland and Labrador are eligible for coverage under the Medical Care Insurance Act, 1999 and the Hospital Insurance Agreement Act. The Medical Care Insurance Act, 1999 defines a "resident" as a person lawfully entitled to be or to remain in Canada, who makes his or her home and is ordinarily present in the province, but does not include tourists, transients or visitors to the province.

The Medical Care Insurance Beneficiaries and Inquiries Regulations identify those residents eligible to receive coverage under the plans. MCP has established rules to ensure that the regulations are applied consistently and fairly in processing applications for coverage. 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.

Persons not eligible for coverage under the plans include: students and their dependants already covered by another province or territory; dependants of residents if covered by another province or territory; certified refugees and refugee claimants and their dependants; foreign workers with employment authorizations and their dependants who do not meet the established criteria; tourists, transients, visitors and their dependants; Canadian Forces and Royal Canadian Mounted Police (RCMP) personnel; inmates of federal prisons; and armed forces personnel from other countries who are stationed in the province. If the status of these individuals changes, they must meet the criteria for eligibility as noted above in order to become eligible.

3.2 Other Categories of Individual

Foreign workers, international students, clergy and dependants of North Atlantic Treaty Organization (NATO) personnel are eligible for benefits. Holders of Minister's permits are also eligible, subject to MCP approval.

4.0 Portability

4.1 Minimum Waiting Period

Insured persons 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 Forces and the RCMP, and individuals released from federal penitentiaries. For coverage to be effective, however, 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.

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 define 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.

Coverage is provided to residents during temporary absences within Canada. The Government of Newfoundland and Labrador has entered into formal agreements (i.e., 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 MCP rules regarding residency in Newfoundland and Labrador. A resident must reside in the province at least four consecutive months in each 12-month period to qualify as a beneficiary. Generally, the rules regarding medical and hospital care coverage during absences include the following:

• Before leaving the province for extended periods, a resident must contact the MCP to obtain an out-of-province coverage certificate.
• Beneficiaries leaving for vacation purposes may receive an initial out-of-province coverage certificate of up to 12 months. Upon return, beneficiaries are required to reside in the province for a minimum four consecutive months. Thereafter, certificates will only be issued for up to eight months of coverage.
• Students leaving the province may receive a certificate, renewable each year, provided they submit proof of full-time enrolment in a recognized educational institution located outside the province.
• Persons leaving the province for employment purposes may receive a certificate for coverage up to 12 months. Verification of employment may be required.
• Persons must not establish residence in another province, territory or country while maintaining coverage under the Newfoundland MCP.
• For out-of-province trips of 30 days or less, an out-of-province coverage certificate is not required, but will be issued upon request.
• For out-of-province trips lasting more than 30 days, a certificate is required as proof of a resident's ability to pay for services while outside the province.

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.

4.3 Coverage During Temporary Absences Outside Canada

The province provides coverage to residents during temporary absences outside Canada. Out-of-country insured hospital in- and out-patient services are covered for emergencies, sudden illness, and elective procedures at established rates. 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 government's hospitalization plan 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 hæmodialysis is $330 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. Physician services are paid at the same rate as would be paid in Newfoundland and Labrador for the same service. If the 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.

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 insurance plan will pay the costs of 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 the 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.

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. There are no co-insurance charges for insured hospital services and there is no extra-billing by physicians in the province.

The Department of Health and Community Services works closely with 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.

In 2010, a record investment of $2.7 billion was allocated for health operations, which signifies an increase of more than 10 percent over the previous year. This includes, investments in health care infrastructure totalling $208.9 million; investments for new construction and redevelopment totalling $125.1 million, $31.6 million for repairs and renovations and $52.2 million to purchase new medical equipment. Funding of $606,000 was also allocated to enhance the Medical Transportation Assistance Program.

The government continues its commitment to cancer care and treatment with the implementation of a new Provincial Colorectal Screening Program. The investment will amount to $4.3 million over a 3 year period. In preparation of this, the Government invested $190,000 in Budget 2010 to develop a provincial wait time strategy for endoscopy services. The strategy included a review of the current capacity within the system and its ability to meet the demands that the new Colorectal Cancer Screening program will generate.

Provincial wait time data for the period ending March 31, 2011, shows that residents of Newfoundland and Labrador are continuing to receive timely access to the majority of benchmark procedures. Patients continue to receive timely access to radiation treatment within the 28 day benchmark. Cardiac bypass patients are also receiving surgery within the recommended timeframes. Nearly eight out of 10 patients undergo cataract procedures within 112 days. Patients continue to access hip and knee replacement surgery within 182 days in three regions. While wait times for these procedures continue to be longer in St. John's, than elsewhere in the province, demand is also greatest there. To help address this, approximately $600,000 will be invested over two years to support the establishment of a central assessment clinic for patients awaiting hip and knee replacement in St. John's. These patients will now be triaged into three different groups: ready for surgery; needing additional services, such as pre-surgery physiotherapy or weight reduction; or, needing specialized medical care prior to surgery.

5.2 Physician Compensation

The legislation governing payments to physicians and dentists for insured services is the Medical Care Insurance Act, 1999. The current methods of remuneration to compensate physicians for providing insured health services include fee-for-service, salary, contract, and sessional block funding.

Compensation agreements are negotiated between the provincial government and the Newfoundland and Labrador Medical Association (NLMA), on behalf of all physicians. Representatives from the regional health authorities (RHAs) play a significant role in this process. A new Memorandum of Agreement was reached with the NLMA in December 2010, which increases overall physician compensation by approximately 26 percent. The Agreement expires on September 20, 2013. Physicians are paid via fee for service, salary or alternate payment plan (APP) with an increasing interest in APPs as a method of remuneration.

5.3 Payments to Hospitals

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

Throughout the fiscal year, the RHAs forwarded additional funding requests to the Department for any changes in program areas or increased workload volume. These requests were reviewed and, when approved by the Department, funded at the end of each fiscal year. Any adjustments to the annual funding level, such as for additional approved positions or program changes, were funded based on the implementation date of such increases and the cash flow requirements.

RHAs are continually facing challenges in addressing increased demands due to inflation and increased workload. Higher patient expectations and new technology are creating new demands for time, resources and funding. RHAs continue to work with the Department to address these issues and provide effective, efficient and quality health services.

6.0 Recognition Given to Federal Transfers

Funding provided by the federal government through the Canada Health Transfer (CHT) and the Canada Social Transfer (CST) 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 2010-2011, these documents include:

• the 2010-2011 Public Accounts;
• the Estimates 2010-2011; and
• the Budget Speech 2010.

The Public Accounts and Estimates, tabled by the Government in the House of Assembly, are publicly available and have been shared with Health Canada for information purposes.

Prince Edward Island

Introduction

In Prince Edward Island the Department of Health and Wellness is responsible for providing policy, strategic and fiscal leadership for the healthcare system.

Following an extensive health system review, the Health Services Act was enacted and subsequently proclaimed, which established regulatory and administrative frameworks for improvements to the healthcare system in Prince Edward Island by:

• mandating the creation of a provincial health plan;
• establishing mechanisms to improve patient safety and support quality improvement processes; and
• creating a Crown corporation ("Health PEI") to oversee the delivery of operational healthcare services.

Within this new governance structure Health PEI is responsible to:

• provide, or provide for the delivery of, health services;
• operate and manage health facilities;
• manage the financial, human and other resources necessary to provide health services and operate health facilities; and
• perform such other duties as the Minister may direct.

1.0 Public Administration

1.1 Health Insurance Plan and Public Authority

The Hospital Services Insurance Plan, under the authority of the Minister of Health and Wellness, is the vehicle for delivering hospital care insurance in Prince Edward Island. The enabling legislation is the Hospital and Diagnostic Services Insurance Act (1988). The Medical Services Insurance Plan provides for insured physician services under the authority of the Health Services Payment Act (1988). Together, the Plans insure services as defined under section 2 of the Canada Health Act.

The Department of Health and Wellness is responsible for providing policy, strategic and fiscal leadership for the healthcare system, while Health PEI is responsible for service delivery and the operation of hospitals, health centres, manors and mental health facilities. The Public Service Commission of PEI hires physicians, nurses and other health related workers.

1.2 Reporting Relationship

An annual report is submitted by the Department to the Minister responsible 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.

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 the province of Prince Edward Island. The public accounts of the province include the financial activities, revenues and expenditures of the Department of Health and Wellness. Public Accounts Volume I Consolidated Financial Statements was published in November 2010. Public Accounts Volume II Operating Fund Financial Statements, Details of Revenues and Expenditures, Financial Statements of Agencies and Crown Corporations was published in February 2011.

The provincial Auditor General, through the Audit Act, has the discretionary authority 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 (1988). The accompanying Regulations (1996) define the insured in- and out-patient hospital services available at no charge to a person who is eligible. Insured hospital services include: necessary nursing services; laboratory, radiological and other diagnostic procedures; accommodations and meals at a standard ward rate; formulary drugs, biologicals and related preparations prescribed by an attending physician and administered in hospital; operating room, case room and anaesthetic facilities; routine surgical supplies; and radiotherapy and physiotherapy services performed in hospital.

The process to add a new hospital service to the list of insured services involves extensive consultation and negotiation between the Department, Health PEI and key stakeholders. The process involves the development of a business plan which, when approved by the Minister, 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 (1988).

Insured physician services are provided by medical practitioners licensed by the College of Physicians and Surgeons. The total number of practitioners, including locums, who billed the Medical Services Insurance Plan as of March 31, 2011, was 399.

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 not participating physicians or practitioners and provide the patient with sufficient information to enable recovery of the cost of services from the Minister of Health and Wellness. 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, 2011, no physicians had opted out of the Medical Services Insurance Plan.

Any basic health services rendered by physicians that are medically required are covered by the Medical Services Insurance Plan. These include most physicians' services in the office, at the hospital or in the patient's home; medically necessary surgical services, including the services of anaesthetists and surgical assistants where necessary; obstetrical services, including pre- and post-natal care, newborn care or any complications of pregnancy such as miscarriage or caesarean section; certain oral surgery procedures performed by an oral surgeon when it is medically required, with prior approval that they be performed in a hospital; sterilization procedures, both female and male; treatment of fractures and dislocations; and certain insured specialist services, when properly referred by an attending physician.

The process to add a physician service to the list of insured services involves negotiation between the Department, Health PEI and the Medical Society. The process involves development of a business plan which, when approved by the Minister, would be taken to Treasury Board for funding approval. Cabinet has the final authority in adding new services.

2.3 Insured Surgical-Dental Services

Dental services are not insured under the Medical Services Insurance Plan. Only oral maxillofacial surgeons are paid through the Plan. There are currently two 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.

2.4 Uninsured Hospital, Physician and Surgical-Dental Services

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

• services that persons are eligible for under other provincial or federal legislation;
• mileage or travel, unless approved by Health PEI;
• advice or prescriptions by telephone, except anticoagulant therapy supervision;
• telephone consultation except by internists and orthopedic surgeons, provided the patient was not seen by that internist or orthopedic surgeon within 3 days of the telephone consult;
• examinations required in connection with employment, insurance, education, etc.;
• group examinations, immunizations or inoculations, unless prior approval is received from Health PEI;
• preparation of records, reports, certificates or communications, except a certificate of committal to a psychiatric, drug or alcoholism facility;
• testimony in court;
• travel clinic and expenses;
• surgery for cosmetic purposes unless medically required;
• dental services other than those procedures included as basic health services;
• dressings, drugs, vaccines, biologicals and related materials;
• eyeglasses and special appliances;
• chiropractic, podiatry, optometry, chiropody, osteopathy, naturopathy, and similar treatments;
• physiotherapy, psychology, audiology, and acupuncture except when provided in hospital;
• reversal of sterilization procedures;
• in vitro fertilization;
• services performed by another person when the supervising physician is not present or not available;
• services rendered by a physician to members of the physician's own household, unless approval is obtained from Health PEI; and
• any other services that the Department may, upon the recommendation of the negotiation process between the Department, Health PEI and the Medical Society, declare non-insured.

Provincial hospital services not covered by the Hospital Services Insurance Plan include private or special duty nursing at the patient's or family's request; preferred accommodation at the patient's request; hospital services rendered in connection with surgery purely for cosmetic reasons; personal conveniences, such as telephones and televisions; drugs, biologicals and prosthetic and orthotic appliances for use after discharge from hospital; and dental extractions, except in cases where the patient must be admitted to hospital for medical reasons with prior approval of Health PEI.

The process to de-insure services covered by the Medical Services Insurance Plan is done in collaboration with the Medical Society, Health PEI and the Department. No services were de-insured during the 2010-2011 fiscal year.

All Island residents have equal access to services. Third parties such as private insurers or the Workers' Compensation Board of Prince Edward Island 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 regulations, section 3, define eligibility for the Medical Services Insurance Plan. The Plan is designed to provide coverage for eligible Prince Edward Island 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 Prince Edward Island.

All new residents must register with the Department in order to become eligible. Persons who establish permanent residence in Prince Edward Island 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.

Residents who are ineligible for insured hospital and medical services coverage in Prince Edward Island are members of the Canadian Forces, Royal Canadian Mounted Police (RCMP), inmates of federal penitentiaries and those eligible for certain services under other government programs, such as Workers' Compensation or the Department of Veterans Affairs' programs.

Ineligible residents may become eligible in certain circumstances. Members of the Canadian Forces or RCMP 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 released 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.

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

New or returning residents must apply for health coverage by completing a registration application from the Department. 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. 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 in Prince Edward Island as of March 31, 2011, was 146,049.

3.2 Other Categories of Individual

Foreign students, temporary workers, refugees and Minister's Permit holders are not eligible for health and medical coverage.

4.0 Portability

4.1 Minimum Waiting Period

Insured persons who move to Prince Edward Island 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

Persons absent each year for winter vacations and similar situations involving regular absences must reside in Prince Edward Island 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 5(1)(e) of the Health Services Payment Act.

The term "temporarily absent" is defined as a period of absence from the province for up to 182 days in a 12 month period, where the absence is for the purpose of a vacation, a visit or a business engagement. Persons leaving the province under the above circumstances must notify the Registration Department before leaving.

Prince Edward Island participates in the Hospital Reciprocal Billing Agreement and the Medical Reciprocal Billing Agreement 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 Canada, as allowed under section 5(1)(e).

Insured residents may be temporarily out of the country for a 12 month period one time only. Students attending a recognized learning institution in another country must provide proof of enrolment from the educational institution on an annual basis. Students must notify the Registration Department upon returning from outside the country.

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

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

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 Prince Edward Island physician. Full coverage may be provided for (Prince Edward Island 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 hospital and medical services insurance plans provide services on uniform terms and conditions on a basis that does not impede or preclude reasonable access to those services by insured persons.

Prince Edward Island 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 teleradiology program initiated in 2009 to help reduce wait times for diagnostic imaging in Prince Edward Island continued until January 2011. The addition of new digital mammography units last year has now been enhanced with a new centralized phone number and booking system that is being installed. Hours of service at screening sites have also been increased, which should result in a significant reduction in wait times for the provincial breast screening program.

Prince Edward Island implemented the first phase of a three-phased provincial organized stroke care model in April of 2010. This model promotes a coordinated approach to early assessment, mobilization and rehabilitation for every patient who can benefit. This first phase created a Provincial Stroke Care Coordinator position; instituted an acute in-patient stroke unit and stroke rehabilitation unit at the Queen Elizabeth Hospital; and created provincial secondary prevention services at Prince County Hospital.

This past year hemodialysis services were enhanced across the province. A new provincial Cancer Patient Navigation program was also implemented, providing necessary support and assistance to cancer patients and their families in navigating the health-care system.

The major multi-year redevelopment project at our provincial referral hospital reached several significant milestones this past year. The new Emergency Department at the Queen Elizabeth Hospital opened in June 2010. In addition, construction began on the Ambulatory Care Centre at the Queen Elizabeth Hospital.

Over the past twelve months the new Health Centre in O'Leary opened which provides enhanced health care services to surrounding communities. Also, as part of a manor replacement strategy construction began on new manors in Alberton and Souris.

The PEI Family Medicine Residency Program has provided ongoing training opportunities to medical school graduates who are training as family physicians. The intent is to better integrate our medical students so that they will want to stay and practice in the province. The first five family medicine residents began in their two year training program on the Island in June 2009, with five new residents each year thereafter, bringing full complement of family medical residents to ten.

As PEI is primarily a rural province where a large segment of the population resides outside the main service centres, local access to health services, including acute services delivered through community hospitals and health centres, is important to small communities. Prince Edward Island continues to expand health infrastructure necessary to support health service delivery in rural communities.

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 three year Physician Master Agreement between the PEI Medical Society, on behalf of Island physicians, and the provincial government, was effective April 1, 2007 to March 31, 2010. It remains in effect until a new agreement is reached.

The legislation governing payments to physicians and dentists for insured services is the Health Services Payment Act.

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 growing and seem to be the preference for new graduates. Currently, 67 percent of PEI's complement of physicians (excluding locums and visiting specialists) are compensated under an alternate payment method (non-fee-for-service) as their primary means of remuneration.

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 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 2010-2011 Annual Budget and in the 2010-2011 Public Accounts, which both 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 its 2010-2011 Annual Report.

Nova Scotia

Introduction

On January 12, 2011, the Departments of Health and Health Promotion and Protection merged into the Department of Health and Wellness to provide better health care to Nova Scotians. The merger served to streamline operations and ensure better integration between the prevention and treatment sides of health care. The Nova Scotia Department of Health and Wellness mission is, "Working together to empower individuals, families, partners, and communities to promote, improve, and maintain the health of Nova Scotians through a proactive and sustainable health system." This will further the collaborative effort to promote and protect health, prevent illness and injury, and reduce disparities in health status.

The Health Authorities Act, Chapter 6 of the Acts of 2000, established the province's nine district health authorities (DHAs) and their community-based supports, community health boards (CHBs). DHAs are responsible for governing, planning, managing, delivering and monitoring health services within each district, and for providing planning support to the CHBs. Services delivered by the DHAs include acute and tertiary care, mental health, and addictions.

The province's thirty-seven CHBs develop community health plans with primary health care and health promotion as their foundation. DHAs draw two thirds of their board nominations from CHBs. Their community health plans are part of the DHAs' annual business planning process. In addition to the nine DHAs, the IWK Health Centre continues to have separate board, administrative and service delivery structures.

The Department of Health and Wellness is responsible for setting the strategic direction and standards for health services; ensuring availability of quality health care; monitoring, evaluating and reporting on performance and outcomes; and funding health services. The Department of Health and Wellness is directly responsible for physician and pharmaceutical services, emergency health, continuing care, and many other insured and publicly funded health programs and services.

Nova Scotia faces a number of challenges in the delivery of health care services. Nova Scotia's population is aging. Approximately 16% of the Nova Scotian population is sixty-five or over and this figure is expected to reach 24.3% by 2026. In response to the needs of the aging population, Nova Scotia has expanded its basket of publicly insured services to include home care, longterm care, and enhanced pharmaceutical coverage. Nova Scotia also has much higher than average rates of chronic diseases such as cancers and diabetes which contribute to the rising costs of health care delivery in Nova Scotia.

Despite these ever increasing pressures and challenges, Nova Scotia continues to be committed to the delivery of medically necessary 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 at www.gov.ns.ca/DHW.

1.0 Public Administration

1.1 Health Care Insurance Plan and Public Authority

Two plans cover insured health services in Nova Scotia: the Hospital Services Insurance (HSI) and the Medical Services Insurance (MSI) Plan. The Department of Health and Wellness administers the HSI Plan, which operates under the Health Services and Insurance Act, Chapter 197, Revised Statutes of Nova Scotia, 1989: sections 3(1), 5, 6, 10, 15, 16, 17(1), 18 and 35.

The MSI is administered and operated by an authority consisting of the Department of Health and Wellness and Medavie Blue Cross (formerly called Atlantic Blue Cross), under the above-mentioned Act (sections 8, 13, 17(2), 23, 27, 28, 29, 30, 31, 32 and 35).

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

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

1.2 Reporting Relationship

Medavie is obliged to provide reports to the Department under various Statements of Requirements for each Business Service Description as listed in the contract. Medavie is audited every year on various areas of reporting. Every year there is a compliance audit.

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.

1.3 Audit of Accounts

The Auditor General audits all expenditures of the Department of Health and Wellness. The Department of Health and Wellness has a service level agreement in place with Medavie Blue Cross. An annual audit is performed on this agreement, including Medicare, Pharmacare and Health Card Registration, which has been recommended by the Auditor General's office.

All long-term care facilities, home care and home support agencies are required to provide the Department with annual audited financial statements.

Under section 34(5) of the Health Authorities Act, every hospital board is required to submit to the Minister of Health and Wellness, by July 1^st each year, an audited financial statement for the preceding fiscal year.

1.4 Designated Agency

Medavie Blue Cross Care administers and has the authority to receive monies to pay physician accounts under a service level agreement with the Department of Health and Wellness. Medavie Blue Cross Care receives written authorization from the Department for the physicians to whom it may make payments. The rates of pay and specific amounts depend on the physician contract negotiated between Doctors Nova Scotia and the Department of Health and Wellness.

All Medavie Blue Cross Care system development for MSI and Pharmacare is controlled through a joint committee. All MSI and Pharmacare transactions are subject to a review by the Office of the Auditor General.

2.0 Comprehensiveness

2.1 Insured Hospital Services

Nine district health authorities and the IWK Health Centre (Women and Children's Tertiary Care Hospital) deliver insured hospital services to both in- and out-patients in Nova Scotia.

Accreditation is not mandatory, but all facilities are accredited at a facility or district level. The enabling legislation that provides for insured hospital services in Nova Scotia is the Health Services and Insurance Act, Chapter 197, Revised Statutes of Nova Scotia, 1989: sections 3(1), 5, 6, 10, 15, 16, 17(1), 18 and 35, passed by the Legislature in 1958. Hospital Insurance Regulations were made pursuant to the Health Services and Insurance Act.

Insured in-patient services include:

• accommodation and meals at the standard ward level;
• necessary nursing services;
• laboratory, radiological and other diagnostic procedures;
• drugs, biologicals and related preparations, when administered in a hospital;
• routine surgical supplies;
• use of operating room(s), case room(s) and anaesthetic services;
• use of radiotherapy and physiotherapy services for inpatients, where available; and
• blood or therapeutic blood fractions.

Out-patient services include:

• laboratory and radiological examinations;
• diagnostic procedures involving the use of radio-pharmaceuticals;
• electroencephalographic examinations;
• use of occupational and physiotherapy facilities, where available;
• necessary nursing services;
• drugs, biologicals and related preparations;
• blood or therapeutic blood fractions;
• hospital services in connection with most minor medical and surgical procedures;
• day-patient diabetic care;
• services provided by the Nova Scotia Hearing and Speech Clinics, where available;
• ultrasonic diagnostic procedures;
• home parenteral nutrition, where available; and
• haemodialysis and peritoneal dialysis, where available.

In order to add a new hospital service to the list of insured hospital services, district health authorities are required to submit a New and/or Expanded Program Proposal^{Footnote 7} to the Department of Health and Wellness. This process is carried out annually by request through the business planning process. A Department-developed process format is forwarded to the districts for their guidance. A Department working group reviews and prioritizes all requests received. Based on available funding, a number of top priorities may be approved by the Minister of Health and Wellness.

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.

As of March 31, 2011, 2,434 physicians and 26 dentists were paid through the Medical Services Insurance (MSI) Plan.

Physicians retain the ability to opt in or out of the MSI Plan. In order to opt out, a physician notifies MSI, relinquishing his or her billing number. MSI reimburses patients who pay the physician directly due to opting out. As of March 31, 2011, no physicians had opted out.

Insured services include those that are medically necessary. Medically necessary may be defined as services provided by a physician to a patient with the intent to diagnose or treat physical or mental disease or dysfunction, as well as those services generally accepted as promoting health through prevention of disease or dysfunction. Services that are not medically necessary are not insured. Services explicitly deemed as non-insured under the Health Services and Insurance Act or its regulations remain uninsured regardless of individual judgments regarding the medical necessity.

Services were added to the list of insured physician services in 2010-2011. A complete list can be obtained from the Nova Scotia Department of Health and Wellness. On an as needed basis, new specific fee codes are approved that represent enhancements, new technologies or new ways of delivering a service.

The addition of new fee codes to the list of insured physician services is accomplished through a collaborative Department of Health and Wellness/District Health Authority/ Doctors Nova Scotia (DHW/DHA/DNS) committee structure. Physicians wishing to have a new fee code added to the MSI Manual submit a formal application to the Fee Schedule Advisory Committee (FSAC) for review. Each request is thoroughly researched. FSAC then makes a recommendation to the Master Agreement Steering Group (MASG) which either approves or denies the proposal. The MASG Committee is comprised of equal representation from Doctors Nova Scotia and the Department of Health and Wellness. 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.

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 and must also be certified competent in the practice of dental surgery. The Health Services and Insurance Act is so written that a dentist may choose not to participate in the MSI Plan. To participate, a dentist must register with MSI. A participating dentist who wishes to reverse election to participate must advise MSI in writing and is then no longer eligible to submit claims to MSI. In 2010-2011, 26 dentists were paid through the MSI Plan for providing insured surgical-dental services.

Insured surgical-dental services must be provided in a health care facility. Insured services are detailed in the Department of Health and Wellness MSI Dentist Manual (Dental Surgical Services Program) and are reviewed annually through the Acute and Tertiary Care Branch as required by Insured Dental Services Tariff Regulations. Services under this program are insured when the conditions of the patient are such that it is medically necessary for the procedure to be done in a hospital and the procedure is of a surgical nature. Generally included as insured surgical-dental services are orthognathic surgery, surgical removal of impacted teeth, and oral and maxillary facial surgery. Requests for an addition to the list of surgical-dental services are accomplished by first approaching the Dental Association of Nova Scotia and having them put forward a proposal to the Department of Health and Wellness for the addition of a new procedure. The Department of Health and Wellness, in consultation with specific experts in the field, renders the decision as to whether or not the new procedure becomes an insured service.

"Other extraction services" (routine extractions) at public expense were approved for the following groups of patients: 1) cardiac patients, 2) transplant patients, 3) immunocompromised patients, and 4) radiation patients. Routine extractions for these patients will be provided at public expense when and only when patients are undergoing active treatment in a hospital setting and the attendant medical procedure must require the removal of teeth that would otherwise be considered routine extractions and not paid at public expense. It is vital to the claims approval process that the dental treatment plans include the name of the medical specialist providing the care and that he/she has indicated in writing in the patient's medical treatment plan that the routine dental extractions are required prior to performing the medical treatment/procedure.

2.4 Uninsured Hospital, Physician and Surgical-Dental Services

Uninsured hospital services include:

• preferred accommodation at the patient's request;
• telephones;
• televisions;
• drugs and biologicals ordered after discharge from hospital;
• cosmetic surgery;
• reversal of sterilization procedures;
• surgery for sex reassignment;
• in-vitro fertilization;
• procedures performed as part of clinical research trials;
• services such as gastric bypass for morbid obesity, breast reduction/augmentation and newborn circumcision;^{Footnote 8} and
• services not deemed medically necessary that are required by third parties, such as insurance companies.

Uninsured physician services include:

• services eligible for coverage under the Workers' Compensation Act or under any other federal or provincial legislation;
• mileage, travel or detention time;
• telephone advice or telephone renewal of prescriptions;
• examinations required by third parties;
• group immunizations or inoculations unless approved by the Department;
• preparation of certificates or reports;
• testimony in court;
• services in connection with an electrocardiogram, electromyogram or electroencephalogram, unless the physician is a specialist in the appropriate specialty;
• cosmetic surgery;
• acupuncture;
• reversal of sterilization; and
• in-vitro fertilization.

Major third party agencies purchasing medically necessary health services in Nova Scotia include Workers' Compensation, Department of National Defence, and the Royal Canadian Mounted Police.

All residents of the province are entitled to services covered under the Health Services and Insurance Act. If enhanced goods and services, such as foldable intraocular lens or fiberglass casts, are offered as an alternative, the specialist/physician is responsible to ensure that the patient is aware of their responsibility for the additional 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 of Health and Wellness also carefully reviews all patient complaints or public concerns that may indicate that the general principles of insured services are not being followed.

The de-insurance of insured physician services is accomplished through a negotiation process between the Doctors Nova Scotia and the Physician Services Branch of the Department of Health and Wellness, who jointly evaluate a procedure or process to determine whether the services should remain an insured benefit. If a process or procedure is deemed not to be medically necessary, 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 process applies to dental and hospital 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 his or her home and is ordinarily present in Nova Scotia.

A person is considered to be "ordinarily present" in Nova Scotia if the person:

• makes his or her permanent home in Nova Scotia;
• is physically present in Nova Scotia for at least 183 days in any calendar year (short term absences under 30 days, within Canada, are not monitored); and
• is a Canadian citizen or "Permanent Resident" as defined by Citizenship and Immigration Canada.

Persons moving to Nova Scotia from another Canadian province will normally be eligible for Medical Services Insurance (MSI) 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 Citizenship and Immi­gration Canada.

Members of the RCMP, members of the Canadian Forces, and federal inmates are ineligible for MSI coverage. When their status changes, they immediately become eligible for provincial Medicare.

There were no changes to eligibility requirements in 2010-2011.

In 2010-2011, the total number of residents registered with the health insurance plan was 988,585.

3.2 Other Categories of Individuals

The following persons may also be eligible for insured health care services in Nova Scotia once they meet the specific eligibility criteria for their situations:

Immigrants: Persons moving from another country to live permanently in Nova Scotia are eligible for health care on the date of arrival. They must possess a landed immigrant document. These individuals, formerly called "landed immigrants," are now referred to as "Permanent Residents."

Convention Refugees and Non-Canadians married to Canadian Citizens/Permanent Residents (copy of Marriage Certificate required), who possess any other document and who have applied within Canada for Permanent Resident status, will be eligible on the date of application for Permanent Resident status, provided they possess a letter or documentation from Citizenship and Immigration Canada stating that they have applied for Permanent Residence.

Non-Canadians married to Canadian Citizens/Permanent Residents (copy of Marriage Certificate required), who possess any other document and who have applied outside Canada for Permanent Resident status, will be eligible on the date of arrival, provided they possess a letter or documentation from Citizenship and Immigration Canada stating that they have applied for Permanent Residence.

In 2010-2011, there were 31,314 Permanent Residents registered with the health care insurance plan.

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, providing 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, except 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.

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 him/her or their dependents.

In 2010-2011, there were 2,946 individuals with Employment Authorizations covered under the health care insurance plan.

Study Permits: Persons moving to Nova Scotia from another country and who possess a Study Permit 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, except 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 2010-2011, there were 1,123 individuals with Student Authorizations covered under the health care insurance plan.

Refugees: Refugees are eligible for MSI if they possess either a work permit or study permit.

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 (MSI) 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 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 attendance 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 full-time students. 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, territory or country. 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 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. The total amount paid by the plan in 2010-2011 for in- and out-patient hospital services received in other provinces and territories was $24,592,207.

Nova Scotia pays the host province rates for insured services in all reciprocal billing situations.

There were no changes made in Nova Scotia in 2010-2011 regarding in-Canada portability.

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 the province. Ordinarily, to be eligible for coverage, residents must not be outside the country for more than six months in a calendar year. In order to be covered, procedures of a non-emergency nature must have prior approval before they will be covered by MSI.

Students and their dependants who are temporarily absent from Nova Scotia and in full-time 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 volunteer/missionary work/research) outside Canada which does not exceed 24 months are still covered by MSI, providing the person has already met the residency requirements.

Emergency out-of-country services are 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. There were no changes made in Nova Scotia in 2010-2011 regarding out-of-Canada portability. The total amount spent in 2010-2011 for insured in-patient services provided outside of Canada was $788,368.

4.4 Prior Approval Requirement

Prior approval must be obtained for elective services outside the country. Application for prior approval is made to the Medical Director 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.

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 on 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.

Nova Scotia continually reviews access situations across Canada to ensure equity of access. In areas where improvement is deemed necessary, depending on the province's financial situation, extra funding is generally allocated to that need.

In December 2010 the province announced the Better Care Sooner plan. The plan will improve the quality of emergency care, reduce overcrowding and wait times for patients in emergency rooms, and provide better health care for families. This will be done through several focus areas, including better access to health professionals, streamlines patient-centred emergency care, better care for seniors and other patients with complex needs, greater awareness of emergency telephone number (911) and the HealthLink 811, and funding for performance and quality of care.

The Department has worked with system partners to address several other areas of health care access. This has included establishing an intermediate care unit, new rapid assessment unit, and new medicine beds for Capital District Health Authority. Nova Scotia will also be expanding pre-hab services to three more sites in the province, and expanded of full-field mammography at eleven fixed sites. There was also the establishment of shared stroke units in Pictou County Health Authority and Guysborough Antigonish District Health Authority, as well as Colchester East Hants Health Authority and Cumberland Health Authority.

Access to Insured Physician and Surgical-Dental Services

In 2010-2011, 2434 physicians and 26 dentists actively provided insured services under the Canada Health Act or provincial legislation. Innovative funding solutions such as block funding and personal services contracts have enhanced recruitment.

The province has increased the capacity for medical education for both Canadian medical students and internationally educated physicians, coordinates ongoing recruitment activities, and has provided funding to create a re-entry program for general practitioners wishing to enter specialty training after completing two years of general practice service in the province.

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 and the Nova Scotia Department of Health and Wellness. Doctors Nova Scotia is recognized as the sole bargaining agent in support of physicians in the province. When negotiations take place, representatives from Doctors Nova Scotia and the Department of Health and Wellness negotiate the total funding and other terms and conditions. The agreement lays out what the medical services unit value will be for physician services and addresses other issues such as the Canadian Medical Protective Association, membership benefits, emergency department payments, on-call funding, specific fee adjustments, dispute resolution processes, and other process or consultation issues.

Fee-for-service is still the most prevalent method of payment for physician services. However, there has been significant growth in the number of alternative payment arrangements in place in Nova Scotia. In the 1997-1998 fiscal year, about 9 percent of doctors were paid solely through alternative funding. In 2010-2011, approximately 26 percent of physicians were remunerated exclusively through alternative funding. Approximately 67 percent of physicians in Nova Scotia receive all or a portion of their remuneration through alternative funding mechanisms.

Alternative funding plans can be broken down into three groups:

1. Academic Funding Plan (these physicians are mainly located in Halifax at the Queen Elizabeth II Health Sciences Centre (QEII) and the IWK Health Centre (IWK)) -- Most of the Academic Specialist groups are on academic funding arrangements with the exception of Urology, QEII and IWK Radiology, IWK Obstetrics & Gynaecology, Ophthalmology and Nephrology.
2. Currently there are regional specialist contracts for anaesthesiology, geriatrics, neonatology, paediatrics, obstetrics/gynaecology, and palliative care.
3. There are also contract arrangements available to general practitioners in certain rural areas and general practitioner/nurse practitioner contracts that support collaborative practice teams in designated areas.

In 2010-2011, total payments to physicians for insured services in Nova Scotia were $661,968,168. The Department of Health and Wellness paid an additional $7,426,414 for insured physician services provided to Nova Scotia residents outside the province, but within Canada.

Payment rates for dental services in the province are negotiated between the Department of Health and Wellness and the Nova Scotia Dental Association, and follow a process similar to physician negotiations. Dentists are paid on a fee-for-service basis. The agreement expired on March 31, 2011 and negotiations are underway for contract renewal.

5.3 Payments to Hospitals

The Department of Health and Wellness establishes budget targets for health care services. It does this by receiving business plans from the nine (9) district health authorities (DHAs), the IWK Health Centre and other non-DHA organizations. Approved provincial estimates form the basis on which payments are made to these organizations for service delivery.

The Health Authorities Act was given Royal Assent on June 8, 2000. The Act instituted the nine DHAs & the IWK that replaced the former regional health boards. The DHAs/IWK are responsible (section 20 of the Act) for overseeing the delivery of health services in their districts, and are fully accountable for explaining their decisions on the community health plans through their business plan submissions to the Department of Health and Wellness.

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 to hospitals for insured hospital services.

In 2010-2011, there were 2960 hospital beds in Nova Scotia (3.1 beds per 1,000 population). Department of Health and Wellness direct expenditures for insured hospital services operating costs were increased to $1.56 billion.

6.0 Recognition Given to Federal Transfers

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

The Government of Nova Scotia also recognized the federal contribution under the CHT in various published documents, including the following documents released in 2010-2011:

• Public Accounts 2010-2011; and
• Budget Estimates and Supplementary Detail 2011-2012.

New Brunswick

Introduction

Through effective leadership and collaboration, New Brunswick's health care system continued to provide excellent and trusted care to the public it served during 2010-2011, while remaining committed to the principles of public administration, comprehensiveness, universality, portability and accessibility in health care services--the principles that form the foundation of the Canada Health Act.

For information about the Ministry's programs and services, please visit  the Ministry of Health website at http://www.gnb.ca/0051/index-e.asp

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") is responsible 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 what Medicare services are covered and which are excluded. It also stipulates the type of agreements the Department may enter into with provinces and territories and with the New Brunswick Medical Society. 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--Insured Services Branch and the Medicare--Eligibility and Claims 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 (RHAs) and sets forth the powers, duties and responsibilities of 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 RHAs.

1.3 Audit of Accounts

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

1. 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 he or she sees fit.
2. 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.
3. The Department's Internal Audit Branch was established to independently review and evaluate departmental activities as a service to all levels of management.

2.0 Comprehensiveness

2.1 Insured Hospital Services

Legislation providing for insured hospital services 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 in-patient and out-patient hospital services.

Insured in-patient services include: accommodation and meals; nursing; laboratory/diagnostic procedures; drugs; the use of facilities (e.g. surgical, radiotherapy, physiotherapy); and services provided by professionals within the facility.

Insured out-patient services include: laboratory and diagnostic procedures; mammography; and the hospital component of available out-patient services for maintaining health, preventing disease and helping diagnose/treat any injury, illness or disability, excluding those related to the provision of drugs or third party diagnostic requests.

2.2 Insured Physician Services

The Medical Services Payment Act and corresponding regulations provide for insured physician services. As of March 31, 2011 there were 1588 physicians in New Brunswick. No physicians rendering health care services have elected to completely opt out of the New Brunswick Medical Services Plan. When a physician opts out of Medicare, they must complete the specified Medicare claim form and indicate the amount charged to the patient. The beneficiary then seeks reimbursement by certifying the claim form that the services have been received and forward the claim form to Medicare. The charges must not exceed the Medicare tariff. If the charges are in excess of the Medicare tariff, the practitioner must inform the beneficiary before rendering the service that:

• they have opted out and charge fees above the Medicare tariff;
• in accepting services under these conditions, the patient waives all rights to Medicare reimbursement;
• the patient is entitled to seek services from another practitioner who participates in the Medical Services Plan; and
• the physician must obtain a signed waiver from the patient on the specified form and forward the form to Medicare.

The services entitled under Medicare include:

1. the medical portion of all services rendered by medical practitioners that are medically required and;
2. certain surgical-dental procedures when performed by a physician or a dental surgeon in a hospital facility.

An individual, a physician or the Department may request the addition of a new service. All requests are considered by the New Service Items Committee, which is jointly managed by the New Brunswick Medical Society and the Department. The decision to add a new service is usually based on conformity to "medically necessary" and whether the service is considered generally acceptable practice (not experimental) within New Brunswick and 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.

No services were added during this reporting period.

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/discharge patients and perform physical examinations, including those performed in an out-patient setting.

As of March 31, 2011, there were 99 OMSs and dentists registered in New Brunswick OMSs and dentists have the same opting out provision as physicians (see section 2.2) and must follow the same guidelines. The Department has no data for the number of non-enrolled dental practitioners in New Brunswick.

2.4 Uninsured Hospital, Physician and Surgical-Dental Services

Uninsured hospital services include: patent medicines; take-home drugs; third-party requests for diagnostic services; visits to administer drugs; vaccines; sera or biological products; televisions and telephones; preferred accommodation at the patient's request; and hospital services directly related to services listed under Schedule 2 of the Regulation under the Medical Services Payment Act. Services are not insured if provided to those entitled under other statutes.

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:

• elective plastic surgery or other services for cosmetic purposes;
• correction of inverted nipple;
• breast augmentation;
• otoplasty for persons over the age of eighteen;
• removal of minor skin lesions, except where the lesions are, or are suspected to be pre-cancerous;
• abortion, unless the abortion is performed by a specialist in the field of obstetrics and gynaecology in a hospital facility approved by the jurisdiction in which the hospital facility is located and two medical practitioners certify in writing that the abortion was medically required;
• surgical assistance for cataract surgery unless such assistance is required because of risk of procedural failure, other than risk inherent in the removal of the cataract itself, due to existence of an illness or other complication;
• medicines, drugs, materials, surgical supplies or prosthetic devices;
• vaccines, serum, drugs and biological products listed in sections 106 and 108 of New Brunswick Regulation 88-200 under the Health Act;
• advice or prescription renewal by telephone which is not specifically provided for in the Schedule of Fees;
• examination of medical records or certificates at the request of a third party, or other services required by hospital regulations or medical by-laws;
• dental services provided by a medical practitioner or an oral and maxillofacial surgeon;
• services that are generally accepted within New Brunswick as experimental or that are provided as applied research;
• services that are provided in conjunction with, or in relation to, the services referred to above;
• testimony in a court or before any other tribunal;
• immunization, examinations or certificates for purpose of travel, employment, emigration, insurance or at the request of any third party;
• services provided by medical practitioners or oral and maxillofacial surgeons to members of their immediate family;
• psychoanalysis;
• electrocardiogram (E.C.G.) where not performed by a specialist in internal medicine or paediatrics;
• laboratory procedures not included as part of an examination or consultation fee;
• refractions;
• services provided within the province by medical practitioners, oral and maxillofacial surgeons or dental practitioners for which the fee exceeds the amount payable under regulation;
• the fitting and supplying of eye glasses or contact lenses;
• trans-sexual surgery;
• radiology services provided in the province by a private radiology clinic;
• acupuncture;
• complete medical examinations when performed for the purposes of periodic check-up and not for medically necessary purposes;
• circumcision of the newborn;
• reversal of vasectomies;
• second and subsequent injections for impotence;
• reversal of tubal ligations;
• intrauterine insemination;
• bariatric surgery unless the person has a body mass index of 40 or greater or of 35 or greater but less than 40, as well as obesity-related comorbid conditions;
• venipuncture for purposes of taking blood when performed as a stand-alone procedure in a facility that is not an approved hospital facility.

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 (i.e., enhanced medical goods and services such as intraocular lenses, fibreglass casts, etc.), provided in conjunction with an insured health service, do not compromise reasonable access to insured services. Intraocular lenses are now provided by the hospitals.

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 2010-2011, no services were removed from the insured service 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 to provide proof of Canadian citizenship, Native status or a valid Canadian immigration document. A resident is defined as a person lawfully entitled to be, or to remain, in Canada, who makes his or her home and is ordinarily present in New Brunswick, but does not include a tourist, transient, or visitor to the province. As of March 31, 2011, there were 748,352 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:

1. In June 2010, Regulation 84-20 under the Medical Services Payment Act was amended to state that dependents of Canadian Armed Forces personnel or their spouses moving from within Canada to New Brunswick will now be entitled to first day coverage under the program, provided they are deemed to have established permanent residence in New Brunswick.
2. In June 2010, Regulation 84-20 under the Medical Services Payment Act was amended to state that immigrants or Canadian residents moving or returning to New Brunswick will now be entitled to first day coverage, provided they are deemed to have established permanent residence in the province. Proper documentation is required (immigration and citizenship documentation) and decisions on coverage/residency are reviewed on a case-by-case basis.

Residents who are not eligible for Medicare coverage include:

• regular members of the Canadian Armed Forces;
• members of the Royal Canadian Mounted Police;
• inmates at federal institutions;
• temporary residents;
• a family member who moves from another province to New Brunswick before other family members move;
• persons who have entered New Brunswick from another province to further their education and who are eligible to receive coverage under the medical services plan of that province; and
• non-Canadians who are issued certain types of Canadian authorization permits (e.g., a Student Authorization).

Provisions to become eligible for Medicare coverage include:

• Non-Canadians who are issued an immigration permit that would not normally entitle them to coverage are eligible if legally married to, or in a common-law relationship with, a New Brunswick resident.

Provisions when status changes include:

• Persons who are discharged or released from the Canadian Armed Forces, the RCMP or a federal penitentiary. Provided they are residing in New Brunswick when discharged/released, these persons become eligible for coverage on the date of their discharge/release. An application must be completed, and the official date of release and proof of citizenship must be provided.

3.2 Other Categories of Individual

Non-Canadians who may be issued an immigration permit that would not normally entitle them to Medicare coverage are eligible provided that they are legally married to, or living in a common-law relationship with an eligible New Brunswick resident and still possess a valid immigration permit. At the time of renewal, they are required to provide an updated immigration document.

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 residence has been established. The three month waiting period is legislated under New Brunswick's Medical Services Payment Act and no exemptions can be made.

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).

Medicare coverage is extended in the case of temporary absences to:

• students in full time attendance at an educational institution outside New Brunswick;
• residents temporarily working in another jurisdiction; and
• residents whose employment requires them to travel outside the province.

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 twelve month period that is renewable, provided the following terms are met:

• proof of enrolment is provided;
• Medicare is contacted once every twelve months;
• permanent residence is not established outside New Brunswick; and
• health coverage is not received elsewhere.

Residents

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

• permanent residence is not established outside New Brunswick; and
• health coverage is not received elsewhere.

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 "temporarily absent" New Brunswick residents is determined in accordance with the Medical Services Payment Act and regulations and the Interprovincial Agreement on Eligibility and Portability.

Residents temporarily employed outside Canada are granted coverage for up to twelve months (regardless if it is known beforehand that they will be absent beyond the twelve month period), provided they do not establish residence outside Canada.

Any absence over one hundred and eighty-two days, whether it is for work purposes or vacation, would require the Director's approval. This approval can only be up to twelve months in duration and will only be granted once every three years. Families of workers temporarily employed outside Canada will continue to be covered, provided they reside in New Brunswick.

New Brunswick residents who exceed the twelve month extension have to reapply for New Brunswick Medicare upon their return to the province, and be subject to the legislated three month waiting period. However, a "grace period" of up to fourteen days may be extended to those residents who have been "temporarily absent" slightly beyond the twelve month period.

Mobile Workers

Mobile Workers are residents whose employment requires them to travel outside the province (e.g., pilots, truck drivers, etc.). Certain guidelines must be met to receive Mobile Worker designation. They are as follows:

• an application is to be submitted in writing;
• documentation is required as proof of Mobile Worker status (e.g., letter from employer confirming that frequent travel is necessary outside the province; a letter from the resident detailing their permanent residence as New Brunswick and the frequency of their return to the province; a copy of their New Brunswick driver's license; if working outside Canada, a copy of resident's immigration documents that allow them to work outside the country); and
• the worker must return to New Brunswick during their off-time.

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:

• a letter of request from the New Brunswick resident with their signature, detailing their absence, including Medicare number, address, departure and return dates, destination, forwarding address, and reason for absence; and
• a copy of a contractual agreement between employee and employer indicating start and end dates of employment.

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 twelve month period that is renewable, provided they comply with the following:

• proof of enrolment be provided;
• contact Medicare once every twelve months to retain eligibility;
• permanent residence is not established outside New Brunswick; and
• health coverage is not received elsewhere.

Insured residents who receive insured emergency services out-of-country are eligible to be reimbursed $100 per day for in-patient stay 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.

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, those who receive such services will assume responsibility for 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:

• the required service/equivalent or alternate service must not be available in Canada;
• the service must be rendered in a hospital listed in the current edition of the American Hospital Association Guide to the Health Care Field (guide to United States hospitals, health care systems, networks, alliances, health organizations, agencies and providers);
• the service must be rendered by a medical doctor; and
• the service must be an accepted method of treatment recognized by the medical community and be regarded as scientifically proven in Canada. Experimental procedures are not covered.

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.

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 the Canadian Medical Network on the province's behalf.

The following are considered exemptions under the out-of-country coverage policy:

• haemodialysis: patients will be required to obtain prior approval and Medicare will reimburse the resident at a rate equivalent to the inter-provincial rate of $472 per session; and
• allergy testing for environmental sensitivity: all tests outside the country will be paid at a maximum rate of $50 per day, an amount equivalent to an out-patient visit.

Prior approval is also required to refer patients to psychiatric hospitals and addiction centres outside the province because they are excluded from the Interprovincial Reciprocal Billing Agreement. A request for prior approval must be received by Medicare from the Addiction Services or Mental Health branches of the Department of Health.

5.0 Accessibility

5.1 Access to Insured Health Services

New Brunswick's health care system delivers quality care to the public it serves. New Brunswick does not charge user fees for insured health services as defined by the Canada Health Act. Therefore, all residents of New Brunswick have equal access to these services

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

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 or alternate payment mechanisms that may also 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 Services 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 (RHAs) 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, laundry, food services, etc.). Funding for the Extra-Mural Program (home care) is also part of the RHA base.

Funding for FacilicorpNB, a shared services agency that manages the information technology, materials management 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/services are submitted to the Deputy Minister of Health for approval. Funding for approved new programs/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 routinely 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.

Quebec

1.0 Public Administration

1.1 Health Care 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 insurance plan, the Régime d'assurance maladie du Québec, is administered by the Régie de l'assurance maladie du Québec (Régie) (the Quebec Health Insurance Board), a public body established by the provincial government that reports to the Minister of Health and Social Services.

1.2 Reporting Relationship

The Public Administration Act (R.S.Q., c. A-6.01) sets forth the government criteria for preparing reports on the planning and performance of public authorities, including the Ministère de la Santé et des Services Sociaux and the Régie de l'assurance maladie du Québec.

1.3 Audit of Accounts

Both plans (the Quebec hospital insurance plan and the Quebec health insurance plan) are operated on a non-profit basis. All books and accounts are audited by the auditor general of the province.

2.0 Comprehensiveness

2.1 Insured Hospital Services

Insured in-patient services include the following: standard ward accommodation and meals; necessary nursing services; routine surgical supplies; diagnostic services; use of operating rooms, delivery rooms and anaesthetic facilities; medication; prosthetic and orthotic devices that can be integrated with the human body; biological products and related preparations; use of radiotherapy, radiology and physiotherapy facilities; and services rendered by hospital staff.

Out-patient services include the following: clinical services for psychiatric care; electroshock, insulin and behaviour therapies; emergency care; minor surgery (day surgery); radiotherapy; diagnostic services; physiotherapy; occupational therapy; inhalation therapy, audiology, speech therapy and orthoptic services; and other services or examinations required under Quebec legislation.

Other insured services are: mechanical, hormonal or chemical contraception services; surgical sterilization services (including tubal ligation or vasectomy); reanastomosis of the fallopian tubes or vas deferens; and extraction of a tooth or root when the patient's health status makes hospital services necessary.

The MSSS administers an ambulance transportation program that is free of charge to persons aged 65 or older.

In addition to basic insured health services, the Régie also covers the following, with some limitations, for certain residents of Quebec, as defined by the Health Insurance Act (R.S.Q. c. A-29), and for employment assistance recipients: optometric services; dental care for children and employment assistance recipients, and acrylic dental prostheses for employment assistance recipients; prostheses, orthopaedic appliances, locomotion and postural aids, and other equipment that helps with a physical disability; external breast prostheses; ocular prostheses; hearing aids, assistive listening devices and visual aids for people with a visual or auditory disability; and permanent ostomy appliances.

With regard to drug insurance, since January 1, 1997, the Régie has covered, in addition to its regular clientele (employment assistance recipients and persons 65 years of age or older), Quebec residents who would not otherwise have access to a private drug insurance plan. In 2010-2011, the drug insurance plan covers 3.3 million insured persons.

2.2 Insured Physician Services

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

Family planning services set forth by legislation and provided by a physician are insured, as are assisted reproduction services set forth by legislation.

2.3 Insured Surgical-Dental Services

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

2.4 Uninsured Hospital, Physician and Surgical-Dental Services

Uninsured hospital services include: plastic surgery; a private or semi-private room at the patient's request; televisions; telephones; drugs and biological products ordered after discharge from hospital; and services for which the patient is covered under the Act respecting industrial accidents and occupational diseases or other federal or provincial legislation.

The following services are not insured: any examination or service not related to a process of curing or preventing illness; psychoanalysis of any kind, unless such service is rendered in a facility maintained by an institution authorized for such purpose by the Minister of Health and Social Services; any service provided solely for aesthetic purposes; any refractive surgery, except where there is documented failure in respect of corrective lenses and contact lenses for astigmatism of more than 3.00 diopters or anisometropia of more than 5.00 diopters measured from the cornea; any consultation by telecommunication or by correspondence; any service rendered by a professional to his or her spouse or children; any examination, expert appraisal, testimony, certificate or other formality required for legal purposes or by a person other than one who has received an insured service, except in certain cases; any visit made for the sole purpose of obtaining the renewal of a prescription; any examinations, vaccinations, immunizations or injections, where the service is provided to a group or for certain purposes; any service rendered by a professional on the basis of an agreement or contract with an employer, association or body; any adjustment of eyeglasses or contact lenses; any surgical extraction of a tooth or dental fragment performed by a physician, unless such a service is provided in a hospital centre in certain cases; all acupuncture procedures; injection of sclerosing substances and the examination performed at that time; mammography used for detection purposes, unless this service is rendered on medical prescription in a place designated by the Minister to a recipient 35 years of age or older, provided that the person has not been so examined for one year; thermography, tomodensitometry, magnetic resonance imaging and use of radionuclides in vivo in humans, unless these services are rendered in a hospital centre; ultrasonography, unless this service is rendered in a hospital centre or, for obstetrical purposes, in a local community service centre (CLSC) recognized for that purpose; any radiological or anaesthetic service provided by a physician if required with a view to providing an uninsured service, with the exception of a dental service provided in a hospital centre or, in the case of radiology, if required by a person other than a physician or dentist; any sex-reassignment surgery, unless it is provided on the recommendation of a physician specializing in psychiatry and is provided in a hospital centre recognized for this purpose; and any services that are not related to pathology and that are rendered by a physician to a patient between 18 and 65 years of age, unless that individual is the holder of a claim booklet, for colour blindness or a refractive error, in order to provide or renew a prescription for eyeglasses or contact lenses.

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 or proof of residence 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 the Régie de l'assurance maladie du Québec to be eligible for hospital services.

3.2 Other Categories of Individuals

Services received by regular members of the Canadian Forces, members of the Royal Canadian Mounted Police (RCMP) and inmates of federal penitentiaries are not covered by the plan. There are no health premium charges.

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 receiving last resort financial assistance benefits are eligible upon registration. Members of the Canadian

Forces and RCMP who have not acquired the status of resident of Quebec, and inmates of federal penitentiaries become eligible 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 become eligible for the plan following a waiting period.

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.

4.2 Coverage During Temporary Absences In Canada

If living outside Quebec in another province or territory for 183 days or more, and provided they notify the Régie of this, students and full-time unpaid trainees may retain their status as residents of Quebec: students for a maximum of four consecutive calendar years, and full-time unpaid trainees for a maximum of two consecutive calendar years.

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

Persons directly employed or working on contract outside of Quebec for a company or corporate body with its headquarters or a place of business in Quebec, to which they report directly, or 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 183 days or more, but less than 12 months within a calendar year, provided such absence occurs only once every seven years.

The costs of medical services received in another province or territory of Canada are reimbursed at the amount actually paid or the rate that would have been paid by the Régie for such services in Quebec, whichever is less. However, Quebec has negotiated a permanent arrangement with Ontario to pay Ottawa doctors 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 Agence de la santé et des services sociaux de l'Outaouais (Outaouais health and social services agency) 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 North Bay.

Costs of hospital services with which a recipient is provided in another province or territory of Canada are paid in accordance with the terms and conditions of the agreement on reciprocal billing of insured services 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. Insured persons who leave Quebec to settle in another province or territory of Canada are covered for up to three months after leaving the province.

4.3 Coverage During Temporary Absences Outside Canada

Students, unpaid trainees, Quebec government officials posted abroad and employees of non profit organizations working in international aid or cooperation programs recognized by the Minister of Health and Social Services must contact the Régie to determine their eligibility. If the Régie grants them special status, they receive full reimbursement of hospital costs in case of emergency or sudden illness, and 75 percent reimbursement in other cases.

As of September 1, 1996, hospital services provided outside Canada in case of emergency or sudden illness are reimbursed by the Régie, usually in Canadian funds, to a maximum of C$100 per day if the patient was hospitalized (including in the case of day surgery) or to a maximum of C$50 per day for out-patient services.

However, haemodialysis treatments are covered to a maximum of C$220 per treatment, including medications, whether the patient is hospitalized or not. In these cases, the Régie covers the associated professional services at the lowest cost, either the amount actually paid or what would have been paid by the Régie for the same services in Quebec. 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.

Costs for insured services provided by physicians, dentists, oral surgeons and optometrists are reimbursed at the rate that would have been paid by the Régie to a health professional recognized in Quebec, up to the amount of the expenses actually incurred. When they are delivered abroad, all services insured by the Régime d'assurance maladie are reimbursed at the Quebec rate, usually in Canadian funds.

An insured person who moves permanently from Quebec to another country ceases to be a recipient on the day of departure.

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 of Health and Social Services and the country in question.

4.4 Prior Approval Requirement

Insured persons requiring medical services in hospitals elsewhere in Canada or abroad that are not available in Quebec are reimbursed 100 percent if prior consent has been given for medical and hospital services that meet certain conditions. Consent is not given by the Plan's officials if the medical service in question is available in Quebec.

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. There is no extra-billing by Quebec physicians.

On March 31, 2011, Quebec had 116 institutions operating as hospital centres for a clientele suffering from acute illnesses. On that date, 20,443 beds for persons requiring short-term care for general or specialized ailments were allotted to these institutions. According to the most recent available data, from April 1, 2009, to March 31, 2010, Quebec hospital institutions had 711,804 admissions for short stays (including newborns) and 347,654 registrations for day surgeries. These hospitalizations accounted for 5,037,044 patient days.

Restructuring of the health network: In November 2003, Quebec announced the implementation of local service networks across the province. At the heart of each local network is a new local authority, the Centre de santé et de services sociaux (CSSS; health and social services centre). These centres are the result of the merger of the public institutions whose mission it was to provide CLSC (local community service centre) services, CHSLD (residential and long-term care) services and, in most cases, neighbourhood hospital services. CSSSs also provide the people in their territory with access to other medical services, general and specialized hospital services, and social services. To do so, they will have to enter into service agreements with other health sector organizations. The linking of services within a territory forms the local services network. Thus, the aim of integrated local health and social services networks is to make all the stakeholders in a given territory collectively responsible for the health and well-being of the people in that territory.

Since 2003-2004, there have been family medicine groups (FMGs). An FMG is a group of doctors working as a team and in close collaboration with nurses and other CSSS professionals to provide services ranging from assessment of health status to case management, monitoring, diagnosis and treatment of acute and chronic problems, and disease prevention. Their services include medical consultations with and without an appointment, seven days a week, and an adapted response to people whose health status requires special arrangements for access to services. As of March 31, 2011, there were 223 accredited FMGs and 46 network-clinics in Quebec.

5.2 Physician Compensation

Physicians are remunerated in accordance with the negotiated fee schedule. Physicians who have withdrawn from the health insurance plan are paid directly by the patient according to the fee schedule after the patient has collected from the Régie. Non-participating physicians are paid directly by their patients according to the amount charged. The Minister may enter into an agreement with the organizations representing any class of health professional. This agreement may prescribe a different rate of compensation for medical services in a territory where the number of professionals is considered insufficient.

While the majority of physicians practise within the provincial plan, Quebec allows two other options: professionals who have withdrawn from the plan and practise outside the plan, but agree to remuneration according to the provincial fee schedule; and non-participating professionals who practise outside the plan, with no reimbursement from the Régie going to either them or their patients.

According to the most recent data available, in 2010-2011 the Régie paid an estimated $5,065.3 million to doctors in the province, while the amount for medical services outside the province reached an estimated $12.1 million.

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.

The payments made in 2010-2011 to institutions operating as hospital centres for insured health services provided to residents of Quebec totalled nearly $10 billion. Payments to hospital centres outside Quebec for hospital services totalled approximately $175.64 million.

Ontario

Introduction

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 and Long-Term Care (MOHLTC), Ontario's health care system was supported by over $44 billion (including capital) in spending for 2010-2011.

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

Fourteen Local Health Integration Networks (LHINs) plan, fund and integrate local health care services. With the LHINs responsible for local health care management, the Ministry assumes a stewardship role establishing overall strategic direction and priorities for the provincial health care system.

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 MOHLTC. OHIP was established in 1972 and is continued under the Health Insurance Act, Revised Statutes of Ontario, 1990, c. H-6, to provide insurance in respect of the cost of insured services provided to Ontario residents in hospitals and health facilities, and by physicians and other health care practitioners.

Local Health Integration Networks (LHINs) were established under the Local Health System Integration Act, 2006 (LHSIA) to improve Ontarians' health through better access to high-quality health services, coordinated health care, and effective and efficient management of the health system at the local level. On April 1, 2007, the LHINs assumed responsibility for funding, planning, and integrating health care services at the local level. These include services delivered by hospitals, community care access centres, long-term care homes, community health centres, community support services, and mental health and addictions agencies.

LHSIA also reaffirms the principles of the French Languages Services Act to ensure equitable access to services in French for French-speaking Ontarians.

1.2 Reporting Relationship

The Health Insurance Act stipulates that the Minister of Health and Long-Term Care is responsible for the administration and operation of OHIP, and is Ontario's public authority for the purposes of the Canada Health Act.

LHSIA requires each LHIN to prepare an annual report for the Minister who is required to table the reports in the Legislative Assembly of Ontario.

The Ministry has accountability agreements with each LHIN that include obligations, measures and targets for the networks. The agreements also include the funding allocations for health service providers. LHSIA also provides the LHINs with the authority to fund defined health service providers and to enter into service accountability agreements with health service providers.

1.3 Audit of Accounts

Every year the Auditor General of Ontario reports on the results of his 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 MOHLTC, which were chosen for review by the Auditor General in any given year are included within this annual report, the last of which was released on December 6, 2010.

MOHLTC's accounts and transactions are published annually in the Public Accounts of Ontario. The 2010-2011 Public Accounts of Ontario was released on August 23, 2011.

2.0 Comprehensiveness

2.1 Insured Hospital Services

Insured in-patient and out-patient hospital services in Ontario are prescribed under the Health Insurance Act, and Regulation 552 under the Act.

Insured in-patient hospital services^{Footnote 18} include medically required: use of operating rooms, obstetrical delivery rooms and anaesthetic facilities; necessary nursing services; laboratory, radiological and other diagnostic procedures together with the necessary interpretations for the purpose of maintaining health, preventing disease and assisting in the diagnosis and treatment of any injury, illness or disability; drugs, biologicals and related preparations; and accommodation and meals at the standard ward level.

Insured out-patient services include medically required: laboratory, radiological and other diagnostic procedures; use of radiotherapy, occupational therapy, physiotherapy and speech therapy facilities, where available; use of diet counselling services; use of the operating room, anaesthetic facilities; surgical supplies; necessary nursing service; and the supply of drugs, biologicals, and related preparations (subject to some exceptions) and certain other specified services, for example, the provision of equipment, supplies and medication to haemophiliac patients for use at home; and certain specified home administered drugs.

2.2 Insured Physician Services

Insured physician services are prescribed under the Health Insurance Act and regulations under the Act.

Under subsection 37.1(1) of Regulation 552 and under the Health Insurance Act, a service provided by a physician in Ontario is an insured service if it is medically necessary; referred to in the Schedule of Benefits--Physician Services; and rendered in such circumstances or under such conditions as specified in the Schedule of Benefits. Physicians provide medical, surgical and diagnostic services, including primary health care services. Services are provided in a variety of settings, including: private physician offices, community health centres, hospitals, mental health facilities, licensed independent health facilities, and long-term care homes.

In general terms, insured physician services include: diagnosis and treatment of medical disabilities and conditions; medical examinations and tests; surgical procedures; maternity care; anaesthesia; radiology and laboratory services in approved facilities; and immunizations, injections and tests.

The Schedule of Benefits is regularly reviewed and revised to reflect current medical practice and new technologies. New services may be added, existing services revised, or obsolete services removed through regulatory amendment. This process involves consultation with the Ontario Medical Association.

During 2010-2011, most physicians submitted claims for all insured services rendered to insured persons directly to the Ontario Health Insurance Plan (OHIP), in accordance with section 15 of the Health Insurance Act, or a limited number could bill the insured person, as permitted by section 15.2 of the Act (see also Part II of the Commitment to the Future of Medicare Act). Physicians who do not bill OHIP directly are commonly referred to as having "opted out." When a physician has opted out, the physician bills the patient (not exceeding the amount payable for the service under the Schedule of Benefits), and the patient is then entitled to reimbursement by OHIP. However, the number of physicians who may opt out was fixed (on a "grandparented" basis) following proclamation of the Commitment to the Future of Medicare Act on September 23, 2004.

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.

There were approximately 25,995 physicians who submitted claims to OHIP in 2010-2011. 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.

2.3 Insured Surgical-Dental Services

Certain surgical-dental services are prescribed as insured services in section 16 of Regulation 552 in the Health Insurance Act and the Dental Schedule of Benefits. The Health Insurance Act authorizes OHIP to cover a limited number of procedures when the insured services are medically necessary and are 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.

Insured surgical-dental services were provided by 282 dental surgeons in Ontario in 2010-2011.

2.4 Uninsured Hospital, Physician and Surgical-Dental Services

Uninsured hospital services include but are not limited to: private or semi-private accommodation unless prescribed by a physician, oral-maxillofacial surgeon or midwife; telephones and televisions; charges for private-duty nursing; and provision of medications for patients to take home from hospital, with prescribed exceptions.

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

Uninsured physician services include, among others: services that are not medically necessary; the preparation or provision of a drug, antigen, antiserum or other substance, unless the drug, antigen or antiserum is used to facilitate a procedure or examination; advice given by telephone at the request of the insured person or the person's representative; the preparation and transfer of records at the insured person's request; a service that is received wholly or partly for producing or completing a document or transmitting information to a "third party" in prescribed circumstances; the production or completion of a document or transmitting information to any person other than the insured person in prescribed circumstances; provision of a prescription when no concomitant insured service is rendered; acupuncture procedures; psychological testing; research and survey programs; experimental treatment; and toll charges for long-distance telephone calls.

3.0 Universality

3.1 Eligibility

Regulation 552 of the Health Insurance Act specifies the eligibility criteria for Ontario Health Insurance Plan (OHIP) coverage.

To be considered a resident of Ontario for the purpose of obtaining Ontario health insurance coverage generally speaking, a person must:

• hold Canadian citizenship or an immigration status as prescribed in Regulation 552 under the Health Insurance Act;
• make his or her primary place of residence in Ontario;
• subject to some limited exceptions, be physically present in Ontario for at least 153 days in any 12-month period; and
• for most new and returning residents, be physically present in Ontario for 153 of the first 183 days following the date residence is established in Ontario (i.e., a person cannot be away from the province for more than 30 days in the first six months of residency).

Individuals who are not eligible for OHIP coverage are those who do not meet the definition of a resident, including those who do not hold an immigration or other status that is set out in Regulation 552, such as tourists, transients, and visitors to the province. Services that a person is entitled to receive under federal legislation are not insured services (i.e., those provided to federal penitentiary inmates, Canadian Forces members and ranked Royal Canadian Mounted Police personnel).

Persons who were previously ineligible for Ontario health insurance coverage but whose status and/or residency situation has changed, e.g., change in immigration status, may be eligible upon application and subject to the requirements of Regulation 552.

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

MOHLTC is the sole payor for OHIP insured physician, hospital, and dental-surgical 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).

Approximately 13.1 million Ontario residents were registered with OHIP and held valid and active health cards as of March 31, 2011.

3.2 Other Categories of Individual

MOHLTC provides health insurance coverage to residents of Ontario other than Canadian citizens and Permanent Residents/Landed Immigrants.

These residents are required to provide acceptable documentation to support their eligible immigration status, their residence in Ontario, and their identity in the same manner as Canadian citizens or Permanent Resident/Landed Immigrant applicants.

The individuals listed below who are resident in Ontario may be eligible for Ontario health insurance coverage in accordance with Regulation 552 of the Health Insurance Act. Individuals are required to apply in person to register for Ontario Health insurance coverage. Registration for OHIP is provided by ServiceOntario, which has the government-wide mandate for the delivery of front-facing services to the residents of Ontario, which also includes the issuance of the Ontario Photo Health Card.

Applicants for Permanent Residence: These are persons who have submitted an application for Permanent Resident status to Citizenship and Immigration Canada (CIC) and CIC 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: These are persons who are determined to be Protected Persons under the terms of the federal Immigration and Refugee Protection Act. Members of this group are provided with immediate Ontario health insurance coverage.

Holders of Temporary Resident Permits/Minister's Permits: A Temporary Resident Permit/Minister's Permit is issued to an individual by CIC 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/Minister's 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 Ontario health insurance coverage. Individuals who hold a permit with a case type of 80 (except for adoption), 81, 84, 85 and 96 are not eligible for Ontario health insurance coverage.

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 Ontario health insurance coverage if the individual has been issued a Work Permit or other document by CIC that permits the person to work in Canada if the person also has a formal agreement in place to work full-time for an employer in Ontario. The work permit/other document issued by CIC, 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 dependant (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 member of the clergy or an eligible foreign worker is also eligible for Ontario health insurance coverage as long as the spouse or dependant is legally entitled to stay in Canada.

Live-in Caregivers: Eligible live-in caregivers are persons who hold a valid Work Permit under the Live-in Caregiver Program (LCP) administered by the Government of Canada. The Work Permit for LCP workers does not have to list the three specific employment conditions required for all other foreign workers.

Applicants for Canadian Citizenship: These individuals are eligible for Ontario health insurance 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 CIC has confirmed that the person meets the eligibility requirements to apply for citizenship under that section and the application has not yet been denied.

Migrant Farm Workers: Migrant farm workers are persons who have been issued a Work Permit 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 Ontario health insurance coverage.

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.

3.3 Premiums

No premiums are required to obtain Ontario health insurance coverage. The Ontario Health Premium is collected through the provincial income tax system and 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

In accordance with section 5 of Regulation 552 under the Health Insurance Act, individuals who move to Ontario are 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, 6.3 of the Regulation, or section 11(2.1) of the Health Insurance Act.

In accordance with section 5 of Regulation 552 under the Health Insurance Act and as provided for in the Interprovincial Agreement on Eligibility and Portability, persons who permanently move to Ontario from another Canadian province or territory where they were insured will typically be eligible for OHIP coverage after the last day of the second full month following the date residency is established (i.e., an "interprovincial waiting period").

Assessment of whether or not an individual is subject to the interprovincial waiting period occurs at the time of their application for Ontario health insurance coverage. Examples of those who are exempt from the three-month waiting period in accordance with the Health Insurance Act and its regulations include 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.

4.2 Coverage During Temporary Absences in Canada

Insured out-of-province services are prescribed under sections 28, 28.0.1, and 29 to 32 of Regulation 552 of the Health Insurance Act.

Ontario adheres to the terms of the Interprovincial Agreement on Eligibility and Portability; therefore, insured residents who are temporarily outside of Ontario can use their Ontario health cards to obtain insured physician (except in Quebec) and hospital services.

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.

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 MOHLTC with documentation 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.

In accordance with Regulation 552 of the Health Insurance Act, 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.

Ontario participates in Reciprocal Hospital Billing Agreements with all other provinces and territories for insured in-patient and out-patient hospital services. Payment is at the agreed upon in-patient rate of the plan in the province or territory where hospitalization occurs.

Ontario pays the standard out-patient charges set out by the Interprovincial Health Insurance Agreements Coordinating Committee. Ontario also participates in the Physicians' Reciprocal Billing Agreements with all other provinces and territories, except Quebec (which has not signed a reciprocal agreement with any other province or territory), for insured physician services. Ontario residents who may be required to pay for physician services received in Quebec can submit their receipts to MOHLTC for payment as an insured service at Ontario rates.

4.3 Coverage During Temporary Absences Outside Canada

Health insurance coverage for insured Ontario residents during extended absences (longer than 212 days) outside Canada is governed by sections 1.7 through 1.14 of Regulation 552 of the Health Insurance Act.

The Ministry requests that residents apply to MOHLTC to confirm this coverage before their departure and provide documents explaining the reason for their absence outside Canada. In accordance with the regulations and MOHLTC policy, most applicants must also have been resident 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:

Certain family members may also qualify for continuous Ontario health insurance coverage while accompanying the primary applicant on an extended absence outside Canada.

Payment of out-of-country services are covered under sections 28.1 to 28.6 inclusive, and sections 29 and 31 of Regulation 552 of the Health Insurance Act.

Out-of-country emergency hospital costs are reimbursed at Ontario fixed per diem rates of:

• a maximum $400 (CAD) for in-patient services;
• a maximum $50 (CAD) for out-patient services (except dialysis); and
• a maximum of $210 (CAD) for out-patient services that include renal dialysis.

During 2010-2011, emergency medically necessary out-of-country physician services were reimbursed at the Ontario rates set out in regulation under the Health Insurance Act or the amount billed, whichever was less. Charges for medically necessary emergency or out-of-country in-patient and out-patient services are reimbursed only when rendered in an eligible hospital or health facility. Medically necessary out-of-country laboratory services, when done on an emergency basis by a physician, are reimbursed in accordance with the formula set out in section 29(1) (b) of the Regulation or the amount billed, whichever is less, and when done on an emergency basis by a laboratory, in accordance with the formula set out in section 31 of the Regulation.

4.4 Prior Approval Requirement

As set out in section 28.4 of Regulation 552 under the Health Insurance Act, written prior approval from MOHLTC is required for payment for non-emergency health services provided outside of Canada prior to the medical services being rendered. Where the identical or equivalent service is not performed in Ontario, or, where the patient faces a delay in accessing the service in Ontario that would result in death or medically significant irreversible tissue damage, the patient may be entitled to full funding for out-of-country insured health services.

Generally speaking, the prior approval application must establish that the services or tests are:

• medically necessary;
• the identical or equivalent service is not performed in Ontario, or the identical or equivalent service is performed in Ontario but it is necessary that the insured person travel out of Canada to avoid a delay that would result in death or medically significant irreversible tissue damage;
• generally accepted by the medical profession in Ontario as appropriate for a person in the same circumstances as the insured person;
• not experimental;
• not performed for research purposes or survey; and
• written prior approval of payment is granted by the General Manager before any of the health services are rendered.

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 laboratory tests performed outside Canada are described in section 28.5 of Regulation 552 of the Health Insurance Act.

There is no formal prior approval process required for services provided to eligible Ontario residents outside the province, but within Canada, if the insured service is covered under the Reciprocal Hospital Billing Agreements.

5.0 Accessibility

5.1 Access to Insured Health Services

All insured hospital, physician and surgical-dental services are available to Ontario residents on uniform terms and conditions.

All insured persons are entitled to all insured physician, surgical-dental and hospital services, as defined in the Health Insurance Act and regulations.

Access to insured services is protected under Part II of the Commitment to the Future of Medicare Act (CFMA), "Health Services Accessibility." The Act prohibits any person or any entity from charging or accepting payment or other benefit for an insured service rendered to an insured person except as permitted in the Act. 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 fee" for an uninsured service. The Act further prohibits any person or entity from paying, conferring, or charging or accepting a payment or other benefit in exchange for preferred access for an insured person to an insured service.

MOHLTC investigates all possible contraventions of Part II of the CFMA that come to its attention. For situations in which it is found that a patient has been extra-billed, the Ministry ensures that the amount is repaid to that patient.

MOHLTC implemented Health Number/Card Validation to aid health care providers and patients with access to the information requested for OHIP and claims payment. Providers may subscribe for validation privileges to verify patient eligibility and health number/version code status (card status). If patients require access to insured services and do not have a health card in their possession, the provider may obtain the necessary information by submitting to the Ministry a Health Number Release Form signed by the patient. An accelerated process
for providers to obtain patient health numbers is also provided by ServiceOntario 24 hours a day, seven days a week through the Health Number Look Up service.

Public hospitals in Ontario are not permitted to refuse the admission of a patient if by refusal of admission the patient's life would be endangered.

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 a time-limited basis. Acute care priority services include:

• selected cardiovascular services;
• selected cancer services;
• chronic kidney disease;
• critical care services; and
• organ and tissue donation and organ transplantation.

Primary Health Care: During 2010-2011, Ontario continued to align its new and existing primary health care delivery models to help improve and expand access to primary health care physician services for all Ontarians. 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 under-serviced communities.

Health Care Connect (HCC): HCC helps Ontarians who are without a family health care provider (family doctor or nurse practitioner) to find one. People without a family health care provider are referred to a family doctor or a nurse practitioner who is accepting new patients in their community.

During 2010-2011, MOHLTC continued to administer various initiatives in order to improve access to health care services across the province. Ontario is increasing physician supply, and enhancing the retention and distribution of physicians in the province by such measures as:

• increasing enrolment in medical schools for undergraduate spaces;
• expanding postgraduate positions for both family medicine and Royal College specialty positions;
• increasing rural and remote clinical education opportunities for medical students;
• supporting the new Northern Ontario School for Medicine (NOSM); and
• supporting training and assessment programs for International Medical Graduates (IMGs) and other qualified physicians who do not meet certain requirements for practice in Ontario.

Two initiatives to improve access across Ontario, including rural and northern communities, are the HealthForceOntario Northern and Rural Recruitment and Retention (NRRR) initiative and the Northern Health Travel Grant (NHTG) program.

• HealthForceOntario Northern and Rural Recruitment and Retention (NRRR) Initiative: The The NRRR (launched April 2010) supports the recruitment and retention of physicians in rural and northern communities. The NRRR initiative provides grants to physicians and new physician graduates to set up new practices in a northern or highly rural community with a Rurality Index for Ontario (RIO) score of 40 or more, or in one of the five major northern urban referral centers (Thunder Bay, Sudbury, North Bay, Sault Ste. Marie and Timmins).
• Northern Health Travel Grant (NHTG) Program: The NHTG helps defray travel-related costs for residents of northern Ontario who must travel long distances to access OHIP insured services that are not locally available, within a radius of 100km. The travel grants are designed to ensure access to medical specialist services, or procedures performed at designated health care facilities. The NHTG also promotes using specialist services located in northern Ontario, which encourages more specialists to practice and remain in the north.

5.2 Physician Compensation and Dental-Surgical Services

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

In 2010-2011, 98% of General Practitioners received fee-for-service payments from OHIP but less than 30% of them were paid solely on a fee-for-service basis. The remaining family physicians in Ontario receive funding through one of the primary health models: Comprehensive Care Models (CCM), Family Health Group (FHG), Family Health Network (FHN), Family Health Organization (FHO), Community Health Care (CHC), Rural and Northern Physician Group Agreement (RNPGA), Group Health Centre (GHC), Blended Salary Model (BSM), and specialized agreements and Family Health Teams (FHTs) build upon existing primary health care physician funded models by providing funding for inter-disciplinary team of providers such as nurse practitioners, nurses, social workers and dietitians. FHTs are located across Ontario, in both urban and rural settings, ranging in size, structure, scope and governance. Physicians participating in FHTs are funded by one of three compensation options that include: Blended Capitation (such as FHN or FHO), Complement Based Models (RNPGA or other specialized agreements) and BSM (for community-sponsored FHTs).

MOHLTC negotiates physician funding with the Ontario Medical Association (OMA). A four year Physician Services Agreement, from April 2008 to March 31, 2012, was reached in October 2008. The 2008 Physician Services Agreement centers on delivering on two key government priorities--access to family health care and reducing congestion in emergency departments. The Agreement provides for a 3% one time payment to physicians in the first year of the Agreement and increases to the Schedule of Benefits, with 5% in the second year, 3% in the third year and 4.25% in the fourth year. Investments in the Schedule of Benefits are not across-the-board but are implemented to address Ministry priorities and provide income relativity between OMA sections.

The Agreement also includes investments in recruitment and retention initiatives and in northern/rural programs to support stabilizing physician human resources as well as investments in other Ministry priority areas, such as mental health, diagnostic services and care of the elderly. Additionally, through the Agreement, $100 million in performance based funding is provided for a new Local Health Integration Network (LHIN)-Physician Collaboration Incentive Fund. The fund recognizes and rewards the local efforts of physician groups who work together and in collaboration with other service providers to support the needs of patients in four key areas: Most Responsible Physician, Emergency Department, Unattached Patients, and Hospital On-Call Coverage.

With respect to insured surgical-dental services, MOHLTC negotiates changes to the Schedule of Benefits for Dental Services with the Ontario Dental Association. In 2002-2003, MOHLTC and the Ontario Dental Association agreed on a multi-year funding agreement for dental services, which became effective on April 1, 2003, and continues to be in effect.

5.3 Payments to Hospitals

The Ontario budget system is a prospective reimburse­ment system that reflects the effects of workload increases, costs related to provincial priority services, wait time strategies, and cost increases in respect of above-average growth in the volume of service in specific geographic locations. Payments are made to hospitals on a semi-monthly basis.

With the Excellent Care for All Act (ECFA), Ontario will be moving to a patient-based payment system for funding hospitals. Patient-based payment (PbP) is an activity-based funding approach that reimburses providers for the types and quantities of patients they treat, using evidence-informed rates that are adjusted for patient complexity and quality of care delivered. PbP will expand on the Ontario Wait Time Strategy funding approach to link the majority of hospitals' funding to the types, volumes and quality of care they provide. PbP is a significant shift from the way Ontario hospitals are currently funded, still largely based on historically derived global budgets established in 1969.

The implementation of patient-based payment will be an enabler for health system transformation and aims to be responsive to the needs of patients and populations, be an incentive to improving quality, efficiency and integration, and support the system transformation agenda of ECFA. ECFA and PbP implementation will combine activity-based funding with a component of fixed budgeting to create a system that promotes access, quality and efficiency, establishes payment levers to advance policy and system objectives, while still ensuring overall cost containment. PbP implementation is a critical structural reform for reducing health spending growth from current 6%-7% annual increases to 3.1% by 2012-2013.

Person-centred, patient-based payment funding promotes care in the most appropriate setting for a patient/client/resident's level of acuity and links providers' funding to services delivered to ensure that appropriate service levels are provided and access is maintained. The Ontario government's Excellent Care for All Strategy represents a significant culture shift in the province's health care system and a change in the province's approach to health care funding through a quality agenda. The funding approach will create a financial environment that supports the business case for providers to invest in quality improvement and provide funding that reflects the quality of care that providers deliver and promote evidence-based practice.

When they assumed responsibility for their local health care systems, LHINs negotiated two-year Hospital Service Accountability Agreements (HSAAs) with the hospitals and are the lead for the Hospital Annual Planning Submissions, which are the precursors to the HSAAs. Payments to hospitals have traditionally been based on historical global allocations and multiyear incremental increases that incorporate population growth and anticipated service demands within the available provincial budget.

Public hospitals submit planning submissions to the LHINs that are the result of broad consultations within the facilities (e.g., all levels of staff, unions, physicians and board), the community and region. Some of the data submitted in the planning submissions are used to populate schedules for service volumes and performance targets that form the contractual basis for the HSAA.

The HSAA outlines the terms and conditions of the services provided by the hospital, the funding it will receive, the performance expected, and service levels. There are various performance indicators that are monitored, managed and evaluated in the agreement. These performance indicators strive to describe:

• Person experience (e.g., Emergency Room length of stay);
• Organizational health (e.g., current ratio, total margin); and
• Patient access and outcomes (e.g., global volumes, i.e., target volumes expected for rehabilitation, complex continuing care, mental health, total acute care, wait time volumes for MRI, CT, cataract surgery, hip and knee surgery) and selected cardiac services.

All the indicators have a performance standard and target that are designed to incentivise the hospital to move in a particular direction within the sector. The targets and performance corridors are negotiated yearly while taking into consideration the overall performance and contribution of the hospital to the larger system. Where particular indicators are outside of the performance corridor and presenting a risk, the hospital and LHIN develop a Performance Improvement Plan to get the hospital back on track to achieving its targets.

The Interprovincial Hospital Reciprocal Billing Agreements are a convenient administrative arrangement in which provincial/territorial governments reimburse hospitals in their jurisdictions for insured services provided to patients from other provinces/territories.

MOHLTC reviews chronic care co-payment regulations and rates annually, accounting for changes in the Consumer Price Index and Old Age Security, and determines whether revisions to the regulations and rates are appropriate.

6.0 Recognition Given to Federal Transfers

The Government of Ontario publicly acknowledged the federal contributions provided through the Canada Health Transfer in its 2010-2011 publications.

Manitoba

Introduction

Manitoba Health provides leadership and support to protect, promote and preserve the health of all Manitobans. The roles and responsibilities of the Department include policy, program and standards development, fiscal and program accountability, and evaluation. In addition, specific direct services continue to be provided in such areas of mental health, diagnostics/laboratory, public health inspection and provincial nursing stations.

Manitoba Health remains committed to the principles of Medicare and improving the health status of all Manitobans. In support of these commitments, highlights of activities initiated in 2010-2011 included:

• Commencement of a revision of strategic priorities and goals established for the Department in September 2010 to set expectations for future accountability. New departmental processes and tools to support this planning were initiated in early 2011.
• Implementation of the Performance Indicator Project to address the regional health authorities' needs for technology to support the collection, storage, reporting, measurement and monitoring of key performance indicators, as well as enabling regional health authorities to track and report on performance indicators that have been identified as shared priorities across regions.
• Launch of eChart Manitoba, the province's electronic health-record system. This included implementation of electronic medical records program processes, procedures and technology to enable timely data feeds from Manitoba Health Pharmacare and immunization data to the provincial eChart program hosted at Manitoba eHealth.
• Implementation of IMPRxOVE (Improving Medication Prescribing and Outcomes via Medical Education) Program, a first-in-Canada initiative, that is expected to improve the safety and health outcomes for Manitobans receiving mental health medications.
• Launch of an online drug formulary which provides health care professionals and the public with current information on drug benefits available through the Pharmacare program.
• Funding and support of the first-in-Canada organ donation physician specialist team to increase organ transplants and access to life saving organ donations.
• Commencement of initiatives towards the Family Doctor for Every Manitoban by 2015 initiative. This initiative supports the nurse practitioner quick-care clinics and mobile clinics while expanding the successful Advanced Access care model in the province.
• Continued support for the improvement to doctor education, recruitment and retention strategies by supporting medical enrolment and keeping medical school tuitions affordable.
• Improvements to the doctor education, recruitment and retention strategy in Manitoba that has resulted in a net increase of 405 new doctors in 2010.
• Continued aggressive recruitment and retention of nurses in 2010, resulting in a net gain of 3,026 nurses since 1999.
• Implemented the Master of Psychiatric Nursing program at Brandon University, the first one in Canada, which started in January 2011.

1.0 Public Administration

1.1 Health Care Insurance Plan and Public Authority

The Manitoba Health Services Insurance Plan (MHSIP) is administered by the Department of Health under the Health Services Insurance Act, R.S.M. 1987, c. H35.

The MHSIP is administered under this Act for insurance in respect of the costs of hospital, personal care, and medical and other health services referred to in acts of the Legislature or regulations thereunder.

The Minister of Health is responsible for administering and operating the Plan. 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 2010-2011 fiscal year that affected the public administration of the Plan.

1.2 Reporting Relationship

Section 6 of the Health Services Insurance Act requires the Minister to have audited financial statements of the Plan 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 Plan 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 2010-2011 fiscal year and is contained in the  Manitoba Health and Healthy Living Annual Report, 2010-2011. It is available at http://www.gov.mb.ca/health/ann/index.html.

2.0 Comprehensiveness

2.1 Insured Hospital Services

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

As of March 31, 2011, 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- and out-patient hospital services include: accommodation and meals at the standard ward level; necessary nursing services; laboratory, radiological and other diagnostic procedures; drugs, biologics and related preparations; routine medical and surgical supplies; use of operating room, case room and anaesthetic facilities; and use of radiotherapy, physiotherapy, occupational and speech therapy facilities, where available.

All hospital services are added to the list of available hospital services through the health planning process. 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. Manitoba Health is sensitive to new developments in the health sciences.

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 practise medicine in Manitoba, and be registered and licensed under the Medical Act. As of March 31, 2011, there were 2,528 registered physicians in Manitoba.

A physician, by giving notice to the Minister in writing, may elect to collect the fees for medical services rendered to insured persons other than from the Minister, 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 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. To date, no physicians have opted out of the medical plan in Manitoba.

The range of physician services insured by Manitoba Health 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 2010-2011, a number of new insured services were added to a revised fee schedule. The  Physician's Manual can be viewed on-line at: http://www.gov.mb.ca/health/manual/index.html

In order for a physician's service to be added to the list of those covered by Manitoba Health, physicians must put forward a proposal to their specific section of Doctors Manitoba (DMb). The DMb will negotiate the item, including the fee, with Manitoba Health. Manitoba Health may also initiate this process.

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 may elect to collect their fees directly from the patient in the same manner as physicians 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 had opted out as of March 31, 2011.

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). The MDA will negotiate the fee with Manitoba Health.

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: examinations and reports for reasons of employment, insurance, attendance at university or camp, or performed at the request of third parties; group immunization or other group services except where authorized by Manitoba Health; services provided by a physician, dentist, chiropractor or optometrist to him or herself or any dependants; preparation of records, reports, certificates, communications and testimony in court; mileage or travelling time; services provided by psychologists, chiropodists and other practitioners not provided for in the legislation; in vitro fertilization; tattoo removal; contact lens fitting; reversal of sterilization procedures; and psychoanalysis.

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 Manitoba Health monitor compliance.

All Manitoba residents have equal 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 Manitoba Health to monitor usage and service concerns.

To de-insure services covered by Manitoba Health, 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 2010-2011.

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 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.

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

There are currently no other waiting periods in Manitoba.

The Manitoba Health Services Insurance Plan (MHSIP) excludes residents covered under the following federal statutes: Aeronautics Act; Civilian War-related Benefits Act; Government Employees Compensation Act; Merchant Seaman Compensation Act; National Defence Act; Pension Act; Royal Canadian Mounted Police Act; Veteran's Rehabilitation Act; or under legislation of any other jurisdiction (Excluded Services Regulations subsection 2(2)). The excluded are residents who are members of the Canadian Forces and the Royal Canadian Mounted Police (RCMP), and federal inmates. These residents become eligible for Manitoba Health coverage upon discharge from the Canadian Forces, the RCMP, or if an inmate of a penitentiary has no resident dependants. Upon change of status, these persons have one month to register with Manitoba Health (Residency and Registration Regulation (M.R. 54/93, subsection 2(3)).

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

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 dependant. This number is used by Manitoba Health to pay for all medical service claims for that individual and all designated dependants. A nine-digit Personal Health Identification Number (PHIN) is used for payment of all hospital services and for the provincial drug program.

As of March 31, 2011, there were 1,246,420 residents registered with the health care insurance plan.

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

3.2 Other Categories of Individual

The Residency and Registration Regulation (M.R. 54/93, sub-section 8(1)) requires that temporary workers possess a work permit issued by Citizenship and Immigration Canada for at least 12 consecutive months, be physically present in Manitoba, and be legally entitled to be in Canada before receiving Manitoba Health coverage. As of March 31, 2011, there were 5,511 individuals on work permits covered under the MHSIP. The definition of "resident" under the Health Services Insurance Act allows the Minister of Health or the Minister's designated representative to provide coverage for holders of a Minister's permit under the Immigration Act (Canada). No legislative amendments to the Act or the regulations in the 2010-2011 fiscal year affected universality.

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 full-time enrolment 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. Manitoba has a bilateral agreement with the Province of Saskatchewan for Saskatchewan residents who receive care in Manitoba border communities.

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 services incurred in all provinces or territories are paid through a reciprocal billing agreement at host province or territory rates. Claims for medical services received in Quebec are submitted by the patient or physician to Manitoba Health 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.

Residents on full-time employment contracts outside Canada will receive Manitoba Health coverage for up to 24 consecutive months. Individuals must return and reside in Manitoba after completing their employment terms. Clergy serving as missionaries on behalf of a religious organization approved as a registered charity under the Income Tax Act (Canada) will be covered by Manitoba Health 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 Manitoba Health for up to 24 consecutive months. These individuals also must return and reside in Manitoba after completing their leave.

Coverage for all these categories is subject to amounts detailed in the Hospital Services Insurance and Admini­stration Regulation (M.R. 48/93). Hospital services received outside Canada due to an emergency or a sudden illness, while temporarily absent, are paid as follows:

In-patient services are paid based on a per-diem rate according to hospital size:

• 1-100 beds: $280
• 101-500 beds: $365
• over 500 beds: $570

Out-patient services are paid at a flat rate of $100 per visit or $215 for haemodialysis.

The calculation of these rates is complex due to the diversity of hospitals in both rural and urban areas.

Manitobans requiring medically necessary hospital services unavailable in Manitoba or elsewhere in Canada may be eligible for costs incurred in the United States by providing Manitoba Health with a recommendation from a specialist stating that the patient requires a specific, medically necessary service. Physician services received in the United States are paid at the equivalent Manitoba rate for similar services. Hospital services are paid at a minimum of 75 percent of the hospital's charges for insured services. Payment for hospital services is made in U.S. funds (the Hospital Services Insurance and Administration Regulation, sections 15-23).

In instances where Manitoba Health has given prior approval for services provided outside Canada and payment is less than 100 percent of the amount billed for insured services, Manitoba Health will consider additional funding based on financial need.

4.4 Prior Approval Requirement

Prior approval by Manitoba Health is not required for services provided in other provinces or territories or for emergency care provided outside Canada. Prior approval is required for elective hospital and medical care provided outside Canada. An appropriate medical specialist must apply to Manitoba Health to receive approval for coverage.

No legislative amendments to the Act or the regulations in the 2010-2011 fiscal year had an effect on portability.

5.0 Accessibility

5.1 Access to Insured Health Services

Manitoba Health 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.

In July 2001, the Health Services Insurance Act, the Private Hospitals Act and the Hospitals Act were amended to strengthen and protect public access to the health care system. The amendments include:

• changes to definitions and other provisions to ensure that no charges can be made to individuals who receive insured surgical services or to anyone else on that person's behalf; and
• ensuring that a surgical facility cannot perform procedures requiring overnight stays and thereby function as a private hospital.

Manitoba Health continues to invest in improving clients' access. In 2010, Manitoba made a commitment that all Manitobans will have access to a family physician by 2015. To achieve this goal, Manitoba invested in new initiatives such as Primary Care Networks (including teams), Quick Care Clinics, mobile Primary Care in communities across the province, and introduced more opportunities and supports for Manitobans to self-manage their health care. Investment also continued in existing initiatives that enhance capacity and efficiency in primary care, such as the Physician Integrated Network, TeleCARE Manitoba (a chronic disease self-management resource for congestive heart failure and diabetes), and an After-Hours Call Community Network pilot (a network of general practitioners linked to patients through the 24-hour Health Links-Info Santé service). Since 2008, Manitoba Health funded and co-ordinated over 30 primary and specialty clinics to successfully complete the Advanced Access training, enabling them to offer patients same-day access to a primary care provider and five-day access to a specialist.

All Manitobans have access to hospital services including acute care, psychiatric extended treatment, mental health, palliative, chronic, long-term assessment/rehabilitation, and to personal care facilities. There has been a shift in focus from hospital beds to community services, out-patients and day surgeries, which are also insured services.

The Western Manitoba Cancer Centre (WMCC) located at the Brandon Regional Health Centre (BRHC) is the first location outside of Winnipeg to provide radiation therapy. This $24 million facility with a linear accelerator is home to a broad range of cancer treatment including chemotherapy and support services. It is expected that the WMCC will reduce wait times for radiation treatment.

In the Provincial Nursing Stations, measures were taken to support access to primary health care professionals and specialists through programming such as MBTeleheath, on-going staff training, and increased communications with local and regional health authorities. Acute and emergency care has been enhanced by increasing the drug formulary, acquisition of new equipment, and by staff recruitment and retention initiatives.

In acute care and diagnostic services, initiatives such as Releasing Time to Care and Lean Six Sigma were implemented to improve patient flow and patient access, along with wait list management activities and enhanced service funding to reduce backlogs. Throughout 2010-2011, the Patient Access Registry Tool, an electronic booking request and wait-time/wait list management system, was implemented throughout the Winnipeg Regional Health Authority (WRHA) for adult elective surgery. It is the standard means of requesting and booking operating room cases, and capturing wait time information for over 190 WRHA surgeons. More than 85% of surgical services in Manitoba are provided in the WRHA. The wait time data collection functions of the tool have also been implemented in various medical and allied health programs to capture access information.

Funding to enhance volume of services has been sustained and increased. Manitoba continues to work with its regional health authority partners in exploring and implementing improved access models, and investigating demand management strategies, including improved appropriateness of services.

The MBTelehealth program continues to grow and currently has over 100 sites in Manitoba, including 24 sites in First Nation communities. Approximately 70% of usage is for the delivery of clinical services; 9327 of a total of 12,817 events. Other uses include continuing education for health care staff, administrative meetings and tele-visitation. Provider and patient response to the program continues to be very positive and demand for new sites continues to be high.

Manitoba continues to have growth in the number of active practicing nurses through expansions to the nursing education programs and strategies of the Nurses Recruitment and Retention Fund (NRRF). According to the registration data received from the Colleges of Registered Nurses, Registered Psychiatric Nurses and Licensed Practical Nurses, there were 17,118 active practicing nurses in Manitoba in 2010. This is a net gain of 494 more nurses than in 2009. There remain, however, ongoing nursing resource challenges in some rural and northern regions, and in specialty care areas in Winnipeg. Manitoba has increased nursing education seats throughout the province resulting in a more than doubling of enrolments in the last 10 years. The Winnipeg Regional Health Authority's strategy, the Winnipeg Critical Care Nursing Education Program (WCNEO), was aimed at increasing the number of intensive care nurses in the province, thus reducing nursing overtime costs, and decreasing surgery cancellations and bed closures. The NRRF also contributes significantly to improving the nursing supply in Manitoba through initiatives such as relocation assistance, the Conditional Grant Program to encourage new graduates to work in rural and northern regions (outside Winnipeg and Brandon), the personal care home grant, and funding for continuing education and specialty education programs. The Extended Practice Regulation allows nurses on the register to independently prescribe drugs, order screening and diagnostic tests, and perform minor surgical and invasive procedures as set out in regulation. The number of nurses on the register has grown from 4 in June 2005 to 101 as of the December 31, 2010 registration year.

Manitoba Health has developed and provided funding for a number of initiatives to address shortages in various allied health professions. Examples include: increasing seats in the ultrasound training program, the medical laboratory technologist training program and the medical radiologic technologist training program as well as reserving seats in training programs in other jurisdictions, such as the nuclear medicine technologist training program in Alberta and the prosthetics and orthotics training program in British Columbia. Along with reserving these seats students are expected to sign return of service agreements to return to Manitoba for employment post graduation for a specified period of time.

The Physician's Manual, a billing and fee guide, provides Manitoba physicians with a listing of medical services that are insured by Manitoba Health. Five main system data checks and processes within the Manitoba Health mainframe ensure that claims for insured services are processed in accordance with the Rules of Application in the Physician's Manual under the Health Services Insurance Act. Appeals under the Physician's Manual are heard by the Medical Review Committee. In addition, the Manitoba Health Appeal Board, a quasi-judicial tribunal, hears appeals if a person is not satisfied with certain decisions of Manitoba Health or is denied entitlement to a benefit under the Health Services Insurance Act.

Manitoba Health continued to support initiatives to improve access to physicians in rural and northern areas of the province.

Manitoba continues to experience increases in the number of new physicians registering with the licensing body. Manitoba has introduced greater funding flexibility to the return of service for students (for example, fourth year grants of $25,000 in return for service in a community designated by the province) by allowing return by locum (maximum 3 months per year over 4 years). The province also provides a provincial specialist fund to specialists recruited to Manitoba, in the amount of $15,000. In order to incent more Manitoba graduates to practice in Manitoba, the eligibility requirements for this fund have been broadened to allow recipients of funding through the Medical Student/Resident Financial Assistance Program (MSRFAP) to receive funding through the specialist fund as well. Recent announcements that further support physicians include the Physician Resettlement Fund and changes to the MSRFAP program. The Resettlement Fund is open to both family practitioners and specialists, and there has been significant take up of the program, with many physicians moving to rural and northern Manitoba. The MSRFAP was re-launched to provide eligible medical undergraduates $12,000 in funding in each of their four years of medical school. Each grant requires a commitment to return six months of service to under-serviced populations upon graduation. The new program will be available to medical students beginning in the fall of 2011. Since 2001, Manitoba has supported an expansion in medical school class sizes. In 2008, the Province, in partnership with the Federal Government introduced the Northern/Remote Family Medicine Residency Stream (formerly known as the Northern Remote Physician Practice Initiative). The initiative is a two-year family medicine residency training stream-specific to the rural/north, after which applicants must return service of 2+ years in rural/remote Manitoba, and upon completion of return of service are guaranteed consideration for a specialty residency position in Manitoba.

In an effort to support the repatriation of Manitobans/Canadians studying abroad back to Manitoba, the Province has established a repatriation coordinator. The coordinator chairs a repatriation working group which aims to develop potential pathways for Manitoba medical students/residents to return to Manitoba for training and practice opportunities.

Through the current assessment and training programs, foreign-trained physicians can achieve conditional licensure to practice medicine in return for agreeing to work in a sponsoring rural regional health authority. Eligible applicants for the Medical Licensure Program for International Medical Graduates may enter one year of residency training similar to family medicine residency training and upon successful completion of that training may be granted conditional licensure for primary care practice in a rural or northern community of Manitoba. Eligible applicants for the family practice assessment process leading to licensure will complete an orientation, a three day Family Practice Assessment, and a three month Clinical Field Assessment. Upon successful completion of the assessments, candidates may be recommended for conditional licensure and upon commencement of practice are linked with a physician mentor for a minimum of 12 months. The Non-Registered Specialist Assessment Program initiative assists in facilitating the assessment of physicians whose practice will be limited to a specialty field of training. Through this program, clinical assessments are organized and facilitated in order for foreign-trained physicians to meet the College of Physicians and Surgeons of Manitoba (CPSM) criteria for conditional licensure. The province has been working with stakeholders to improve the transparency and consistency of licensure processes related to foreign-trained physicians. There is now an integrated process through the University of Manitoba, Faculty of Medicine, for screening and assessing candidates. The improvements will ensure that the strongest candidates are identified and supported to transition successfully to practice in Manitoba. The PRCO has also concluded amendments to the Non-Registered Specialist Assessment Program (NRSAP), which will streamline the process for applicants.

5.2 Physician Compensation

Manitoba continues to employ the following methods of payment for physicians: fee-for-service, contract, blended and sessional.

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 2010-2011 fiscal year.

Fee-for-service remains the dominant method of payment for physician services. Notwithstanding, 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 to adjust fee-for-service income that may not be adequate to compensate for all services rendered by the physician. 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.

Manitoba Health represents Manitoba in negotiations with physicians. The physicians are typically represented by Doctors Manitoba with some notable exceptions, such as oncologists.

The current Master Agreement between Doctors Manitoba and Manitoba has an effective date from April 1, 2008 to March 31, 2011.

5.3 Payments to Hospitals

Division 3.1 of Part 4 of the Regional Health Authorities Act sets out the requirements for operational 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 this division, 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 enables the health services to be provided by the health corporation, the funding to be provided by the regional health authority for the health services, the term of the agreement, and a dispute resolution process and remedies for breaches. If the parties cannot reach an agreement, the Act enables them to request that the Minister of Health appoint a mediator to help them resolve outstanding issues. If the mediation is unsuccessful, the Minister is empowered to resolve the matter or matters in dispute. The Minister's resolution is binding on the parties.

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

The allocation of resources by regional health authorities for providing hospital services is approved by Manitoba Health through the approval of the regional health authorities' regional health plans, which the regional health authorities are required to submit for approval pursuant to section 24 of the Regional Health Authorities Act. Section 23 of the Act requires that authorities allocate their resources in accordance with the approved regional health plan.

Pursuant to subsection 50(2.1) of the Health Services Insurance Act, payments from the Medical 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 2010-2011 had an effect on payments to hospitals.

6.0 Recognition Given to Federal Transfers

Manitoba routinely recognizes the federal role regarding the contributions provided under the Canada Health Transfer (CHT) 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. In addition, Manitoba Health cites the federal contribution from the First Ministers Ten Year Plan to Strengthen Health Care (the 2004 Health Accord--Wait Time Reduction Fund) in funding letters to the regional health authorities and other organizations who are implementing programs using this funding.

Saskatchewan

Introduction

Through leadership and partnership, the Ministry of Health is committed to providing high-quality health care to the people of Saskatchewan through a responsive, efficient, and patient- and family-centered health care system. The Ministry's priority is a health system that puts patients and families first, and provides the best possible health care.

The health care system in Saskatchewan is multi-faceted and complex. To ensure the provision of essential and appropriate services, the Ministry establishes provincial strategy and policy direction, sets and monitors standards, and provides funding.

The Ministry also works in partnership with organizations at the local, regional, provincial, national and international levels to provide Saskatchewan residents with access to quality health care. The Ministry oversees a health care system that includes 12 regional health authorities (RHAs), the Saskatchewan Cancer Agency (SCA), the Athabasca Health Authority, affiliated health care organizations and a diverse group of professionals, many of whom are in private practice.

There are 26 self-regulated health professions in the province and the health system as a whole employs more than 38,000 people who provide a broad range of services. The Ministry supports the RHAs, SCA and other stakeholders to recruit and retain health care providers, including nurses and physicians. The Ministry is also responsible for approximately 50 different pieces of legislation.

In 2010-2011, the Ministry was re-organized into: Specialized Programs; Community and Primary Health; and Strategy and Performance Management. The Saskatchewan Surgical Initiative; Communications Branch; and Quality and Process Improvement (a component of the Strategy and Innovation Branch) report directly to the Deputy Minister.

The re-organization was designed to strengthen the Ministry's customer/client-focus; increase opportunities for innovation and collaboration; and, through these, transform the health care experience to make it more patient- and family-focused.

For more information about the Ministry's programs and services, please visit the  Ministry of Health website at: www.health.gov.sk.ca

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 Department of Health Act authorizes that the Minister of Health may:

• pay part of, or the whole of, the cost of providing health services for any persons or classes of person who may be designated by the Lieutenant Governor-in-Council;
• make grants or loans, or provide subsidies to regional health authorities, health care organizations or municipalities for providing and operating health services or public health services;
• pay part of, or the whole of, the cost of providing health services in any health region or part of a health region in which those services are considered by the Minister to be required;
• make grants or provide subsidies to any health agency that the Minister considers necessary; and
• make grants or provide subsidies to stimulate and develop public health research, and to conduct surveys and studies in the area of public health.

Sections 8 and 9 of the Saskatchewan Medical Care Insurance Act provide the authority for the Minister of Health to establish and administer a plan of medical care insurance for residents. The Regional Health Services Act provides the authority to establish 12 regional health authorities, replacing the former 32 district health boards.

Sections 3 and 9 of the Cancer Agency Act provide for establishing a Saskatchewan Cancer Agency and for the Agency to coordinate a program for diagnosing, preventing and treating cancer.

The mandates of the Ministry of Health, regional health authorities and the Saskatchewan Cancer Agency are outlined in the Department of Health Act, the Regional Health Services Act and the Cancer Agency Act.

1.2 Reporting Relationship

The Ministry of Health is directly accountable, and regularly reports, to the Minister of Health on the funding and administering the funds for insured physician, surgical-dental and hospital services.

Section 36 of the Saskatchewan Medical Care Insurance Act prescribes that the Minister of Health submit an annual report concerning the medical care insurance plan to the Legislative Assembly.

The Regional Health Services Act prescribes that each regional health authority shall submit to the Minister of Health:

• a report on the activities of the regional health authority; and
• a detailed, audited set of financial statements.

Section 54 of the Regional Health Services Act requires that regional health authorities and the Cancer Agency shall submit to the Minister any reports that the Minister may request from time to time. Regional health authorities and the Cancer Agency are required to submit a financial and health service plan to the Saskatchewan Ministry of Health.

1.3 Audit of Accounts

The Provincial Auditor conducts an annual audit of government ministries and agencies, including the Ministry of Health. It includes an audit of Ministry payments to regional health authorities, to the Saskatchewan Cancer Agency, and to physicians and dental surgeons for insured physician and surgical-dental services.

Section 57 of the Regional Health Services Act requires that an independent auditor, who possesses the prescribed qualification and is appointed for that purpose by a regional health authority and the Cancer Agency, shall audit the accounts of a regional health authority or the Cancer Agency at least once in every fiscal year. Each regional health authority and the Cancer Agency must annually submit to the Minister of Health a detailed, audited set of financial statements.

Section 34 of the Cancer Foundation Act prescribes that the records and accounts of the Saskatchewan Cancer Foundation shall be audited at least once a year by the Provincial Auditor or by a designated representative.

The most recent audits were for the year ended March 31, 2011.

The audits of the Government of Saskatchewan, regional health authorities and Saskatchewan Cancer Agency are tabled in the Saskatchewan Legislature each year. The reports are available to the public directly from each entity or are available on their websites.

The Office of the Provincial Auditor for Saskatchewan also prepares reports to the Legislative Assembly of Saskatchewan. These reports are designed to assist the government in managing public resources and to improve the information provided to the Legislative Assembly. They are available on the  Provincial Auditor's website at: http://www.auditor.sk.ca

2.0 Comprehensiveness

2.1 Insured Hospital Services

Section 8 of the Regional Health Services Act (the Act) gives the Minister the authority to provide funding to a regional health authority or a health care organization for the purpose of the Act.

Section 10 of the Regional Health Services Act permits the Minister to designate facilities including hospitals, special care homes and health centres. Section 11 allows the Minister to prescribe standards for delivering services in those facilities by regional health authorities and health care organizations that have entered into service agreements with a regional health authority.

The Act sets out the accountability requirements for regional health authorities and health care organizations. These requirements include submitting annual operational, financial and health service plans for ministerial approval (sections 50-51); establishing community advisory networks (section 28); and reporting critical incidents (section 58). The Minister also has the authority to establish a provincial surgical registry to help manage surgical wait times (section 12). The Minister retains authority to inquire into matters (section 59); appoint a public administrator if necessary (section 60); and approve general and staff practitioner by-laws (sections 42-44).

Funding for hospitals is included in the funding provided to regional health authorities.

A comprehensive range of insured services is provided by hospitals. These may include: public ward accommodation; necessary nursing services; the use of operating room and case room facilities; required medical and surgical materials and appliances; x-ray, laboratory, radiological and other diagnostic procedures; radiotherapy facilities; anaesthetic agents and the use of anaesthesia equipment; physiotherapeutic procedures; all drugs, biological and related preparations required for hospitalized patients; and services rendered by individuals who receive remuneration from the hospital.

Hospitals are grouped into the following five categories: Community Hospitals; Northern Hospitals; District Hospitals; Regional Hospitals; and Provincial Hospitals, so people know what they can expect 24 hours a day, 365 days a year at each hospital. While not all hospitals will offer the same kinds of services, reliability and predictability means:

• it is widely understood which services each hospital offers; and
• these services will be provided on a continuous basis, subject to the availability of appropriate health providers.

Regional health authorities have 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. A regional 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 health regions, service providers and the public.

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. All fee items for physicians can be found in the  Physician Payment Schedule: www.health.gov.sk.ca/physician-information

As of March 31, 2011, there were 1,946 physicians licensed to practice in the province and eligible to participate in the medical care insurance plan.

Physicians may opt out or not participate in the Medical Services Plan, but if doing so, they must fully opt out of all insured physician services. The opted-out 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, 2011, there were no opted-out physicians in Saskatchewan.

Insured physician services are those that are medically necessary, are covered by the Medical Services Plan of the 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 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 (modernization) with significant monetary impact. The Executive Director of the Medical Services Branch manages this process. When the Medical Services Plan covers a new insured physician service or significant revisions occur to the Physician Payment Schedule, a regulatory amendment is made to the Physician Payment Schedule.

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 opt out or not participate in the Medical Services Plan, but if doing so, they must opt out of all insured surgical-dental services. The 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. Written acknowledgement from the beneficiary indicating that he or she understands the advice given by the dentist is also required. There were no opted-out dentists in Saskatchewan as of March 31, 2011.

Insured surgical-dental services are limited to: services in connection with maxillo-facial surgery required as a result of trauma; treatment services for the orthodontic care of cleft palate; extraction of teeth when medically required for the provision of heart surgery, services for chronic renal disease, head and neck cancer services, and services for total joint replacement by prosthesis when a proper referral has been made and prior approval obtained from Medical Services Branch; and certain services in connection with abnormalities of the mouth and surrounding structures.

Surgical-dental services can be added to the list of insured services covered under the Medical Services Plan through a process of discussion and consultation 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 Plan.

2.4 Uninsured Hospital, Physician and Surgical-Dental Services

Uninsured hospital, physician and surgical-dental services in Saskatchewan include: in-patient and out-patient hospital services provided for reasons other than medical necessity; the extra cost of private and semi-private hospital accommodation not ordered by a physician; physiotherapy and occupational therapy services not provided by or under contract with a regional health authority; services provided by health facilities other than hospitals unless through an agreement with a health region and licensed under the Health Facilities Licensing Act; non-emergency bone mineral densitometry provided outside Saskatchewan without prior written approval; non-emergency insured hospital, physician or surgical-dental services obtained outside Canada without prior written approval; non-medically required elective physician services; surgical-dental services that are not medically necessary; and services received under other public programs including the Workers' Compensation Act, the federal Department of Veteran Affairs and the Mental Health Services Act.

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. Compliance is periodically monitored through consultation with regional health authorities, physicians and dentists. There are no charges allowed in Saskatchewan for medically necessary 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. Compliance is monitored through consultations with regional health authorities, physicians and dentists.

Insured hospital services could be de-insured by the government if they were determined to be no longer medically necessary. The process is based on discussions among regional health authorities, practitioners, and officials from the Ministry of Health.

Insured physician services could be de-insured if they were determined not to be medically required. The process is based on 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. The process is based on 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.

The Ministry of Health implemented a new policy on the coverage of chiropractic services effective April 1, 2010. Universal chiropractic coverage was de-insured and low-income individuals receiving Supplementary or Family Health benefits, or on the Seniors Income Plan, became eligible for a maximum 12 treatments per year. Previous to this policy change, chiropractic services for the general public were insured on a co-payment basis and low income residents received full coverage.

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.

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.

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 eligible for insured health services in Saskatchewan:

• members of the Canadian Forces and the Royal Canadian Mounted Police (RCMP), federal inmates and refugee claimants; visitors to the province; and
• persons eligible for coverage from their home province or territory for the period of their stay in Saskatchewan (e.g., students and workers covered under temporary absence provisions from their home province or territory).

Such people become eligible for coverage as follows:

• discharged members of the Canadian Forces and the RCMP, if stationed in or resident in Saskatchewan on their discharge date;
• released federal inmates (this includes those prisoners who have completed their sentences in a federal penitentiary and those prisoners who have been granted parole and are living in the community); and
• refugee claimants, on receiving Convention Refugee status (immigration documentation is required).

The number of persons registered for health services in Saskatchewan on June 30, 2010, was 1,070,477.

3.2 Other Categories of Individual

Other categories of individual 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 Citizenship and Immigration Canada. Their accompanying family may also be eligible for insured health service coverage.

Refugees are eligible on confirmation of Convention status combined with a study/work permit, Minister's permit or permanent resident, that is, landed immigrant, record.

On June 30, 2010, there were 9,552 such temporary residents registered with the Saskatchewan Ministry of Health.

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 later arriving spouse is established on the earlier of 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.

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. There were no changes to the in-Canada temporary absence provisions in 2010-2011.

Section 6.6 of the Department of Health 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.

Continued coverage during a period of temporary absence is conditional upon the registrant's intent to return to Saskatchewan residency immediately on expiration of the approved absence period as follows:

• education: for the duration of studies at a recognized educational facility (confirmation by the facility of full-time student status and expected graduation date is required);
• employment of up to 12 months (no documentation required); and
• vacation and travel of up to 12 months.

Saskatchewan has bilateral reciprocal billing agreements with all provinces for hospital services, and all but Quebec for physician services. Rates paid are at the host province rates. The reciprocal arrangement for physician services applies to every province except Quebec.

Payments/reimbursement to Quebec physicians, for services to Saskatchewan residents, are made at Saskatchewan rates (Saskatchewan Physician Payment Schedule). However, the physician fees may be paid at Quebec rates with prior approval. In recent years, the out-of-province reciprocal hospital per diem billing rates have increased significantly.

4.3 Coverage During Temporary Absences Outside Canada

Section 3 of the Medical Care Insurance Beneficiary and Administration Regulations describe the portability of health insurance provided to Saskatchewan residents who are temporarily absent from Canada.

Continued coverage for students, temporary workers, and vacationers and travellers during a period of temporary absence from Canada is conditional on the registrant's intent to return to Saskatchewan residence immediately on the expiration of the approved period as follows:

• education: for the duration of studies at a recognized educational facility (confirmation by the facility of full-time student status and expected graduation date is required);
• contract employment of up to 24 months (written confirmation from the employer is required); and
• vacation and travel of up to 12 months.

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 six 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 Department of Health 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.

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 a reciprocal billing arrangement. This arrangement means that residents do not need prior approval and may not be billed for most services received 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:

• alcohol and drug, mental health and problem gambling services; and
• bone mineral densitometry testing.

Prior approval from the Ministry must be obtained by the patient's specialist.

Out-of-Country

Prior approval is required for the following services provided outside Canada:

• If a specialist physician refers a patient outside Canada for treatment not available in Saskatchewan or another province, the referring specialist must seek prior approval from the Medical Services Plan of the Ministry of Health. The Saskatchewan Cancer Agency is consulted for out-of-country cancer treatment requests. If approved, the Ministry of Health will pay the full cost of treatment, excluding any items that would not be covered in Saskatchewan.

5.0 Accessibility

5.1 Access to Insured Health Services

To ensure that access to insured hospital, physician and surgical-dental services are 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.

The Saskatchewan Human Rights Code prohibits discrimination in providing public services, which include insured health services, on the basis of race, creed, religion, colour, sex, sexual orientation, family status, marital status, disability, age, nationality, ancestry or place of origin.

The Saskatchewan Ministry of Health continues to place priority on promoting surgical access and improving the province's surgical system.

Sooner, Safer, Smarter: A Plan to Transform the Surgical Patient Experience was released on March 29, 2010. The plan will guide efforts to improve the surgical experience and reduce surgical wait times to a maximum of three months within four years, while ensuring shorter wait times can be sustained into the future. The four year plan is in response to recommendations in the Patient First Review, and was developed with assistance from stakeholder advisory groups. It is designed to improve the patients' experience across the entire continuum of care -- from initial contact with a health provider, to surgery, to recuperation in the community.

The plan is based on five objectives: 1) shorter waits for surgical care; 2) a better experience for patients and families; 3) safe, high quality care; 4) support for good health, and 5) patient centred providers. Supporting the objectives are 25 initiatives such as increasing surgical procedures and diagnostic imaging services, offering opportunities for greater patient choice, mechanisms to improve safety, health promotion and injury prevention activities, and initiatives to support an effective health work force.

As of March 31, 2011, there were 1,946 physicians licensed to practice in the province and eligible to participate in the Medical Care Insurance Plan. Of these, 1,034 (53.1 percent) were family practitioners and 912 (46.9 percent) were specialists.

As of March 31, 2011, there were approximately 387 practising dentists and dental surgeons located in all major centres in Saskatchewan. Eighty five provided services insured under the Medical Services Plan.

In May 2009, the Government of Saskatchewan released the Physician Recruitment Strategy in an effort to address province-wide physician shortages. In 2010-2011 the following initiatives were implemented:

• The 2010-2011 budget allocated $1.5 million (from within the $3.5 million Physician Recruitment Strategy funding) to the Physician Recruitment Agency of Saskatchewan to provide recruitment expertise to communities, physician practices and health agencies.
• The provincial plan for distributed medical education continued to be developed and rolled out with the goal of increasing the number of medical seats in rural centres. Post-graduate seats were offered in Regina, Prince Albert and Swift Current.
• The Ministry engaged in a dialogue with stakeholders to begin the development of a provincially-based program to assess foreign-trained family physicians. The first iteration of the new program was January 2011.

In addition to the new initiatives noted above, the Ministry provides various practicing establishment grants, training grants, and residency positions in exchange for return-of-service commitments. The Ministry funds compensation mechanisms for emergency room coverage to ensure patients have access to emergency medical services.

There are also a number of programs to stabilize and support medical services in rural areas, such as the following:

• The Saskatchewan Medical Association is funded to provide locum relief to rural physicians through the Locum Service Program while they take vacation, education or other leave.
• The Northern Medical Services Program is a tripartite endeavour of the Ministry of Health, Health Canada and the University of Saskatchewan to help stabilize the supply of physicians in northern Saskatchewan.
• The Northern Telehealth Network provides physicians in remote or isolated areas with access to colleagues, specialty expertise and continuing education.

Other Programs

• Support is provided to initiatives for physicians to use allied health professionals and enhance the integration of medical services with other community-based services through the Alternate Payments and Primary Health Services Program.
• A Long-term Service Retention Program rewards physicians who work in the province for 10 or more years.
• The Parental Leave Program was developed in 2004 to provide benefits for self-employed physicians who take a maternity, paternity or adoption child care leave from clinical practice.

5.2 Physician Compensation

The last agreement with the Saskatchewan Medical Association expired on March 31, 2009. The Ministry continued to meet with the Association throughout 2010-2011 to reach a new agreement.

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, salaries, capitation arrangements 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 2010-2011 amounted to $747.6 million: $450.8 million for fee-for-service billings; $27.7 million for Emergency Coverage Programs; $235.9 million in non-fee-for-service expenditures; and $33.2 million for Saskatchewan Medical Association programs. During 2010-2011 negotiations with the Saskatchewan Medical Association, the Ministry continued to fund and support these programs at the level that was defined in the expired agreement.

5.3 Payments to Hospitals

Funding to regional health authorities is based on historical funding levels adjusted for inflation, collective agreement costs and utilization increases. Each regional health authority 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.

Regional health authorities may receive additional funds for providing specialized hospital programs (e.g., renal dialysis, specialized medical imaging services, specialized respiratory services, and surgical services), or for providing services to residents from other health regions.

Payments to regional health authorities for delivering services are made pursuant to section 8 of the Regional Health Services Act. The legislation provides the authority for the Minister of Health to make grants to regional health authorities and health care organizations for the purposes of the Act, and to arrange for providing services in any area of Saskatchewan if it is in the public interest to do so.

Regional health authorities provide an annual report on the aggregate financial results of their operations.

6.0 Recognition Given to Federal Transfers

The Government of Saskatchewan publicly acknowledged the federal contributions provided through the Canada Health Transfer (CHT) in the Ministry's 2010-2011 Annual Report, the Government of Saskatchewan 2010-2011 Budget and related documents, its 2010-2011 Public Accounts, and the Quarterly and Mid-Year Financial Reports. These documents were tabled in the Legislative Assembly and are publicly available to Saskatchewan residents. Federal contributions have also been acknowledged on the Ministry of Health website, in news releases and issue papers, and in speeches and remarks made at various conferences, meetings and public policy forums.

Alberta

Introduction

Alberta's Health Care System

In 2010-2011, the Ministry of Alberta Health and Wellness (Health and Wellness) continued to pursue its goal of improving the performance and accessibility of the health system in meeting the needs of Albertans. Some key achievements include:

• The Government of Alberta released Becoming the Best: Alberta's 5-year Health Action Plan in November 2010. The plan provides Albertans clear direction on what they can expect from their health care system over the next five years. The Plan provides the detailed targets the province will use to drive further improvements in the health care system, and is organized under five core areas:
  • Improve access and reduce wait times;
  • Provide more options for continuing care;
  • Strengthen primary health care;
  • Be healthy, stay healthy; and
  • Build one health system.
• The Plan is supported by 50 accompanying performance measures, and is one of the most aggressive plans to reduce wait times and increase access anywhere in Canada. The performance measures include: reduced wait times for hip surgery; quicker access to radiation oncologists for cancer patients; faster treatment at emergency departments; more continuing care spaces; and a greater emphasis on wellness to keep Albertans healthy.
• A new Act called the Alberta Health Act (Act) received Royal Assent in December 2010 and is awaiting proclamation. The Act provides principles to guide the health system, requirements to establish a health charter and a health advocate, as well as provisions for public input into the regulations proposed for the Act.

1.0 Public Administration

1.1 Health Care Insurance Plan and Public Authority

Health and Wellness administers the Alberta Health Care Insurance Plan on a non-profit basis and in accordance with the Canada Health Act. Since 1969, the Alberta Health Care Insurance Act has governed the operation of the Alberta Health Care Insurance Plan. The Minister determines which services are covered by the Alberta Health Care Insurance Plan.

1.2 Reporting Relationship

The Minister of Health and Wellness is accountable for the Alberta Health Care Insurance Plan. The Government Accountability Act establishes the planning, reporting and accountability structures that government and accountable organizations must adhere to.

1.3 Audit of Accounts

The Auditor General of Alberta audits all government ministries, departments, regulated funds and provincial agencies, and is responsible for assuring the public that the government's financial reporting is credible. The Auditor General of Alberta completed its audit of Health and Wellness on March 31, 2011, and indicated that the statements fairly present, in all material respects, the financial position and results of operations for the year ended March 31, 2011.

2.0 Comprehensiveness

2.1 Insured Hospital Services

In Alberta, Alberta Health Services is the body 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 and the Health Care Protection Regulation (AR 208/2000) regulate the provision of insured services by hospitals or designated non-hospital surgical facilities. A  directory of approved hospitals in Alberta can be found at: http://www.health.alberta.ca/documents/Hospital-Services-Alberta-2011-4.pdf

During 2010-2011, no amendments were made to the legislation regarding insured hospital services.

The publicly funded services provided by approved hospitals in Alberta range from the most advanced levels of diagnostic and treatment services for in-patients and out-patients to the 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 (AR 244/1990). The Regulation is available at: www.health.alberta.ca/about/health-legislation.html

There is no regular process to review insured hospital services, as the list of insured services included in the regulations is intended to be both comprehensive and generic, and does not require routine review and updating. Changes to specific physician services can be found in the Schedule of Medical Benefits, and are described in the next section.

2.2 Insured Physician Services

The Alberta Health Care Insurance Act governs the payment of physicians for insured physician services under the Alberta Health Care Insurance Plan (section 6). Only physicians who meet the requirements stated in the Alberta Health Care Insurance Act are allowed to provide insured services under the Alberta Health Care Insurance Plan.

Alberta had 6,743 fee-for-service physicians who were billing the Alberta Health Care Insurance Plan as of March 31, 2011.

Before being registered with the Alberta Health Care Insurance Plan, a physician must complete the appropriate registration forms and include a copy of his or her license issued by the appropriate governing body or association, such as the College of Physicians and Surgeons of Alberta.

Under section 8 of the Alberta Health Care Insurance Act, all physicians are deemed to be opted into the Alberta Health Care Insurance Plan. A physician may, however, opt out of the Alberta Health Care Insurance Plan by notifying the Minister in writing indicating the effective date of the opting out, publishing a notice of the proposed opting out in a newspaper having general circulation in the area in which the physician practices and posting a notice of the proposed opting out in a part of the physician's office to which patients have access, at least 180 days prior to the effective date of the opting out. A physician who has opted out must post a notice in part of the physician's office to which patients have access advising patients of the physician's opted out status and ensuring that each patient is advised of their opted out status before any service is provided to the patient. As of March 31, 2011, there were zero opted out physicians in the province.

The Alberta Health Care Insurance Regulation lists services which are not considered to be either basic or extended health services. The Medical Benefits Regulation 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 (SOMB), which can be accessed at: http://www.health.alberta.ca/professionals/SOMB.html

The SOMB is continuously revised. Effective April 1, 2010, extensive changes were made to the SOMB. All changes to the SOMB require ministerial approval. Some of the highlights for these changes included:

• 39 new Health Service Codes, two new modifier types and four new General Rules;
• 47 deleted Health Service Codes and two deleted General Rules; and
• 99 amendments to Health Service Codes, 10 amendments to modifiers and 40 amendments to General Rules.
• The changes outlined above include:
  • New Health Service Code for Group Sessions, multiple patients, where a physician is involved in providing care and teaching to patients in attendance.
  • A redevelopment and modernization of the General Surgery and Neurosurgery schedule items.
  • New "corrected age" modifiers to remunerate surgeons at a higher rate when performing surgery on infants up to three months old corrected age (i.e., where their chronological age is reduced by the number of weeks born before 40 weeks gestation).
  • New "L40" modifiers to remunerate surgeons at a higher rate when performing surgery on infants under 40 weeks of conceptual age.

Under the 2003-2011 Tri-lateral Master Agreement, any changes to the insured physician services listed in the SOMB were the result of negotiation between Health and Wellness, the Alberta Medical Association, and Alberta Health Services. The Agreement expired on March 31, 2011.

2.3 Insured Surgical-Dental Services

In Alberta, a small number of surgical-dental services are insured. The majority of dental procedures that can be billed to the Alberta Health Care Insurance Plan can only be performed by a dentist certified as an oral and maxillofacial surgeon who meets the requirements stated in the Alberta Health Care Insurance Act. Under section 7 of the Alberta Health Care Insurance Act, all dentists are deemed to have opted into the Plan. A dentist may opt out of the plan by notifying the Minister in writing of the effective date of their opting out and by ensuring that each patient is advised of their opted out status before any service is provided to the patient. As of March 31, 2011, no dentists were opted out of the Alberta Health Care Insurance Plan.

Alberta insures a number of medically necessary oral surgical and dental procedures that are listed in the  Schedule of Oral and Maxillofacial Surgery Benefits, available at: http://www.health.alberta.ca/professionals/allied-services-schedule.html. Although there is no formal agreement with dentists, Health and Wellness meets with members of the Alberta Dental Association and College to discuss changes to the Schedule of Oral and Maxillofacial Surgery Benefits. All changes to the benefit schedule require ministerial approval.

2.4 Uninsured Hospital, Physician and Surgical-Dental Services

Section 12 of the Alberta Health Care Insurance Regulation lists services which are not insured as basic or extended health services. Section 4(2) of the Hospitalization Benefits Regulation provides a list of hospital services that are not considered to be insured.  Alberta's policy for Preferred Accommodation and Non-Standard Goods or Services is available at: http://www.health.alberta.ca/newsroom/pub-health-authorities.html.

The policy describes the Government of Alberta's expectations of Alberta Health Services and guides its decision-making with respect to the provision of preferred accommodation and enhanced or non-standard goods and services. This policy framework requires Alberta Health Services to provide 30 days advance notice to the Minister's designate regarding the categories of preferred accommodation offered and the charges associated with each category. Alberta Health Services is also required to provide 30 days advance notice to the Minister's designate regarding any goods or services that will be provided as non-standard goods or services. They are also required to 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.

3.0 Universality

3.1 Eligibility

Under the terms of the Alberta Health Care Insurance Act, all Alberta residents are eligible to receive publicly funded health care services under the Alberta Health Care Insurance Plan. A resident is defined as a person lawfully entitled to be or to remain in Canada who makes the province his or her home and is ordinarily present in Alberta. 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 are landed immigrants, returning landed immigrants or returning Canadian citizens. Persons in Alberta on an approved Canada entry permit may also be eligible for coverage under the Alberta Health Care Insurance Plan; and their eligibility is reviewed on a case-by-case basis.

Residents who are not eligible for coverage under the Alberta Health Care Insurance Plan, but receive health care coverage from the federal government, include:

• members of the Canadian Armed Forces;
• members of the Royal Canadian Mounted Police (RCMP) who are appointed to a rank in it; and
• persons serving a term in a federal penitentiary.

The Alberta Health Care Insurance Plan covers persons released from the RCMP, the Canadian Armed Forces and federal penitentiaries, effective the date of release, if notified within three months. If they 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. During 2010-2011, no amendments were made to the legislation regarding eligibility.

All Alberta residents are required to register themselves and their eligible dependants with the Alberta Health Care Insurance Plan. Family members are registered on the same account. New residents in Alberta should apply for coverage within three months of arrival or effective dates may be affected. For persons moving from within Canada, their registration is effective on the first day of the third month after their arrival. For persons moving from outside Canada, their registration is effective the day they become an Alberta resident. The Alberta Health Care Insurance Plan process for registering Albertans and issuing replacement health cards require registrants to provide documentation that proves their identity, legal entitlement to be in Canada, and Alberta residency.

As of March 31, 2011, there were 3,786,238 Alberta residents registered with the Alberta Health Care Insurance Plan. Under the Health Insurance Premiums Act, a resident may opt out of the Alberta Health Care Insurance Plan by filing a declaration with the Minister. As of March 31, 2011, there were 228 Alberta residents who were opted out of the Plan.

3.2 Other Categories of Individual

Persons on an approved Canada entry permit who may be eligible include those with Student or Employment Permits, Temporary Resident Permits and Visitor Records. There were 61,404 people covered under these conditions as of March 31, 2011.

4.0 Portability

4.1 Minimum Waiting Period

Under the Alberta Health Care Insurance Plan, persons moving permanently to Alberta from another part of Canada are eligible for coverage on the first day of the third month following their arrival.

4.2 Coverage During Temporary Absences in Canada

The Alberta Health Care Insurance Plan provides coverage for eligible Alberta residents for the first 12 months of absence who temporarily leave Alberta for other parts of Canada. Residents who wish to maintain coverage for a longer period may apply for an extension.

Individuals who are routinely absent from Alberta every year normally need to 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 Health and Wellness of their permanent and principal place of residence within the province.

Alberta participates in the interprovincial hospital and 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/territories (Quebec does not participate in the medical reciprocal agreement). Under these agreements, Alberta pays for insured services that Albertans receive in other parts of Canada at the host provincial or territorial rates.

In 2010-2011, no amendments were made to the legislation regarding in-Canada portability. More information on  coverage during temporary absences outside Alberta is available at: http://www.health.alberta.ca/AHCIP/Q-coverage-outside-Alberta.html

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 2010-2011.

4.3 Coverage During Temporary Absences Outside Canada

The Alberta Health Care Insurance Plan provides coverage to eligible Alberta residents for the first six consecutive months of temporary absence from Canada. Residents who wish to maintain coverage for a longer period may apply for an extension of coverage.

Individuals who are routinely absent from Alberta every year normally need to 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 Health and Wellness of their permanent and principal place of residence within the province.

The maximum amount payable for out-of-country in-patient hospital services is $100 (Canadian) per day (not including day of discharge). The maximum hospital out-patient visit rate is $50 (Canadian), 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 $472 per visit, with a limit of one visit per day. Physician and dental specialist/oral surgeon services are paid according to Alberta rates. Funding may also be available through the Out-of-Country Health Services Committee process that evaluates reimbursement requests by Alberta residents for medically necessary services which are covered under the Alberta Health Care Insurance Plan, but are not available in Canada. More information on  coverage during temporary absences outside Canada is accessible at: http://www.health.alberta.ca/AHCIP/Q-coverage-outside-Alberta.html

Section 16 of the Hospitalization Benefits Regulation addresses payment for hospital services obtained outside of Canada. Section 5 of the Medical Benefits Regulation addresses payment of physician services obtained outside of Canada. These sections were not amended in 2010-2011.

4.4 Prior Approval Requirement

Prior approval is not required for elective insured services received in another Canadian province/territory, except for high-cost items not included in reciprocal agreements such as gamma knife surgery. Prior application is required for elective services received out-of-country and approval may only be given for insured services that are medically required, are not experimental, and are not available in Alberta or elsewhere in Canada.

5.0 Accessibility

5.1 Access to Insured Health Services

All Alberta residents have access to provincially funded and insured health services regardless of where they live in the province. Within Alberta, there are two major metropolitan zones, the Calgary zone and the Capital (Edmonton) zone, which provide provincially-funded, province-wide services to Alberta residents who need tertiary-level diagnostic and treatment services.

Alberta Health Services is responsible for overseeing the planning and delivery of health supports and services to more than three and a half million adults and children living in the province of Alberta. The board for Alberta Health Services governs all health services in the province, working in partnership with Health and Wellness to ensure all Albertans have equal access to health services across the province.

Health and Wellness announced, as part of its 2010-2013 Health Capital Plan, funding for several ambulatory, and primary and acute care projects designed to improve Albertans' access to insured health services. These projects include:

• The redevelopment of the Medicine Hat Regional Hospital and will include renovations to create additional ambulatory treatment space.
• A new health centre in Edson, which will be built on a new site to provide health care services and programs to meet the needs of the community, including acute care, emergency and out-patient services.
• A new health centre in High Prairie to replace the existing complex and the J.B. Wood Nursing Home. The new High Prairie Health Centre will be built on a new site and will include a wide range of health services such as acute care, continuing care and community health programs.
• A new regional hospital in Grande Prairie, which will include a state-of-the-art cancer centre.
• The addition of 1,166 new and upgraded spaces to Alberta's continuing care system to address the needs of an aging population. New construction or renovations involving 13 facilities were initiated across 11 Alberta communities.
• The launch of seven new Primary Care Networks (PCNs) throughout 2010-2011: Athabasca PCN was launched on April 1, 2010; Cold Lake PCN and Vegreville PCN were launched on July 1, 2010; Wetaskiwin PCN and Vermilion PCN were launched on September 1, 2010; Grande Prairie PCN was launched on October 1, 2010; and Lloydminster PCN was launched on January 1, 2011. As of March 31, 2011, there were 39 PCNs operating in Alberta.

5.2 Physician Compensation

The Alberta Health Care Insurance Act governs the payment of physicians. Most physicians are compensated through the Alberta Health Care Insurance Plan on a volume-driven, fee-for-service basis. Alternate Relationship Plans (ARPs) for specialists and family physicians offer alternative compensation models to the fee-for-service payment system. ARPs contribute to better health outcomes by supporting innovative health care delivery.

Under the 2003-2011 Tri-Lateral Master Agreement that expired on March 31, 2011, changes to physician compensation for the provision of insured services were subject to the negotiation. The Agreement established overall increases to compensation under the fee-for-service and ARPs streams. Once overall increases were established, by virtue of the negotiated agreement, the parties undertook an allocation process in which increases were divided between the different medical specialties.

Under the Agreement, ARPs were established to enhance physician recruitment and retention, team-based approaches to service delivery, access to services, patient satisfaction, and value for money. ARPs provide predictable funding that enables physician groups to recruit new physicians to their programs and retain their services. ARPs are unique in that they offer an alternative funding model to the way government has traditionally funded health care service delivery. (With the expiry of the Agreement on March 31, 2011, funding for ARPs was continued through Ministerial Order.)

Beyond matters of compensation for the provision of insured services, the Agreement also contained provisions for programs involving patient access and service improvements. The Agreement established the Primary Care Initiative under which Primary Care Networks received funding. PCNs support innovative health care delivery and use a team approach to coordinate care for their patients. Family physicians work with Alberta Health Services to better integrate health services by linking to regional services such as home care. Family physicians also work with other health care providers such as nurses, dieticians, pharmacists, physiotherapists and mental health workers who help to provide services within the PCNs. Funding for PCNs, which was extended by the Ministry when the 2003-2011 agreement expired, is not intended to compensate physicians for the provision of insured services although physicians can receive payment for uninsured services related to work done on behalf of the PCN.

The negotiated agreement also provided for payments to physicians under a physician on-call program, an office information technology program, direct overhead payments and rural incentive programs. The Ministry extended funding for these programs as well when the negotiated agreement expired on March 31, 2011.

As with the majority of physicians, dentists performing oral surgical services insured under the Alberta Health Care Insurance Plan are compensated through the Plan on a volume driven, fee-for-service basis. Health and Wellness establishes fees through a consultation process with the Alberta Dental Association and College.

5.3 Payments to Hospitals

The Regional Health Authorities Act governs the funding of Alberta's single regional health authority--Alberta Health Services. Most insured hospital services in Alberta are funded through a population-based funding formula. A mental health funding grant is provided for insured services provided in mental health hospitals and for community mental health services. A funding grant is provided for insured services in cancer hospitals and to pay for cancer services that patients receive in regional hospitals. Hospitals in Edmonton and Calgary receive funding to provide highly specialized province-wide services to all Alberta residents.

Alberta's Health Care Protection Act governs the provision of insured surgical services performed in non-hospital surgical facilities. Ministerial approval of a contract between the facility and/or operator and Alberta Health Services is required in order for the facility to provide insured services. Ministerial designation of a non-hospital surgical facility and accreditation by the College of Physicians and Surgeons of Alberta are also required.

According to the Health Care Protection Act, ministerial approval for a contractual agreement shall not be given unless:

• the insured surgical services are consistent with the principles of the Canada Health Act;
• there is a current and likely future need for the services in the geographical area;
• the proposed surgical services will not have a negative impact on the province's public health system;
• there will be an expected benefit to the public;
• Alberta Health Services has an acceptable business plan to pay for the services;
• the proposed agreement contains performance expectations and measures; and
• the physicians providing the services will comply with the conflict of interest and ethical requirements of the Medical Profession Act and bylaws.

6.0 Recognition Given to Federal Transfers

The Government of Alberta publicly acknowledged the federal contributions provided through the Canada Health Transfer in its 2010-2011 publications.

British Columbia

Introduction

The British Columbia health system is one of our most valued social programs; virtually every person in the province will access some level of health care or health service during their lives. British Columbia has a progressive and integrated health system that includes insured services funded under the Canada Health Act, services funded wholly or partially by the Government of British Columbia and services regulated, but not funded by, government. The Ministry of Health (the Ministry) has overall responsibility for ensuring that quality, appropriate, and timely health services are available to all British Columbians.

The Ministry works with health authorities, care providers, agencies, and other groups to guide and enhance the province's health services, provide access to care, and ensure British Columbians are supported in their efforts to maintain and improve their health. The Ministry provides leadership, direction, and support to these service delivery partners and sets province-wide goals, standards, and expectations for health service delivery by health authorities. The Ministry directly manages a number of provincial programs and services. These programs include: the Medical Services Plan, which covers most physician services; PharmaCare, which provides prescription drug insurance for British Columbians; the BC Vital Statistics Agency, which registers and reports on vital events such as a birth, death or marriage; and HealthLink BC, a confidential, non-emergency health information, advice, and health system navigation platform providing  multi-disciplinary comprehensive self-care service. It is available 24/7 by telephone (8-1-1), on the web (www.healthlinkbc.ca), and in print resources (BC HealthGuide Handbook).

The province's six health authorities are the organizations primarily responsible for health service delivery. Five regional health authorities deliver a full continuum of health services to meet the needs of the population within their respective geographic regions. A sixth health authority, the Provincial Health Services Authority, is responsible for managing the quality, coordination, and accessibility of services and province-wide health programs. These include the specialized programs and services provided through the following agencies: Emergency and Health Services Commission which operates both BC Ambulance Service and BC Bedline, the provincial acute bed management system; BC Cancer Agency; BC Centre for Disease Control; BC Children's Hospital and Sunny Hill Health Centre for Children; BC Women's Hospital and Health Centre; BC Provincial Renal Agency; BC Transplant Society; Cardiac Services BC; BC Mental Health and Addiction Services including Riverview Hospital and the Forensic Psychiatric Services Commission; and Perinatal Services BC.

In 2010-2011, the Government of British Columbia invested $16.15 billion to meet the health needs of British Columbians. This expenditure was made across a wide spectrum of programs and services aligned with the Ministry's goals. The delivery of health services and the health of the population are monitored by the Ministry on an ongoing basis. These activities inform the Ministry's strategic planning and policy direction to ensure the delivery of health information and services continue to meet the needs of British Columbians.

The following section highlights significant achievements in 2010-2011 in areas relevant to the Canada Health Act Annual Report: providing increased access to care, innovation in health care, and health human resources.

Access to care:

• Opened the $9.4 million renal unit at Nanaimo Regional General Hospital, benefitting kidney patients across Central and Northern Vancouver Island, and opened the $349 million Patient Care Centre at Royal Jubilee Hospital in Victoria.
• Completed the $4.3 million newly redeveloped Invermere and District Hospital emergency department, doubling the size of the emergency department and improving patient flow, and completed the $24.7 million Shuswap Lake General Hospital redevelopment.
• Began construction on the new $36.9 million emergency department at Nanaimo Regional General Hospital, and worked with Canuck Place, the Provincial Health Services Authority, the Ministry of Children and Family Development, and the Fraser Health Authority to guide the expansion of hospice services for children in British Columbia.
• Increased investment in cancer care and control through the BC Cancer Agency by 151 percent since 2000-2001. Began construction on the $106 million BC Cancer Agency for the North, which will eliminate the need for northern residents to travel south for treatment.
• Reached a new agreement with emergency room physicians, providing an increase to the number of doctors in 19 emergency departments across the province. Over the 2010-2011 and 2011-2012 fiscal years, the Province's funding commitment will increase by up to $12 million for physician services in the affected hospitals over the two years.
• Continued to close the gap in health status between Aboriginal peoples and the rest of the British Columbia population by negotiating the BC Framework Agreement on First Nations Health Governance, which outlines the transfer of health resources to First Nations, to enable and empower First Nations people to better govern their own health and well-being.
• Launched a new surgical wait times website, which helps patients work with their general practitioners to decide whether there is a faster or more appropriate treatment available, and helps health authorities and the Province make decisions about funding and surgical resource allocation.
• Increased guideline-based care by family physicians; for example, planned chronic disease or complex care was provided to 575,894 patients as at February 2011, which is ten percent higher than at February 2010.

Innovation in health care:

In early 2010, British Columbia embarked on an innovation and change agenda, which is based on two key actions: 1) Where possible and appropriate, British Columbia can lower cost, improve patient outcomes, and improve patient experience by moving patient care from high cost, high intensity services such as hospital care to lower cost services within the community, and 2) Improve the efficiency of the system and drive innovation while continuing to meet the needs of the British Columbia population.

The innovation and change agenda is showing results:

• Patient-focused funding was introduced in April 2010 to provide quicker emergency department care, reduce surgery wait times, and increase the number of same-day surgical procedures where appropriate. With 2010-2011 patient-focused funding, an additional 36,000 patients received surgeries and diagnostic care and an additional 67,000 emergency department patients were seen within the targeted wait times.
• More than 125 Lean events were held across the province aimed at improving workflow and efficiency, improving services to patients, and reducing costs in the health system.
• Through initiatives such as active waitlist management and Activity-Based Funding, British Columbia has increased the number of hip replacements from 4,478 in 2009-2010 to 4,600 in 2010-2011. Over 400 more knee joint replacements were completed from the previous fiscal year and the 90th percentile wait time dropped by 3.7 weeks.
• The Province is providing help to British Columbia smokers who want to quit as part of its prevention initiative. The Prescription for Health program helps primary care providers give British Columbia doctors additional tools to help support those patients who smoke, are physically inactive, obese, or have unhealthy eating practices. QuitNow Services offers free smoking cessation supports 24 hours a day through web, text, and telephone services.
• The Province negotiated an agreement with the community pharmacy sector that will reduce the price of generic drugs in British Columbia, and save the British Columbia health system tens of millions of dollars per year.

Health human resources:

• Since 2004, the University of British Columbia (UBC) medical school has more than doubled the number of first-year seats for undergraduate medical students to 256, and distributed training programs outside the Lower Mainland to the Northern Medical Program in Prince George, the Island Medical Program in Victoria, and the Southern Medical Program which opened in the Okanagan in September 2011. By 2015, approximately 1,150 medical students are expected to be in training at any one time in BC.
• Growth in postgraduate medical education (residencies) has kept pace with undergraduate expansion. Since 2004, British Columbia has more than doubled the number of first-year residencies for Canadian medical graduates to 256, and tripled the number for international medical graduates (IMG) to 19.
• Starting in 2011, the IMG-BC Program is expected to expand and distribute its program by an additional 40 first-year residencies in family medicine over the next five years. By 2015, 1,200 residents are expected to be in training at any one time, and by 2020, over 300 new physicians are expected to be ready to enter practice each year.
• The College of Physicians and Surgeons of British Columbia reported 10,726 professionally active physicians in British Columbia in 2010.

1.0 Public Administration

1.1 Health Care Insurance Plan and Public Authority

The British Columbia Medical Services Plan (MSP) is administered by the British Columbia Ministry of Health. MSP insures medically required services provided by physicians and supplementary health care practitioners, laboratory services, and diagnostic procedures. The Ministry of Health sets goals, standards and performance agreements for health service delivery and works with the six health authorities to provide quality, appropriate and timely health services to British Columbians. General hospital services are provided under the Hospital Insurance Act (section 8) and its Regulation; the Hospital Act (section 4); and the Hospital District Act (section 20).

The Medical Services Commission (MSC) manages MSP on behalf of the Government of British Columbia in accordance with the Medicare Protection Act (section 3) and its Regulation. The purpose is to preserve a publicly-managed and fiscally sustainable health care system for British Columbia, in which access to necessary medical care is based on need and not on an individual's ability to pay. The function and mandate of the MSC is to facilitate, under MSP, reasonable access to quality medical care, health care, and diagnostic services for British Columbians.

The MSC is a nine-member statutory body made up of three representatives from the Government of British Columbia, three representatives from the British Columbia Medical Association (BCMA), and three members from the public jointly nominated by the BCMA and government.

1.2 Reporting Relationship

The Medical Services Commission (MSC) is accountable to the Government of British Columbia through the Minister of Health; a report is published annually for the prior fiscal year which provides an annual accounting of the business of the MSC, its subcommittees and other delegated bodies. In addition, the MSC Financial Statement is published annually: it contains an alphabetical listing of payments made by the MSC to practitioners, groups, clinics, hospitals, and diagnostic facilities for each fiscal year.

The Ministry of Health (the Ministry) provides extensive information in the Annual Service Plan Report on the performance of British Columbia's publicly funded health system. Tracking and reporting this information is consistent with the Ministry's strategic approach to performance planning and reporting and is consistent with requirements contained in the provincial Budget Transparency and Accountability Act (2000).

In addition to the Annual Service Plan Report, the Ministry reports through various publications, including:

• Vital Statistics Annual Report;
• Health Authority Government Letters of Expectations and Reports;
• Provincial Health Officer's Annual Report (on the health of the population);
• Nationally Comparable Indicators Report (Canadian Institute for Health Information); and
• Medical Services Commission Annual Report.

1.3 Audit of Accounts

The Ministry is subject to audit of accounts and financial transactions through:

• The Office of the Comptroller General's Internal Audit and Advisory Services, the government's internal auditor. The Comptroller General determines the scope of the internal audits and timing of the audits in consultation with the audit committee of the Ministry.
• The Office of the Auditor General (OAG) of British Columbia is responsible for conducting audits and reporting its findings to the Legislative Assembly. The OAG initiates its own audits and the scope of its audits. The Public Accounts Committee of the Legislative Assembly reviews the recommendations of the OAG and determines when the Ministry has complied with the audit recommendations.

1.4 Designated Agency

The MSP of British Columbia requires premiums to be paid by eligible residents. The monies were collected by the Ministry of Finance during the 2010-2011 fiscal year. Revenue Services of British Columbia (RSBC) performs revenue management services, including account management, billing, remittance and collection, on behalf of the Province of British Columbia (Ministry of Finance). The Province remains responsible for, retains control of, and performs all government-administered collection actions.

RSBC is required to comply with all applicable laws, including:

• Ombudsman Act (British Columbia)
• Business Practices and Consumer Protection Act (British Columbia)
• Financial Administration Act (British Columbia)
• Freedom of Information Legislation: i.e., Freedom of Information and Protection of Privacy Act (British Columbia) including FOIPPA Inspections; the Personal Information Protection Act (British Columbia) and the equivalent federal legislation, if applicable.

In 2005, the Ministry of Health contracted with MAXIMUS BC to deliver the operations of the Medical Services Plan and PharmaCare (including responding to public inquiries, registering clients, and processing medical and pharmaceutical claims from health professionals). The new organization is called Health Insurance BC (HIBC). Policy and decision-making functions remain with the Ministry of Health (the Ministry).

• HIBC submits monthly reports to the Ministry, reporting performance on service levels to the public and health care providers. HIBC also posts reports on its website on performance of key service levels.
• HIBC applies payments against fee items approved by the Ministry. The Ministry approves all payments before they are released.

2.0 Comprehensiveness

2.1 Insured Hospital Services

The Hospital Act and Hospital Act Regulation provide authority for the Minister of Health to designate facilities as hospitals, to license private residential care hospitals, to approve the bylaws of hospitals, to inspect hospitals, and to appoint a public administrator. This legislation also establishes broad parameters for the operation of hospitals.

The Hospital Insurance Act provides the authority for the Minister of Health to make payments to health authorities for the purpose of operating hospitals, outlines who is entitled to receive insured services, and defines the "general hospital services" which are to be provided as benefits.

Hospital services are insured when they are provided to a beneficiary, in a publicly funded hospital and are deemed medically required by the attending physician or midwife. These services are provided to beneficiaries without charge, with the exception of incremental charges for preferred, but not medically required, medical/surgical supplies, nonstandard accommodation when not medically required and, for residential care patients in extended care or general hospitals, a daily fee based on income.

General hospital services and the conditions under which they are provided are described in the Hospital Insurance Act Regulations and include the following for in-patients: accommodation and meals at the standard or public ward level; necessary nursing services; laboratory and radiological procedures and necessary interpretations together with such other diagnostic procedures as approved by the Minister in a particular hospital with the necessary interpretations, for maintaining health, preventing disease and helping diagnose and treat illness, injury or disability; drugs, biological, and related preparations; routine surgical supplies; use of operating room and case room and anaesthetic facilities, including necessary equipment and supplies; use of radiotherapy and physiotherapy facilities, where available; and other services approved by the Minister.

The following out-patient general hospital services are also insured: day care surgical services; out-patient renal dialysis treatments in designated hospitals or other approved facilities; diabetic day-care services in designated hospitals; out-patient dietetic counselling services at hospitals with qualified staff dieticians; psychiatric out-patient and day-care services; rehabilitation out-patient services; cancer therapy and cytology services; out-patient psoriasis treatment; abortion services; and magnetic resonance imaging (MRI) services. In addition, a wide variety of out-patient clinic services are insured when delivered in a hospital.

Insured services in rehabilitation hospitals include: accommodation and meals at the standard or public ward level; necessary nursing services; drugs, biologicals and related preparations; use of physiotherapy and occupational therapy facilities; laboratory and radiological procedures and necessary interpretations together with such other diagnostic procedures as approved by the Minister in a particular hospital with the necessary interpretations, for maintaining health, preventing disease, and helping diagnose and treat illness, injury, or disability; and other services approved by the Minister.

Insured services in extended care hospitals include: accommodation and meals at the standard ward level; necessary nursing services; drugs, biologicals, and related preparations; laboratory and radiological procedures and necessary interpretations together with such other diagnostic procedures as approved by the Minister in a particular hospital with the necessary interpretations, for maintaining health, preventing disease and helping diagnose and treat illness, injury, or disability; and other services approved by the Minister.

Insured hospital services do not include: transportation to and from hospital (however, ambulance transfers are insured under another Ministry program, with a small user charge); services or treatment that the Minister, or a person designated by the Minister, determines, on a review of the medical evidence, the beneficiary does not require; services or treatment for an illness or condition excluded by regulation of the Lieutenant Governor in Council; and services provided to non-beneficiaries.

No new hospital services were added during the 2010-2011 fiscal year. There is no regular process to review insured hospital services, as the list of insured services included in the regulations is intended to be both comprehensive and generic and does not require routine review and updating. There is a formal process to add specific medical services (physician fee items) to the list of services insured under the Medicare Protection Act, and this process is described in Section 2.2 of this report.

2.2 Insured Physician Services

The range of insured physician services covered by the Medical Services Plan (MSP) includes all medically necessary diagnostic and treatment services. Insured physician services are provided under the Medicare Protection Act (MPA). Section 13 provides that practitioners (including medical practitioners and health care practitioners, such as midwives) who are enrolled and who render benefits to a beneficiary are eligible to be paid for services rendered in accordance with the appropriate payment schedule.

Unless specifically excluded, the following medical services are insured as MSP benefits under the MPA in accordance with the Canada Health Act:

• medically required services provided to "beneficiaries" (residents of British Columbia) by a medical practitioner enrolled with MSP; and
• medically required services performed in an approved diagnostic facility under the supervision of an enrolled medical practitioner.

To practice in British Columbia, physicians must be registered and in good standing with the College of Physicians and Surgeons of British Columbia. To receive payment for insured services, they must be enrolled with MSP. In the fiscal year 2010-2011, 9,417 physicians (includes only general practitioners and medical specialists who billed fee-for-service (FFS) in 2010-2011) were enrolled with MSP and billed FFS. In addition, some physicians practice solely on salary, receive sessional payments, or are on contract (service agreements) with the health authorities. Physicians paid by these alternative mechanisms may also practice on a FFS basis. Non-physician healthcare practitioners who may be enrolled to provide insured services under MSP are midwives and supplementary benefit practitioners (dental surgeons, optometrists, osteopaths, surgical podiatrists, and acupuncture practitioners). Only those MSP beneficiaries with premium assistance status qualify for MSP coverage of physiotherapy, massage therapy, chiropractic, naturopathy, acupuncture, and non-surgical podiatry services. In 2010-2011, there were 180 midwives and 6,071 supplementary benefits practitioners paid FFS through MSP.

A physician may choose not to enrol or to de-enrol with the Medical Services Commission (MSC). Enrolled physicians may cancel their enrolment by giving 30 days written notice to MSC. Patients are responsible for the full cost of services provided by non-enrolled physicians. In 2010-2011, MSP had 5 opted-out physicians. Based on reclassification of information and corresponding data, British Columbia does not track non-participating physicians.

Enrolled physicians can elect to be paid directly by patients by giving written notice to MSC. MSC will specify the effective date between 30 and 45 days following receipt of the notice. In this case, patients may apply to MSP for reimbursement of the fee for insured services rendered.

Under the Master Agreement between the government, MSC, and the British Columbia Medical Association (BCMA), modifications to the Payment Schedule such as additions, deletions or fee changes are made by MSC, upon advice from the BCMA. Physicians who wish to modify the payment schedule must submit proposals to the BCMA Tariff Committee. On recommendation of the Tariff Committee, interim listings may be designated by MSC for new procedures or other services for a limited period of time while definitive listings are established.

During fiscal year 2010-2011, physician services which were added as MSP insured benefits included 116 new fee items which reflect current practice standards, for example:

• Obstetrical B scan >14 weeks with Nuchal translucency measurement;
• General Surgery lysis of intra-abdominal adhesions;
• Specialist group medical visits; and
• Cardiovascular risk assessment.

2.3 Insured Surgical-Dental Services

Surgical-dental services are covered by the Medical Services Plan (MSP) when hospitalization is medically required for the safe and proper completion of surgery and when they are listed in the Dental Payment Schedule. Included as insured surgical-dental procedures are those related to remedying a disorder of the oral cavity or a functional component of mastication. Generally this would include: oral surgery related to trauma; orthognathic surgery; medically required extractions; and surgical treatment of temporomandibular joint dysfunction. No new insured surgical-dental services were added during the fiscal year 2010-2011. Additions or changes to the list of insured services are managed by MSP on the advice of the Dental Liaison Committee. Additions and changes must be approved by the Medical Services Commission.

Any general dental and/or oral surgeon in good standing with the College of Dental Surgeons and enrolled in MSP may provide insured surgical-dental services in hospital. There were 236 dentists (includes only oral surgeons, dental surgeons, oral medicine, and orthodontists) enrolled with MSP and billing FFS in 2010-2011.

2.4 Uninsured Hospital, Physician and Surgical-Dental Services

Medical necessity, as determined by the attending physician and hospital, is the basis for access to hospital and medical services.

For out-patients, take-home drugs and certain hospital drugs are not insured, except those provided under the provincial PharmaCare program. Other procedures not insured under the Hospital Insurance Act include: services of medical personnel not employed by the hospital; treatment for which Worksafe BC, the Department of Veterans Affairs, or any other agency is responsible; services solely for the alteration of appearance; and reversal of sterilization procedures. Uninsured hospital services also include: preferred accommodation at the patient's request; televisions, telephones, and private nursing services; preferred medical/surgical supplies; dental care that could be provided in a dental office including prosthetic and orthodontic services; and, preferred services provided to patients of extended care units or hospitals.

Services not insured under the Medical Services Plan include: those covered by the Workers' Compensation Act or by other federal or provincial legislation; provision of non-implanted prostheses; orthotic devices; proprietary or patent medicines; any medical examinations that are not medically required; oral surgery rendered in a dentist's office; telephone advice unrelated to insured visits; reversal of sterilization procedures; in vitro fertilization; medico-legal services; and most cosmetic surgeries.

The Medicare Protection Act (section 45) prohibits the sale or issuance of health insurance by private insurers to patients for services that would be benefits if performed by a practitioner. Section 17 prohibits persons from being charged for a benefit or for "materials, consultations, procedures, and use of an office, clinic, or other place or for any other matters that relate to the rendering of a benefit."

The Ministry of Health (the Ministry) responds to complaints made by patients and takes appropriate actions to correct situations identified to the Ministry. The MSC determines which services are benefits and has the authority to de-list insured services. Proposals to de-insure services must be made to MSC. Consultation may take place through a sub-committee of MSC and usually includes a review by the BCMA's Tariff Committee. In 2010-2011, 65 obsolete fee items were removed from the Fee Schedule. The fee items which were removed included those for out-dated technology in the Laboratory, Ophthalmology, and Orthopaedic Sections, amongst others.

3.0 Universality

3.1 Eligibility

Section 7 of the Medicare Protection Act (MPA) defines the eligibility and enrolment of beneficiaries for insured services. Under the MPA, Part 2 of the Medical and Health Care Services Regulation details residency requirements. A person must be a resident of British Columbia to qualify for provincial health care benefits.

Section 1 of the MPA, defines a resident as a person who:

• is a citizen of Canada or is lawfully admitted to Canada for permanent residence;
• makes his or her home in British Columbia;
• is physically present in British Columbia at least six months in a calendar year; and
• is deemed under the regulations to be a resident.

Certain other individuals, such as some holders of permits issued under the federal Immigration and Refugee Protection Act are deemed to be residents (see Section 3.2 of this report), but this does not include a tourist or visitor to British Columbia.

New residents or persons re-establishing residence in British Columbia are eligible for coverage after completing a waiting period that normally consists of the balance of the month of arrival plus two months. For example, if an eligible person arrives 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.

All residents are entitled to hospital and medical care insurance coverage. Those residents who are members of the Canadian Forces, appointed members of the Royal Canadian Mounted Police (RCMP), or serving a term of imprisonment in a penitentiary as defined in the Penitentiary Act, are eligible for federally funded health insurance. The Medical Services Plan (MSP) provides first-day coverage to discharged members of the RCMP and the Canadian Forces, and to those returning from an overseas tour of duty, as well as to released inmates of federal penitentiaries.

The number of residents registered with MSP as of March 31, 2011, was 4,521,503.

3.2 Other Categories of Individual

Holders of Minister's Permits, Temporary Resident Permits, study permits, and work permits are eligible for benefits when deemed to be residents under the Medicare Protection Act and section 2 of the Medical and Health Care Services Regulation.

3.3 Premiums

The enabling legislation is:

• Medicare Protection Act (British Columbia), Part 2 -- Beneficiaries section 8; and
• Medical and Health Care Services Regulation (British Columbia) Part 3 -- Premiums.

Enrolment in MSP is mandatory and payment of premiums is ordinarily a requirement for coverage. However, failure to pay premiums is not a barrier to coverage for those who meet the basic enrolment eligibility criteria. Monthly premiums for MSP since January 1, 2011, are $60.50 for one person, $109 for a family of two, and $121 for a family of three or more.

Residents with limited incomes may be eligible for premium assistance. There are five levels of assistance, ranging from 20 to 100 percent of the full premium. Premium assistance is available only to beneficiaries who, for the last 12 consecutive months, have resided in Canada and are either a Canadian citizen or holder of permanent resident (landed immigrant) status under the (federal) Immigration and Refugee Protection Act.

4.0 Portability

4.1 Minimum Waiting Period

New residents or persons re-establishing residence in British Columbia are eligible for coverage after completing a waiting period that normally consists of the balance of the month of arrival plus two months. For example, if an eligible person arrives 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 medical plan during the waiting period.

4.2 Coverage during Temporary Absences in Canada

Sections 3, 4 and 5 of the Medical and Health Care Services Regulation of the Medicare Protection Act define portability provisions for persons temporarily absent from British Columbia with regard to insured services. In 2010-2011, there were no amendments to the Medical and Health Care Services Regulation with respect to portability provisions.

Individuals leaving the province temporarily on extended vacations, or for temporary employment, may be eligible for coverage for up to 24 months. Approval is limited to once in five years for absences exceeding six months in a calendar year. Residents who spend part of every year outside British Columbia must be physically present in Canada at least six months in a calendar year and continue to maintain their home in British Columbia in order to retain coverage. When a beneficiary stays outside British Columbia longer than the approved period, they will be required to fulfill a waiting period upon returning to the province before coverage can be renewed. 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 interprovincial and interterritorial reciprocal billing arrangements, physicians, except in Quebec, bill their own medical plans directly for services rendered to eligible British Columbia residents, upon presentation of a valid MSP CareCard. British Columbia 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 interprovincial and interterritorial reciprocal billing rate. Payment for these services, except for excluded services that are billed to the patient, is handled though interprovincial and interterritorial reciprocal billing procedures.

Quebec does not participate in reciprocal billing agreements for physician services. As a result, claims for services provided to British Columbia 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 MSP.

British Columbia pays host provincial rates for insured services according to rates established by the Interprovincial Health Insurance Agreements Coordinating Committee.

4.3 Coverage During Temporary Absences Outside Canada

The enabling legislation that defines portability of health insurance during temporary absences outside Canada is stated in the Hospital Insurance Act, section 24; the Hospital Insurance Act Regulations, Division 6; the Medicare Protection Act, section 51; and the Medical and Health Care Service Regulation, sections 3, 4, 5. The Medical and Health Care Services Regulation was amended by British Columbia Regulation 111/2005. The relevant issues addressed by the amendments are as follows:

Residents who leave British Columbia temporarily to attend school or university may be eligible for MSP coverage for the duration of their studies, provided they are in full-time attendance at a recognized educational facility and are enrolled in a program which leads to a degree or certificate recognized in Canada. Generally, 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 British Columbia within that timeframe, and who has been away for less than 24 months, should contact MSP.

Residents who spend part of every year outside British Columbia must be physically present in Canada at least six months in a calendar year and continue to maintain their home in British Columbia in order to retain coverage. However, because of increasing demand for a specialized and mobile work force employed for short-term contracts and assignments, exceptions may be made to enable coverage for up to 24 consecutive months of absence while temporarily outside British Columbia. Approval is limited to once in five years for absences that exceed six months in a calendar year. In addition, if a person's employment requires them to routinely travel outside British Columbia for more than six months per calendar year they can apply for approval to maintain their eligibility.

British Columbia residents who are temporarily absent from British Columbia and cannot return due to extenuating health circumstances are deemed residents for 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.

4.4 Prior Approval Requirement

No prior approval is required for elective procedures that are covered under the interprovincial reciprocal agreements with other provinces. Prior approval from the Medical Services Commission is required for procedures that are not covered under the reciprocal agreements.

The physician services excluded under the Interprovincial Agreements for the Reciprocal Processing of Out-of-Province Medical Claims are: surgery for alteration of appearance (cosmetic surgery); gender reassignment surgery; surgery for reversal of sterilization; therapeutic abortions; routine periodic health examinations including routine eye examinations; in vitro fertilization, artificial insemination; acupuncture, acupressure, transcutaneous electro-nerve stimulation (TENS), moxibustion, biofeedback, hypnotherapy; services to persons covered by other agencies (e.g., RCMP, Canadian Armed Forces, Workers' Compensation Board, Department of Veterans Affairs, Correctional Services of Canada); services requested by a "third party"; team conference(s); genetic screening and other genetic investigation, including DNA probes; procedures still in the experimental/developmental phase; and anaesthetic services and surgical assistant services associated with all of the foregoing.

The services on this list may or may not be reimbursed by the home province. The patient should make inquiries of that home province after direct payment to the British Columbia physician. Some treatments (e.g., treatment for anorexia) may require the approval of the Health Authorities Division of the Ministry of Health.

All non-emergency procedures performed outside Canada require approval from the MSC before the procedure.

5.0 Accessibility

5.1 Access to Insured Health Services

Beneficiaries in British Columbia, as defined in section 1 of the Medicare Protection Act, are eligible for all insured hospital and medical care services as required. To ensure equal access to all, regardless of income, the Medicare Protection Act, sections 17 and 18, prohibits extra-billing by enrolled practitioners.

Access to Insured Physician and Dental-Surgical Services:

In 2010-2011, approximately 3,000 general practitioners (GPs) and specialists received all or part of their income through British Columbia's Alternative Payments Program (APP). APP funds regional health authorities to hire salaried physicians or contract with physicians, in order to deliver insured clinical services.

The Ministry implemented several programs under the 2002 Subsidiary Agreement for Physicians in Rural Practice, which were continued in the Physician Master Agreements (PMA) to enhance the availability and stability of physician services in smaller urban, rural, and remote areas of British Columbia. These programs include:

• Rural Retention Program, which provides eligible physicians (estimated at 1,300) with fee premiums. It is available to resident and visiting physicians and locums, and also provides a flat fee sum for eligible physicians who reside and practice in a rural community.
• Northern and Isolation Travel Assistance Outreach Program, which provides funding support for approved physicians who visit rural and isolated communities to provide medical service(s).
• Rural General Practitioner Locum Program, which assists rural general practitioners in taking reasonable periods of leave from their practices by providing up to 43 days of paid locum coverage per year. This program assisted physicians in approximately 56 small communities to attend continuing medical education and also provided vacation relief.
• Rural Specialist Locum Program, which assists rural specialists in taking vacations and continuing medical education by providing paid locum support. The program provided locum support for core specialists in 10 rural communities to provide vacation relief and assistance while physician recruitment efforts were underway.
• Rural Education Action Plan, which supports the training needs of physicians in rural practice. This program supports training in physicians' rural practices through several components, including rural practice experience for medical students
  and enhanced skills for practicing physicians.
• Isolation Allowance Fund, which provides funding to communities with fewer than four physicians and no hospital, and where the Medical On-Call/Availability Program, call-back, or Doctor of the Day payments is not available.
• Rural Loan Forgiveness Program, which decreases British Columbia student loans by 20 percent for each year of rural practice for physicians, nurse practitioners, nurses, midwives, and pharmacists.

The Full-Service Family Practice Incentive Program has been expanded as the Ministry of Health and physicians continue to work together to develop incentives aimed at helping to support and sustain full service family practice. In 2010-2011, further new and revised fees were in place to support general practitioners in providing primary care to their patients. As of March 31, 2011, 2,689 general practitioners (GPs) billed the Annual Complex Care fee (14033) for 141,838 patients, and 2,302 GPs participated in the Mental Health Planning Fee, developing a mental health plan for 77,273 patients. There were eight conferencing and planning fees available and billed for 12,429 patients in facilities, acute care, or palliative care.

Infrastructure and Capital Planning:

British Columbia continues to make strategic investments in health sector capital infrastructure. The Ministry of Health 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 British Columbia. The Ministry is developing a ten year capital plan to ensure health infrastructure is maintained and renewed within expected asset lifecycle timelines.

As noted in the Introduction section of the report, the Ministry has committed to a significant number of major capital projects at hospitals in locations including Victoria, Surrey, Abbotsford, Vancouver, Prince George, Vernon, Kelowna, and Fort St. John, developed as public-private partnerships. Major capital projects are overseen by Project Boards comprised of senior executives from health authorities and government to ensure projects are appropriately defined and stay within their approved scope, cost, and completion schedules.

The province is nearing completion of the construction on a new cancer treatment centre in Prince George and is in the process of procurement for a new cardiac care centre in Kelowna. These projects represent an extension of strategic health services and reduce the need for patients to travel to the Vancouver area for treatment. British Columbia has also started construction on a new Critical Care Tower at Surrey Memorial Hospital to accommodate an expanded emergency department, neonatal intensive care beds, and acute care beds.

5.2 Physician Compensation

Through negotiations with the British Columbia Medical Association (BCMA), British Columbia established the compensation and benefit structure for physicians who perform publicly funded medical procedures. In 2007, as provided for by the 2006 Letter of Agreement, the Province and the BCMA concluded negotiations for a Physician Master Agreement (PMA). The PMA remains in effect until 2012. In addition to the PMA, the Province and the BCMA also have five subsidiary agreements: General Practitioners Subsidiary Agreement; Specialists Subsidiary Agreement; Rural Practice Subsidiary Agree­ment; Alternative Payments Subsidiary Agreement; and Benefits Subsidiary Agreement. These agreements address matters unique to each aspect of medicine addressed by an individual subsidiary agreement. All five subsidiary agreements terminate in 2012 along with the PMA.

Being long-term, the PMA provides support for a more structured relationship between the BCMA and the Province than had been in place previously. Health authorities have a larger role in making decisions which affect health care in their respective regions. A main focus of the PMA is the establishment of mech­anisms which promote enhanced collaboration and accountabilities between the province and the BCMA. Key to the success of these mechanisms is a strengthened conflict resolution process.

British Columbia anticipates additional benefits from the new PMA structure including: efficiencies stemming from the amalgamation of most agreements with the BCMA into a single agreement framework; streamlining committee structure and communication; providing a formal conflict management process which addresses issues at both the local and provincial levels; limiting physician service withdrawals; and establishing a structured process for physicians wishing to change their method of compensation to better align with strategies and priorities of the Province and of health authorities.

Effective April 1, 2009, physician compensation rates were increased by 3 percent. Over the life of the PMA, the province also provides financial support targeted towards: increasing rural physician incentive programs; providing for new fee items; increasing physician benefit programs; supporting full service family practices; and improving information technology and promoting eHealth initiatives.

Medical practitioners are licensed under the Health Professions Act. A Payment Schedule for medical practitioners is established under section 26 of the Medicare Protection Act and is referred to in the Second Master Agreement between the Government of British Columbia, the Medical Services Commission, and the British Columbia Medical Association.

Dentists are licensed under the Health Professions Act. The province and the British Columbia Dental Association (BCDA) negotiated a Memorandum of Understanding in 2007 that is effective through March 2012 and covers the following services: dental surgery; oral surgery; orthodontic services; oral medicine; and dental technical procedures. Both the Province and the BCDA agree to meet through a Joint Dental Surgery Policy Committee for the duration of the Agreement.

Compensation Methods for Physicians and Dentists:

Payment for medical services delivered in the province is made through the Medical Services Plan to individual physicians, based on submitted claims, and through the APP to health authorities for physicians' services. Over 74 percent of medical expenditures were distributed as fee-for-service and 11 percent were distributed as alternative payments. Of the alternative payments, 77 percent were distributed through contracts, 21 percent as sessions (3.5-hour units of service), and 2 percent as salaried arrangements. The government funds health authorities for alternative payments; it does not pay physicians directly. In British Columbia, for dentistry services, MSP pays for medically required dental services and medically required dental surgical services performed in a hospital; the rest is self-pay.

5.3 Payments to Hospitals

Funding for hospital services is included in the annual funding allocation and payments made to regional health authorities. This funding allocation is to be 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 British Columbia), including the provision of hospital services. The Hospital Insurance Act and its related regulations govern payments made by the health care plan to health authorities. This statute establishes the authority of the Minister to make payments to hospitals, and specifies in broad terms what services are insured when provided within a hospital.

The hospitals' portion of the funding allocation is not specified; however the exception to this rule is funding targeted for specific priority projects (e.g., reduction in wait times for hips and knees, and patient-focused funding). For these types of initiatives, funding is provided to health authorities rather than hospitals and it is specifically earmarked and must be reported on separately.

As noted in the Introduction of this report, in April 2010, the Ministry of Health (the Ministry) introduced patient-focused funding under which a significant portion of eligible acute care funding is based on actual workload performed. By 2013, it is expected that around 20 percent of acute care funding (or ten percent of total funding to health authorities) will be allocated using the patient-focused funding methodology.

Annual funding allocations to health authorities are determined as part of the Ministry of Health's annual budget process in consultation with the Ministry of Finance and Treasury Board. The final funding amount is conveyed to health authorities by means of an annual funding letter.

Insured hospital services are included within the annual funding allocations to health authorities, as well as specific targeted funding from time to time. Incremental funding is allocated to health authorities using the Ministry of Health's Population Needs-Based Funding Formula and other funding allocation methodologies (e.g. to reflect targeted funding allocations directed to specific health authorities). The annual funding allocation to health authorities does not include funding for programs directly operated by the Ministry of Health, such as the payments to physicians and payments for prescription drugs covered under PharmaCare.

The accountability mechanisms associated with government funding for hospitals is part of several comprehensive documents which set expectations for health authorities. These are the annual funding letter, annual service plans, and annual Government Letters of Expectations. 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. In 2010-2011, a full continuum of care (acute, residential, community care, public and preventive health, adult mental health, addictions programs, etc.) was provided.

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 British Columbia through various government websites and provincial government documents. In 2010-2011, these documents included:

• 2010-2011 Third Quarterly Report, available at: http://www.fin.gov.bc.ca/qrt-rpt/qr10/Q3_10.pdf
• Estimates, Fiscal Year Ending March 31, 2011, available at: http://www.bcbudget.gov.bc.ca/2010/estimates/2010_Estimates.pdf
• 2010-2011 Budget and Fiscal Plan, available at: http://www.bcbudget.gov.bc.ca/2010/bfp/2010_Budget_Fiscal_Plan.pdf
• Public Accounts 2010-2011, available at: http://www.fin.gov.bc.ca/OCG/pa/10_11/Pa10_11.htm

General information for statistical indicators 1-2: Historical and current data may differ from report to report because of changes in data sources, definitions and methodology from year to year. The count of facilities in this table may not match counts produced from the Discharge Abstract Database, the MIS reporting system, or the Societies Act because each reporting system has different approaches to counting multiple site facilities and categorizing them by function.

Yukon

Introduction

The health care insurance plans operated by the Government of Yukon are the Yukon Health Care Insurance Plan (YHCIP) and the Yukon Hospital Insurance Services Plan (YHISP). The YHCIP is administered by the Director, as appointed by the Executive Council Member (Minister of Health and Social Services). The YHISP is administered by the Administrator, as appointed by the Commissioner in Executive Council (Commissioner of the Yukon Territory). The Director of the YHCIP and the Administrator of the YHISP are hereafter referred to as the Director, Insured Health and Hearing Services. References in this text to the "Plan" refer to either the Yukon Health Care Insurance Plan or the Yukon Hospital Insurance Services Plan.

The objective of the Yukon health care system is to ensure access to, and portability of, insured physician and hospital services according to the provisions of the Health Care Insurance Plan Act and the Hospital Insurance Services Act. The Minister, Health and Social Services, is responsible for delivering all insured health care services. Service delivery is administered centrally by the Department of Health and Social Services.

Other insured services provided to eligible Yukon residents include the Children's Drug and Optical Program; the Chronic Disease and Disability Benefits Program; the Pharmacare and Extended Benefits Programs; and the Travel for Medical Treatment Program. Non-insured health service programs include Community Health; Community Nursing; Continuing Care; and Mental Health Services.

In February 2009, the Yukon government launched a four-year Licensed Practical Nurse (LPN) program at Yukon College to encourage Northerners who are interested in pursuing a career in a medical profession to remain in Yukon. Training LPNs locally is helping us address Yukon's demand for health care professionals, particularly in continuing care and home care.

In 2010, the Yukon government introduced a motion to develop a Wellness Strategy to promote healthy living habits for all Yukoners. This strategy will focus on children and youth, healthy aging, and social inclusion, with the goal of improving overall health outcomes and reducing health disparities.

The Yukon Hospital Corporation is investing approximately $70 million for three major infrastructure projects: construction of the Residence for Visiting Health Care Professionals and Staff Office Complex in Whitehorse, and the construction of two new Regional Hospitals in Dawson City and Watson Lake.

The Yukon government is also utilizing modern technology to improve health care services for Yukoners. It has invested in teleradiology to provide computer radiology in 13 Community Health Centres across the territory, and has expanded the Telehealth video conferencing equipment capabilities within the First Nations health offices.

The Department of Health and Social Services has also introduced the Weight Wise program to the territory. A local physician and a local nurse were trained to deliver the program by Alberta Health Services, which also provides the Weight Wise program to its clients. The Weight Wise program is a 10-module re-education series for obese patients. It is designed to help clients achieve a healthy weight in order to reduce medical complications for the client and reduce potential costs to the healthcare system. Fifteen clients participated in the first intake of the program.

1.0 Public Administration

1.1 Health Care Insurance Plan and Public Authority

The Health Care Insurance Plan Act, section 3(2) and section 4, establishes the public authority to operate the health medical care plan. There were no amendments made to these sections of the Act in 2010-2011.

The Hospital Insurance Services Act, section 3(1) and section 5, establishes the public authority to operate the health hospital care plan. There were no amendments made to these sections of the Act in 2010-2011.

Subject to the Health Care Insurance Plan Act (section 5) and regulations, the mandate and function of the Director, Insured Health and Hearing Services, is to:

• develop and administer the Plan;
• determine eligibility for entitlement to insured health services;
• register persons in the Plan;
• make payments under the Plan, including the determination of eligibility and amounts;
• determine the amounts payable for insured health services outside the Yukon;
• establish advisory committees and appoint individuals to advise or assist in the operation of the plan;
• conduct actions and negotiate settlements in the exercise of the Government of Yukon's right of subrogation under the Act to the rights of insured persons;
• conduct surveys and research programs and obtain statistics for such purposes;
• establish what information is required to be provided under the Act and the form that information must take;
• appoint inspectors and auditors to examine and obtain information from medical records, reports, and accounts; and
• perform any other functions and discharge any other duties assigned by the Minister of Health and Social Services under the Act.

Subject to the Hospital Insurance Services Act (section 6) and the regulations, the mandate and function of the Director, Insured Health and Hearing Services, is to:

• develop and administer the hospital insurance plan;
• determine eligibility for and entitlement to insured services;
• determine the amounts that may be paid for the cost of insured services provided to insured persons;
• enter into agreements on behalf of the Government of Yukon with hospitals in or outside of Yukon, or with the Government of Canada or any province or an appropriate agency thereof, for the provision of insured services to insured persons;
• approve hospitals for the purposes of the Act;
• conduct surveys and research programmes and obtain statistics for those purposes;
• appoint inspectors and auditors to examine and obtain information from hospital records, reports, and accounts;
• prescribe the forms and records necessary to carry out the provisions of the Act; and
• perform any other functions and discharge any other duties assigned to the administrator by the Regulations.

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.

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 30 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.

Regarding the Yukon Hospital Corporation, section 13(2) of the Hospital Act requires every hospital to submit a report of the operations of the Corporation for that fiscal year; the report is to include the financial statements of the Corporation and the auditor's report. The report is to be provided to the Department of Health and Social Services within six months of the end of each fiscal year.

2.0 Comprehensiveness

2.1 Insured Hospital Services

The Hospital Insurance Services Act, sections 3, 4, 5 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. There were no amendments made to these sections of the legislation in 2010-2011.

In 2010-2011, insured in-patient and out-patient hospital services were delivered in 15 facilities throughout the territory. These facilities include one general hospital, one hospital and 13 health centres. 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 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.

Currently, the Yukon Hospital Corporation is operated under a three-year accreditation through the Canadian Council on Health Services Accreditation. The surveyors did an accreditation review for renewal in May 2010.

The Yukon government assumed responsibility for operating health centres from the federal government in April 1997. These facilities, including the Watson Lake Cottage Hospital, operate in compliance with the adopted Medical Services Branch Scope of Practice for Community Health Nurses/Nursing Station Facility/ Health Centre Treatment Facility, and the Community Health Nurse Scope of Practice. The General Duty Nurse Scope of Practice was completed and implemented in February 2002.

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: accommodation and meals at the standard or public ward level; necessary nursing service; laboratory, radiological and other diagnostic procedures together with the necessary interpretations for the purpose of maintaining health, preventing disease and assisting in the diagnosis and treatment of an injury, illness or disability; drugs, biologicals and related preparations as provided in Schedule B of the regulations, when administered in the hospital; use of operating room, case room and anaesthetic facilities, including necessary equipment and supplies; routine surgical supplies; use of radiotherapy facilities where available; use of physiotherapy facilities where available; and services rendered by persons who receive remuneration therefore from the hospital.

Section 2(f) of the regulations defines "outpatient insured services" as all of the following services to out-patients, when used for emergency diagnosis or treatment within 24 hours of an accident, which period may be extended by the Administrator, provided the service could not be obtained within 24 hours of the accident, namely: necessary nursing service; laboratory, radiological and other diagnostic procedures, together with the necessary interpretations for the purpose of assisting in the diagnosis and treatment of an injury; drugs, biologicals and related preparations as provided in Schedule B, when administered in a hospital; use of operating room and anaesthetic facilities, including necessary equipment and supplies; routine surgical supplies; services rendered by persons who receive remuneration therefore from the hospital; use of radiotherapy facilities where available; and use of physiotherapy facilities where available.

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.

Additional funds have been provided to Yukon to assist patients with recourse options who have orthopaedic (knees and hip) or ophthalmology surgery requirements.

These measures will help reduce Yukon's reliance on out-of-territory services.

The territory is now administering the Weight Wise program in Whitehorse. In previous years, clients were sent to Alberta to participate in the program. With the help of Alberta Health Services, a local physician and a local registered nurse have been trained in delivering the program in-territory. The first intake of clients began in the summer of 2010.

2.2 Insured Physician Services

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. There were no amendments made to these sections of the legislation in 2010-2011.

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:

• register for licensure pursuant to the Health Professions Act; and
• maintain licensure, pursuant to the Health Professions Act.

The number of resident physicians participating in the Yukon Health Care Insurance Plan in 2010-2011 was 69.

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 a fee for services rendered. Notice in writing of this election must be submitted to the Director, Insured Health and Hearing Services. In 2010-2011, no physicians provided written notice of their election to collect fees other than from the Yukon Health Care Insurance Plan.

Insured physician services in Yukon are defined as medically required services rendered by a medical practitioner.

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 Liaison Committee.

Following review by this committee, a decision is made to include or exclude the service. The relevant costs or fees are normally set in accordance with similar costs or 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 Director, Insured Health and Hearing Services, manages this process and no public consultation is required.

In 2010-2011, new insured physician services included the use of a portable ultrasound in the emergency room, extended consultations for paediatrics, and specialist services in physiatry.

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.

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 2010-2011.

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: non-resident hospital stays; special/private nurses requested by the patient or family; additional charges for preferred accommodation unless prescribed by a physician; crutches and other such appliances; nursing home charges; televisions; telephones; and drugs and biologicals following discharge. (These services are not provided by the hospital.)

Section 3 of the Yukon Health Care Insurance Plan Regulations contains a non-exhaustive list of services that are prescribed as non-insured. Uninsured physician services include: advice by telephone; medical-legal services; testimony in court; preparation of records, reports, certificates and communications; services or examinations required by a third party; services, examinations or reports for reasons of attending university or camp; examination or immunization for the purpose of travel, employment or emigration; cosmetic services; services not medically required; giving or writing prescriptions; the supply of drugs; dental care except procedures listed in Schedule B; and experimental procedures.

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 fibreglass 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.

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: completion of employment forms; medical-legal reports; transferring records; third-party examinations; some elective services; and telephone prescriptions, advice or counselling. 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.

The process used to de-insure services covered by the Yukon Health Insurance Plan is as follows:

• Physician services -- the Yukon Health Care Insurance Plan/Yukon Medical Association 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. The Director, Insured Health and Hearing Services, manages this process. No services were removed from the Payment Schedule for Yukon in fiscal year 2010-2011.
• 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, 2011, no insured in-patient or out-patient hospital services, as provided for in the regulations, have been de-insured. The Director, Insured Health and Hearing Services, is responsible for managing this process in conjunction with the Yukon Hospital Corporation.
• 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 2010-2011.

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 respectively, and the Hospital Insurance Services Act and regulations, sections 2 and 4 respectively. No changes were made to these sections of the legislation in 2010-2011. 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 or visitor. 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 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:

• persons entitled to coverage from their home province or territory (e.g., students and workers covered under temporary absence provisions);
• visitors to Yukon;
• refugee claimants;
• members of the Canadian Forces;
• convention refugees;
• members of the Royal Canadian Mounted Police (RCMP);
• inmates in federal penitentiaries;
• study permit holders, unless they are a child and they are listed as the dependent of a person who holds a one year work permit; and
• employment authorizations of less than one year.

The above persons may become eligible for coverage if they meet one or more of the following conditions:

• establish residency in Yukon;
• become a permanent resident; or
• For Canadian Forces members, RCMP members or inmates at the Whitehorse Correctional Centre, the day following discharge or release if stationed in or resident in Yukon.

The number of registrants on the Yukon Health Care Insurance Plan as of March 31, 2011 was 36,063.

3.2 Other Categories of Individual

The Yukon Health Care Insurance Plan provides health care coverage for other categories of individuals, as follows:

• Returning Canadians -- waiting period is applied
• Permanent Residents -- waiting period is applied
• Minister's Permit -- waiting period is applied, if authorized
• Foreign Workers -- waiting period is applied, if holding Employment Authorization
• Clergy -- waiting period is applied, if holding Employment Authorization

Employment Authorizations must be in excess of 12 months.

4.0 Portability

4.1 Minimum Waiting Period

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 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.

The regulations state that, "where an insured person is absent from the Territory and intends to return, he is entitled to insured services during a period of 12 months continuous absence." Persons leaving Yukon for a period exceeding three months are advised to 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 of Insured Health and Hearing Services 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 of Insured Health and Hearing Services 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.

No amendments were made to these sections of the legislation in 2010-2011.

The Yukon participates fully with the Inter-Provincial 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. Payment is made to the host province at the rates established by that province.

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.

No amendments were made to these sections of the legislation in 2010-2011. Sections 5 and 6 state that, "where an insured person is absent from Yukon and intends to return, he is entitled to insured services during a period of 12 months continuous absence."

Persons leaving Yukon for a period exceeding three months are advised to 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.

Insured out-patient hospital services provided to eligible Yukon residents outside Canada are paid at the rate established in the Charges for Out-Patient Procedures Regulation.

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.

5.0 Accessibility

5.1 Access to Insured Health Services

There are no user fees or co-insurance charges 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 the Yukon for any services covered by the Plan.

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 visiting specialists was increased to better serve patients in the territory. A physiatrist was contracted to provide services within our visiting specialist clinic. The Department also increased the number of contract physicians in communities to better serve the rural population.

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 Memorandum of Understanding in effect for the time period of this report came into effect on April 1, 2008 and is ending on March 31, 2012. It establishes the terms and conditions for payment of physicians.

The legislation governing payments to physicians and dentists for insured services are the Health Care Insurance Plan Act and the Health Care Insurance Plan Regulations. No amendments were made to these sections of the legislation in 2010-2011.

The fee-for-service system is used to reimburse the majority of physicians providing insured services to residents. Other systems of reimbursement include contract payments and sessional payments.

5.3 Payments to Hospitals

The Government of Yukon funds the Yukon Hospital Corporation (Whitehorse General Hospital) through global contribution agreements with the Department of Health and Social Services. Global operations and maintenance (O&M) and capital funding levels are negotiated and adjusted based on operational requirements and utilization projections from prior years. 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.

Only the Whitehorse General Hospital is funded directly through a contribution agreement. The Watson Lake Cottage Hospital and all health centres are funded through the Government of Yukon budget process.

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. No amendments were made to these sections of the legislation in 2010-2011.

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 2010-2011 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.

Northwest Territories

Introduction

The Department of Health and Social Services (DHSS) along with seven regional Health and Social Service Authorities (HSSA) and the Tlicho Community Services Agency (TCSA), plan, manage, deliver and evaluate a full repertoire of health and social services at both the community and facility level throughout the Northwest Territories (NWT).

During the fiscal year the Department carried out the following activities:

• The Medical Profession Act came into force in April 2010 and provides an updated registration process for physicians based on best practices. It also modernized the discipline and conduct provisions of the Act to make them consistent with other legislation in the NWT and across the country.
• Immunization Regulations under the Public Health Act were drafted. These regulations will allow for the development of a notifiable immunization registry and will improve immunization surveillance and coverage throughout the Northwest Territories.
• A new Health Information Act is under development. This new Act will provide up-to-date health-specific access, and protection of privacy provisions that will apply to health providers, including private sector providers, such as pharmacies. This will include standards for consent and notice, provisions for access for research and system planning, as well as information systems management. Requirements for compliance and reporting will also be completed.
• A renewal process is underway for the Extended Health Benefits Program to ensure up to date and accurate information for the administration of the benefits of the Program.
• Preparation began for a new Umbrella Health and Social Services Discipline Act. Several professions will be regulated under this Act. Existing legislation that is very outdated could also be modernized under this legislative model.

1.0 Public Administration

1.1 Health Care Insurance Plan and Public Authority

The NWT Health Care Plan consists of the Medical Care Plan and the Hospital Insurance Plan. The Medical Care Plan is administered by the public authority of the Director of Medical Insurance, as appointed by the Minister of Health and Social Services (hereafter referred to as the Minister) under the Medical Care Act. The Minister administers the Hospital Insurance Plan through each Health and Social Service Authorities' board of management as per section 10 of the Hospital Insurance and Health and Social Services Administration Act (HIHSSA). Legislation that enables the Health Care Insurance Plan with the NWT includes the Medical Care Act and the HIHSSA.

1.2 Reporting Relationship

Reporting to the Minister, the Department, along with seven regional Health and Social Service Authorities (HSSA) and the Tlicho Community Services Agency (TCSA), plan, manage, deliver and evaluate a full repertoire of health and social services at both the community and facility level throughout the NWT.

The Minister appoints the Director of Medical Insurance who is responsible for administering the Medical Care Act and its regulations. The Director reports to the Minister any matters concerning the operational status of the Medical Care Plan. The Minister, through the Boards of Management, administers the Hospital Insurance Plan.

The Hospital Insurance Plan is administered in each HSSA by a Minister appointed Management Board. The Boards manage, control and operate health and social services within the current parameters, resources and policies. The Boards are responsible to the Minister. Board members serve for three years, with exception of the chairperson whose term is indeterminate. The TCSA has a Board in which each Tlicho community is represented by one appointed person who may serve a tenure of up to four years. The chairperson on the Board is appointed by the Minister of Aboriginal Affairs and Intergovernmental Relations in consultation with the members appointed by each community government. The Minister of Aboriginal Affairs and Intergovernmental Relations decides and fixes the length of the chairperson's term.

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.

1.3 Audit of Accounts

As part of the Government of the Northwest Territories annual audit, the Office of the Auditor General of Canada audits payments under the Hospital Insurance Plan and the Medical Care Plan.

2.0 Comprehensiveness

2.1 Insured Hospital Services

Insured hospital services in the NWT are provided under the Hospital Insurance and Health and Social Services Administration Act.

During the reporting period, insured hospital services were provided to in- and out-patients by 4 hos­pitals and 23 health centers throughout the NWT. Consistent with section 9 of the Canada Health Act, the NWT provides an exhaustive list of services to provide care to its residents.

Insured in-patient hospital services include:

• meals and accommodation at the ward level;
• required nursing services;
• laboratory, diagnostic and imaging services (along with necessary interpretations);
• drugs, biologicals and other preparations prescribed by a physician;
• surgical supplies and use of operating room;
• case room and anaesthesiology services;
• radiology and rehab therapy (physio, audio, occupational and speech);
• psychiatric and psychological services within an approved program; and
• detoxification at approved centers.

Insured out-patient hospital services include:

• laboratory tests;
• diagnostic Imaging (including interpretations when needed);
• physiotherapy, speech and language pathology therapy and occupational therapy;
• minor medical and surgical procedures and related supplies; and
• psychiatric and psychological services under approved hospital program.

Travel assistance is provided for residents who require medically necessary procedures that are not offered in their community or elsewhere within the NWT. Medical Travel Assistance (as outlined in the Medical Travel Policy) provides barrier free access to care services and procedures for the residents of the NWT in accordance with the Canada Health Act.

The Minister may change, add or delete insured hospital services, and determine whether public consultation will occur.

2.2 Insured Physician Services

The NWT Medical Care Act and the NWT Medical Care Regulation provide NWT residents insurance for physician services. Physicians, nurse practitioners and midwives provide insured services under the Medical Profession Act, Nursing Profession Act and the Midwifery Act, respectively; all of whom are required by legislation to be licensed to practise in the NWT. As of March 31, 2011, there were approximately 286 physicians licensed in the NWT.

Physicians may opt out and collect fees other than under the Medical Care Plan by providing written notice to the Director of Medical Insurance. There are no opted-out physicians in the NWT.

The Medical Care Plan insures all medically necessary physician services such as:

• diagnostics and therapeutics;
• surgical supplies and services;
• eye examinations provided by a licensed ophthalmologist;
• obstetrics; and
• specialist visits with proper approval from a medical practitioner.

The Director of Medical Insurance is responsible to recommend tariffs for services payable by the NWT Medical Care Plan, though it is the Minister who ultimately determines if services will be added, altered or deleted from insured physician services under the authority of the following regulations:

• establishing a medical care plan that provides insured services to insured persons by medical practitioners that will qualify and enable the NWT to receive payments of contributions from the Government of Canada under the Canada Health Act; and
• prescribing rates of fees and charges that may be paid in respect of insured service rendered by medical practitioners whether in or outside the NWT, and the conditions under which fees and charges are payable.

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.

2.4 Uninsured Hospital, Physician and Surgical-Dental Services

Not all services provided by hospitals, medical practitioners and dentists are covered under the Health Care Plan. Some uninsured services include:

• in-vitro fertilization;
• third party examinations;
• dental services that are not surgical in nature;
• group immunizations;
• medical-legal services;
• advice or prescriptions done over the phone;
• services rendered to the physician's family;
• dressings, bandages, drugs and other consumables used at the medical practitioner's office;
• eye glasses and other appliances;
• plaster; and
• services carried out by people who usually are not medical practitioners such as osteopathy, naturo­pathy, chiropractics. Physiotherapy, psychiatry and psychological therapies are not covered if delivered in a non-approved location.

For NWT residents to receive items and/or services that are generally considered uninsured under the health care plan, prior approval is required. A Medical Advisor makes recommendations to the Director of Insured Services regarding the appropriateness of the request.

The Workers' Safety and Compensation Committee has several  policies that are applied when interpreting the Workers' Compensation Act(s). These policies are available on their website at www.wscc.nt.ca.

The process used to make changes to the list of uninsured hospital, physician and surgical-dental services is described in sections 2.1 and 2.2 of this report.

3.0 Universality

3.1 Eligibility

The NWT uses the Health Care Plan Registration Guidelines, defined in the Medical Care Act, in accordance with the Interprovincial Agreement on Eligibility and Portability, to determine eligibility and fulfill obligations of section 10 in the Canada Health Act.

Ineligible individuals for NWT health care coverage are members of the Canadian Forces, the Royal Canadian Mounted Police (RCMP), 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 order to register, residents fill out an application form and provide applicable documentation (e.g. visa, immigration papers, proof of residency if requested). Residents may register prior to eligibility. Registration is directly linked to eligibility and claims are only paid if the client has registered.

As of March 31, 2011 there were 42,391 individuals registered with the NWT health care plan.

No formal terms exist for clients to opt out of 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 health care plan coverage.

4.0 Portability

4.1 Minimum Waiting Period

Waiting periods for persons moving to the 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, or the first day of the thirteenth month for those whose work term was for one year and has been extended. Confirmation of extension may be required.

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, in accordance with section 11(1)(b)(i) of the Canada Health Act. The Department adheres to the Interprovincial Agreement on Eligibility and Portability as described in the NWT Health Care Plan Registration Guidelines.

Once an individual has filled out the Temporary Absence form and it is approved by the Department, NWT residents are covered for up to one year to leave 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 jurisdictions.

With an NWT health care card, most medical practitioner visits and hospital services are billed directly to the Department. Reimbursement guidelines exist for patients having to pay up front for medically required services. During the reporting period over 16 million dollars per paid out for hospital in-patient and out-patient services in other provinces and territories.

The NWT participates in both the Hospital Reciprocal Billing Agreement and the Medical Reciprocal Billing Agreement with other jurisdictions.

4.3 Coverage During Temporary Absences Outside Canada

Through the Medical Care Act, section 4(3), the NWT Health Care Plan Registration Guidelines provide criteria that define medical practitioner and hospital fees payable for costs incurred by NWT residents while they are out of Canada on a temporary basis.

Per 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. Individuals are required to pay up front and seek reimbursement upon their return to the NWT. Services rendered outside of Canada will not be reimbursed in excess of amounts payable when the benefit is rendered in the NWT.

Residents temporarily out of Canada may receive coverage for up to one year; however, prior approval is required as well as documentation proving the NWT will be the individual's permanent residence upon return.

4.4 Prior Approval Requirement

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

5.0 Accessibility

5.1 Access to Insured Health Services

The Medical Travel Program provides barrier free access to necessary medical services for NWT residents, in accordance with section 12(1)(a) of the Canada Health Act. The Medical Travel Program, through an approval process, guarantees rural residents access to regional or territorial centers for services not available in the individual's community, and all NWT residents with access to services not offered in the NWT through contractual agreements with southern health authorities.

Telehealth services increased accessibility to insured health services throughout the territory. During the 2010-2011 fiscal year telehealth was provided to 38 facilities, up from 20 in the previous fiscal year. Every community in the NWT now has access to Telehealth. The only exception is Enterprise, which shares services with neighbouring Hay River. All NWT residents, including those in isolated communities, have access to all Government of the Northwest Territories (GNWT) facilities via the Medical Travel Program and Telehealth, including access to specialists, rehabilitation professionals and other medical practitioners.

Extra-billing is not permitted in the NWT, in adherence to section 14 of the Canada Health Act. The only exception is if a medical practitioner opts out of the Medical Care Plan and collects his or her own fees. This did not occur during the reporting period.

5.2 Physician Compensation

The NWT Medical Association and the Department negotiate physician compensation. Generally, family practitioners are compensated through contractual agreements with the GNWT; while the remainder are mostly compensated on a fee-for-service basis as determined under the NWT Medical Care Act.

5.3 Payments to Hospitals

Contribution agreements between the Department and the Boards of Management for each HSSA and the TCSA dictate payments made to hospitals. Government budgets, resources and levels of services offered determine the allocated amounts.

Payments to HSSA's providing 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 GNWT through press releases and other documents.

For the current reporting period these documents include:

• 2010-2011 Budget Address;
• 2010-2011 Main Estimates;
• 2010-2011 Public Accounts;
• 2011-2012 Business Plan for the Department of Health and Social Services;
• 2010-2011 Business Plan for the Department of Finance; and
• 2009-2010 Health and Social Services Annual Report.

The Main Estimates report (noted above) is presented annually to the Legislative Assembly and represents the government's financial plan.

All data are subject to future revisions. 2010-2011 estimated based on claim data as of September 14, 2011.

Nunavut

Introduction

The Department of Health and Social Services faces many unique challenges when providing for the health and well-being of Nunavummiut. The population of 33,220^{Footnote 48} is approximately 84 percent Inuit, and almost 53 percent of the population is under the age of 25 years.^{Footnote 49} The territory is made up of 25 communities located across three time zones and divided into three regions: the Baffin (or Qikiqtaaluk), the Kivalliq and the Kitikmeot.

The health status of Nunavummiut is significantly below the national average, and overall life expectancy trails the Canadian average by 10 years.^{Footnote 50} There are no roads or railways connecting Nunavut's communities, and air travel is the only means of travelling into, around and out of the territory. As the cost of airfare, agency nurses, medical technology, infrastructure and other related expenditures continues to rise, the Government of Nunavut continues to invest additional resources into public health; by making investments in health promotion and preventative care now, the high cost of primary health care in the future can be offset.^{Footnote 51}

The Government of Nunavut strives to incorporate 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, community health nurses, and pharmacists.

The territorial operations and maintenance budget for the Department of Health and Social Services in 2010-2011 was $291,020,000.^{Footnote 52} Over one quarter of the Department's total operational budget is spent on costs associated with medical travel and treatment provided in out-of-territory facilities. Due to the very low population density in this vast territory and limited health infrastructure (i.e., diagnostic services), access to a range of hospital and specialist services often requires that residents be sent out of the territory. An additional $18,269,000 was allocated to the Department for capital projects.^{Footnote 53}

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 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 has a regional office in each of the three regions that manages the delivery of health services at a regional level. Iqaluit operations are administered separately. The Department retained regional operations in each region of Nunavut to support front-line workers and community based delivery of a wide range of health and social services programs and services.

There were no legislative amendments in fiscal year 2010-2011.

1.2 Reporting Relationship

Legislation governing the administration of health and social 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 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 regulations. Section 24 requires the Director to submit an annual report on the operation of the Medical Care Plan (Nunavut Health Care Plan) to the Minister for tabling in the Legislative Assembly.

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 transactions and consolidated financial statements of the Government of Nunavut. The most recent audited report was issued March 30, 2011.

The Auditor General has the mandate to audit the activities of the Department. A report specific to the financial management practices of the Department of Health and Social Services was issued by the Office of the Auditor General in 2009-2010. In June 2010, a report was tabled in response to the Standing Committee on Oversight of Government Operations and Public Accounts' Report on the Review of the 2009 Reports of the Auditor General of Canada to the Legislative Assembly of Nunavut on the Financial Management Practices of the Department of Health and Social Services and the Follow-up on the 2005 Report to the Legislative Assembly of Nunavut on the Financial Management Practices of the Government of Nunavut.

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 2010-2011.

In 2010-2011, insured hospital services were delivered in 28 facilities across Nunavut, including one general hospital (Iqaluit), two regional health facilities (Rankin Inlet and Cambridge Bay), 22 community health centres, one public health facility (Iqaluit), and one family practice clinic (Iqaluit). There is also rehabilitative treatment available through the Timimut Ikajuksivik Centre, located in Iqaluit.

The Qikiqtani General Hospital (QGH) is currently the only acute care facility in Nunavut 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, paediatrics and palliative care), surgical services, laboratory services, diagnostic imaging, respiratory therapy, and health records and information. However, as the two regional facilities in Rankin Inlet and Cambridge Bay are able to recruit additional physicians, they will also be able to offer a broader range of in-patient and out-patient services. Community health centres provide public health services, out-patient services and urgent treatment services. There are also a limited number of birthing beds at the Rankin Inlet Birthing Centre. Public health services are provided at public health clinics located in Rankin Inlet and Iqaluit.

The Department also operates a Family Practice Clinic in Iqaluit. The clinic, established in 2006 with funding from the Primary Health Care Transition Fund, has been successful in helping to reduce pressure on the emergency and out-patient departments of the QGH during working hours. The clinic provides a steady source of primary care appointments and programs, such as a Diabetes Clinic, and receives physician support via 2-3 physician days per month. At present, the clinic is staffed by three nurse practitioners who provide approximately 41% of all primary care visits in Iqaluit.

The Department is responsible for authorizing, licensing, inspecting and supervising all health facilities and social services facilities in the territory. Insured in-patient hospital services include: accommodation and meals at the standard ward level; necessary nursing services; laboratory, radiological and other diagnostic procedures, together with the necessary interpretations; drugs, biological and related preparations prescribed by a physician and administered in hospital; routine surgical supplies; use of operating room, case-room and anaesthetic facilities; use of radiotherapy and physiotherapy services where available; psychiatric and psychological services provided under an approved program; services rendered by persons who are paid by the hospital; and services rendered by an approved detoxification centre.

Out-patient services include: laboratory tests and x-rays, including interpretations, when requested by a physician and performed in an out-patient facility or in an approved hospital; hospital services in connection with most minor medical and surgical procedures; physiotherapy, occupational therapy, limited audiology and speech therapy services in an out-patient facility or in an approved hospital; and psychiatric and psychology services provided under an approved hospital program. The Department makes the determination to add insured services in its facilities 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 2010-2011 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 regulations in 2010-2011. The Nursing Act allows for licensure of nurse practitioners in Nunavut; this permits nurses to deliver insured physician services in Nunavut.

Physicians must be in good standing with a College of Physicians and Surgeons (Canada) 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 hires its own family physicians, and accesses specialist services primarily from its main referral centres in Ottawa, Winnipeg, and Yellowknife. Recruitment of full-time family physicians has improved significantly and there are 25 family physician positions funded through the Department, providing over 5,000 days of service annually across the territory. In 2010-2011, all family physician positions in Nunavut were staffed.

There are a total of 25 full-time physician positions in Nunavut (14 in the Baffin region; 4.5 positions in the Kivalliq region; 2.5 positions in the Kitikmeot region; as well as 1 surgeon, 1 anaesthetist, 1 pediatrician and 1 psychiatrist at the Qiqiktani General Hospital). Visiting specialists, general practitioners and locums, through arrangements made by each of the Department's three regions, also provide insured physician services. On March 31, 2011, Nunavut had 225 physicians participating in the health insurance plan.

Physicians can make an election 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 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 2010-2011, no physicians provided written notice of this election.

All physicians practising in Nunavut are under contract with the Department.

Insured physician services refers 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 in place 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 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 deleted in 2010-2011.

2.3 Insured Surgical-Dental Services

Dentists providing insured surgical-dental services under the Medical Care Insurance Plan of the territory 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. 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.

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 2010-2011.

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: yearly physicals; cosmetic surgery; services that are considered experimental; prescription drugs; physical examinations done at the request of a third party; optometric services; dental services other than specific procedures related to jaw injury or disease; the services of chiropractors, naturopaths, podiatrists, osteopaths and acupuncture treatments; and physiotherapy, speech therapy and psychology services received in a facility that is not an insured out-patient facility (hospital).

Services not covered in a hospital include: hospital charges above the standard ward rate for private or semi-private accommodation; services that are not medically required, such as cosmetic surgery; services that are considered experimental; ambulance charges (except inter-hospital transfers); dental services, other than specific procedures related to jaw injury or disease; and alcohol and drug rehabilitation, without prior approval.

In 2010-2011 the Qikiqtani General Hospital charged $2,046 per diem for services provided for non-Canadian resident stays.

When residents are sent out of the 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 under Portability). 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 Health 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 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 2010-2011.

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 or to remain in Canada, who makes his or her home and is ordinarily present in Nunavut, but does not include a tourist, transient or visitor to Nunavut. Applications are accepted for health coverage, and supporting documentation is required to confirm residency. 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 was initiated in Nunavut in 2006. 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/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 (e.g., newborns whose mothers or fathers are eligible for coverage). Permanent residents (landed immigrants), returning Canadians, repatriated Canadians, returning permanent residents, and non-Canadian 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 the Royal Canadian Mounted Police (RCMP), 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, persons 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, 2011, 35,515 individuals were registered with the Nunavut Health Care Plan, up by 1,975 from the previous year. There are no formal provisions for Nunavut residents to opt out of the health care insurance plan.

3.2 Other Categories of Individual

Non-Canadian holders of employment visas of less than 12 months, foreign students with visas of less than 12 months, transient workers, and individuals holding a Minister's Permit (with one exception) are not eligible for coverage. When unique circumstances occur, assessment is 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 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 2010-2011 with respect to coverage outside Nunavut.

Students studying outside Nunavut must notify the Department and provide proof of enrolment to ensure continuing coverage. Requests for extensions must be renewed yearly and are subject to approval by the Director. Temporary absences for work, vacation or other reasons for 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 person.

The provisions regarding coverage during temporary absences in Canada fully comply with the terms and conditions of the Interprovincial Agreement on Eligibility and Portability, as of January 1, 2001.

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- and out-patient hospital services to eligible Nunavut residents receiving insured services outside the territory. High-cost procedure rates, newborn rates and out-patient rates are based on those established by the Interprovincial Health Insurance Agreements Coordinating Committee. A special agreement exists between the Northwest Territories and Nunavut, which, based on a block-funding approach, enables the Stanton Hospital in Yellowknife to provide services to Nunavut residents in the hospital and through visiting specialist services in the Kitikmeot area (western part of the territory).

The Physician Reciprocal Billing Agreements provide payment of insured physician services on behalf of eligible Nunavut residents receiving insured services outside the territory. Payment is made to the host province at the rates established by that province.

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. Individuals 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. For services provided to residents who have been referred out of the country for highly specialized procedures unavailable in Nunavut and Canada, Nunavut will pay the full cost. For non-referred or non-emergency services, the payment for hospital services is $2,046 per day and $260 for out-patient care. These rates increased by $112 and $22 respectively from 2009-2010.

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 person or directly to the provider of the insured service.

4.4 Prior Approval Requirement

Prior approval is required for elective services provided in private facilities in Canada or in any facility outside the country.

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 the Inuit language are also provided to patients in any health care setting.

The Qikiqtani General Hospital in Iqaluit is the only operating acute care hospital facility in Nunavut. The hospital has a total of 35 beds available for acute, rehabilitative, palliative and chronic care services. There are also 6 day surgery beds and 4 recovery 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, limited intensive care services, and general medical, maternity and palliative care. Surgical services provided include minor orthopaedics, gynaecology, paediatrics, general abdominal, emergency trauma and ENT/otolaryngology. Patients requiring specialized surgeries are sent to other jurisdictions. Diagnostic services include radiology, laboratory and electrocardiogram. Rehabilitative services are limited to Iqaluit. Although nursing and other health professionals were not at full capacity, basic services were provided in 2010-2011.

Outside of Iqaluit, out-patient and 24-hour emergency nursing services are provided by local health centres in Nunavut's 24 other communities. Telehealth services are available in all 25 communities in Nunavut. 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.

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 2010-2011 under the visiting specialists program: ophthalmology; orthopaedics; internal medicine; otolaryngology; neurology; rheumatology; dermatology; paediatrics; obstetrics; physiotherapy; occupational therapy; psychiatry; and oral surgery. Visiting specialist clinics are held depending on demand and availability of specialists.

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 counselling sessions; family visitation; and continuing medical education.

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 terms of the contracts are set by the Department. Visiting consultants are either paid on a per-diem basis or through fee-for-service.

5.3 Payments to Hospitals

Funding for the Qiqiktani 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 2010-2011, they included:

• 2010-2011 Budget Address; and
• 2010-2011 Government of Nunavut Business Plan.

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 current to October 2009. It is provided for the convenience of the reader only. For the official text of the Canada Health Act, please contact Justice Canada.

Annex B - Policy Interpretation Letters

There are two key policy statements that clarify the federal position on the Canada Health Act. These statements have been made in the form of min­isterial letters from former Federal Health Ministers to their provincial and territorial counterparts.

Epp Letter

In June 1985, approximately one year following the passage of the Canada Health Act in Parliament, then-federal Health Minister Jake Epp wrote to his provincial and territorial counterparts to set out and confirm the federal position on the interpretation and implementation of the Canada Health Act.

Minister Epp's letter followed several months of consultation with his provincial and territorial counterparts. The letter sets forth statements of federal policy intent which clarify the criteria, conditions and regulatory provisions of the Canada Health Act. These clarifications have been used by the federal government in the assessment and interpretation of compliance with the Act. The Epp letter remains an important reference for interpretation of the Act.

Federal Policy on Private Clinics

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

At the Federal/Provincial/Territorial Health Ministers Meeting of September 1994 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 Canada Health Act, includes any facility that provides acute, rehabilitative or chronic care. Thus, when a provincial/territorial health insu­rance plan pays the physician fee for a medically necessary service delivered at a private clinic, it must also pay the facility fee or face a deduction from federal transfer payments.

[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 pro­vision 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:

• weakened public support for the tax funded and publicly administered system;
• the diminished ability of governments to control costs once they have shifted from the public to the private sector;
• the possibility, supported by the experience of other jurisdictions, that private facilities will concentrate on easy procedures, leaving public facilities to handle more complicated, costly cases; and
• the ability of private facilities to offer financial incentives to health care providers that could draw them away from the public system--resources may also be devoted to features which attract consumers, without in any way contributing to the quality of care.

The only way to deal effectively with these concerns is to regulate the operation of private clinics.

I now call on Ministers in provinces which have not already done so to introduce regulatory frameworks to govern the operation of private clinics. I would emphasize that, while my immediate concern is the elimination of user charges, it is equally important that these regulatory frameworks be put in place to ensure reasonable access to medically necessary services and to support the viability of the publicly funded and administered system in the future. I do not feel the implementation of such frameworks should be long delayed.

I welcome any questions you may have with respect to my position on private clinics and facility fees. My officials are willing to meet with yours at any time to discuss these matters. I believe that our officials need to focus their attention, in the coming weeks, on the broader concerns about private clinics referred to above.

As I mentioned at the beginning of this letter, divergent interpretations of the Canada Health Act apply to a number of other practices. It is always my preference that matters of interpretation of the Act be resolved by finding a Federal/Provincial/Territorial consensus consistent with its fundamental principles. I have therefore encouraged F/P/T consul­tations in all cases where there are disagreements. In situations such as out-of-province or out-of-country coverage, I remain committed to following through on these consultative processes as long as they continue to promise a satis­factory conclusion in a reasonable time.

In closing, I would like to quote Mr. Justice Emmett M. Hall. In 1980, he reminded us:

I trust that, mindful of these words, we will continue to work together to ensure the survival, and renewal, of what is perhaps our finest social project.

As the issues addressed in this letter are of great concern to Canadians, I intend to make this letter publicly available once all provincial Health Ministers have received it.

Yours sincerely,

Diane Marleau
Minister of Health

Annex C - Dispute Avoidance and Resolution Process under the Canada Health Act

In April 2002, the Honourable A. Anne McLellan outlined in 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 principles of the Canada Health Act, and when this is not possible, resolving disputes in a fair, transparent and timely manner.

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

Where dispute avoidance activities prove unsuccessful, dispute resolution activities may be initiated, beginning with government-to-government fact-finding and 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.

Minister of Health
Ministre de la Santé

Ottawa, Canada K1A 0K9

April 2, 2002

The Honourable Gary Mar, M.L.A.
Minister of Health and Wellness
Province of Alberta
Room 323, Legislature Building
Edmonton, Alberta
T5K 2B6

Dear Mr. Mar:

I am writing in fulfilment of my commitment to move forward on dispute avoidance and resolution as it applies to the interpretation of the principles of the Canada Health Act.

I understand the importance provincial and territorial governments attach to having a third party provide advice and recommendations when differences occur regarding the interpretation of the Canada Health Act. This feature has been incorporated in the approach to the Canada Health Act Dispute Avoidance and Resolution process set out below. I believe this approach will enable us to avoid and resolve issues related to the interpretation of the principles of the Canada Health Act in a fair, transparent and timely manner.

Dispute Avoidance

The best way to resolve a dispute is to prevent it from occurring in the first place. The federal government has rarely resorted to penalties and only when all other efforts to resolve the issue have proven unsuccessful. Dispute avoidance has worked for us in the past and it can serve our shared interests in the future. Therefore, it is important that governments continue to participate actively in ad hoc federal/provincial/territorial committees on Canada Health Act issues and undertake government-to-government information exchange, discussions and clarification on issues as they arise.

Moreover, Health Canada commits to provide advance assessments to any province or territory upon request.

Dispute Resolution

Where the dispute avoidance activities between the federal government and a provincial or territorial government prove unsuccessful, either Minister of Health involved may initiate dispute resolution by writing to his or her counterpart. Such a letter would describe the issue in dispute. If initiated, dispute resolution will precede any action taken under the non-compliance provisions of the Act.

As a first step, governments involved in the dispute will, within 60 days of the date of the letter initiating the process, jointly:

• collect and share all relevant facts;
• prepare a fact-finding report;
• negotiate to resolve the issue in dispute; and
• prepare a report on how the issue was resolved.

If, however, there is no agreement on the facts, or if negotiations fail to resolve the issue, any Minister of Health involved in the dispute may initiate the process to refer the issue to a third party panel by writing to his or her counterpart. Within 30 days of the date of that letter, a panel will be struck. The panel will be composed of one provincial/territorial appointee and one federal appointee who, together, will select a chairperson. The panel will assess the issue in dispute in accordance with the provisions of the Canada Health Act, will undertake fact-finding and provide advice and recommendations. It will then report to the governments involved on the issue within 60 days of appointment.

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

Public Reporting

Governments will report publicly on Canada Health Act dispute avoidance and resolution activities, including any panel report.

I believe that the Government of Canada has followed through on its September 2000 Health Agreement commitments by providing funding of $21.1 billion in the fiscal framework and by working collaboratively in other areas identified in the agreement. I expect that provincial and territorial premiers and Health Ministers will honour their commitment to the health system accountability framework agreed to by First Ministers in September 2000. The work of officials on performance indicators has been collaborative and effective to date. Canadians will expect us to report on the full range of indicators by the agreed deadline of September 2002. While I am aware that some jurisdictions may not be able to fully report on all indicators in this timeframe, public accountability is an essential component of our effort to renew Canada's health care system. As such, it is very important that all jurisdictions work to report on the full range of indicators in subsequent reports.

In addition, I hope that all provincial and territorial governments will participate in and complete the joint review process agreed to by all Premiers who signed the Social Union Framework Agreement.

The Canada Health Act Dispute Avoidance and Resolution process outlined in this letter is simple and straightforward. Should adjustments be necessary in the future, I commit to review the process with you and other Provincial/Territorial Ministers of Health. By using this approach, we will demonstrate to Canadians that we are committed to strengthening and preserving medicare by preventing and resolving Canada Health Act disputes in a fair and timely manner.

Yours sincerely,

A. Anne McLellan

Fact Sheet: Canada Health 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:

• 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.

Health Canada commits to provide advance assessments to any province or territory upon request.

Dispute Resolution

Where the dispute avoidance activities between the federal government and a provincial or territorial government prove unsuccessful, either Minister of Health involved may initiate dispute resolution by writing to his or her counterpart. Such a letter would describe the issue in dispute. If initiated, dispute resolution will precede any action taken under the non-compliance provisions of the Act.

As a first step, governments involved in the dispute will, within 60 days of the date of the letter initiating the process, jointly:

• collect and share all relevant facts;
• prepare a fact-finding report;
• negotiate to resolve the issue in dispute; and
• prepare a report on how the issue was resolved.

If however, there is no agreement on the facts, or if negotiations fail to resolve the issue, any Minister of Health involved in the dispute may initiate the process to refer the issue to a third party panel by writing to his or her counterpart.

• Within 30 days of the date of that letter, a panel will be struck. The panel will be composed of one provincial/territorial appointee and one federal appointee, who, together will select a chairperson.
• The panel will assess the issue in dispute in accordance with the provisions of the Canada Health Act, will undertake fact-finding and provide advice and recommendations.
• The panel 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.