Excessive demand on health services and on social services

This section contains policy, procedures and guidance used by IRCC staff. It is posted on the department’s website as a courtesy to stakeholders.

Note: The centralization and application processing instructions (not to be confused with the medical examination processing instructions) outlined in these program delivery instructions are to be followed by the Humanitarian Migration and Integrity Division at the Immigration, Refugees and Citizenship Canada (IRCC) Niagara Falls office (HMID-NF) and, if applicable, by appeal hearings officers or border services officers at any Canadian port of entry.

Applications with 1 or more excessive demand medical assessments should be centralized at the HMID-NF office.

Part of the immigration application review and decision-making process involves Immigration, Refugees, and Citizenship Canada (IRCC) decision makers determining whether an individual might reasonably be expected to cause excessive demand on health or social services in Canada.

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Excessive demand provisions

Subsection R1(1) of the Immigration and Refugee Protection Regulations (IRPR) defines “excessive demand” as either of the following:

  • a demand on health services or social services for which the anticipated costs exceed triple the average Canadian per capita health services and social services costs over a period of 5 consecutive years immediately following the most recent medical examination required under paragraph A16(2)(b) of the Immigration and Refugee Protection Act (IRPA), or
  • a demand on health services or social services that would add to existing waiting lists and would increase the rate of mortality and morbidity in Canada as a result of an inability to provide timely services to Canadian citizens or permanent residents

Health services means any health services for which the majority of the funds are contributed by governments, including the services of family physicians, medical specialists, nurses, chiropractors and physiotherapists; laboratory services; and the supply of pharmaceutical or hospital care.

Social services means any social services, such as home care, specialized residences and residential services, special education services, social and vocational rehabilitation services, personal support services and the provision of devices related to those services

  1. that are intended to assist a person in functioning physically, emotionally, socially, psychologically or vocationally
  2. for which the majority of the funding, including funding that provides direct or indirect financial support to an assisted person, is contributed by governments, either directly or through publicly funded agencies

Excessive demand threshold is the cut-off limit that medical officers use to determine whether the cost of an applicant’s health and social services would exceed 3 times the Canadian average for health and social services, as defined in the Regulations. As of January 1, 2023, the excessive demand threshold is CAN$25,689 per year.

The excessive demand threshold applied is determined by the date the medical assessment is performed by a medical officer. If the medical assessment was made

  • between March 16, 2022, and January 1, 2023, the excessive demand threshold applied to the assessment was CAN$24,057 per year
  • prior to March 16, 2022, the excessive demand threshold was CAN$8,019 per year. A public policy was implemented to grant an exemption from excessive demand provisions when an applicant met certain conditions set out by the Minister. One of these conditions was that the costs of health and social services required by an applicant were less than $24,057 per year.

Note: Medical officers should not include the following social services when calculating the costs of health and social services if the foreign national might reasonably be expected to pose a risk of excessive demand on health or social services:

  • special education related services, including services related to the preparation of an individualized education plan and educational assistants
  • social and vocational rehabilitation services, including services related to rehabilitation facilities, occupational therapy, behavioural therapy and speech language therapy
  • personal, non-professional support services, such as assistance with activities of daily living (for example, bathing, dressing, feeding), meal preparation and housecleaning

Processing overview

The Migration Health Branch (MHB) completes a medical assessment with a finding that the principal applicant, accompanying family member or non-accompanying family member (applicant) might reasonably be expected to cause excessive demand on health or social services.

The excessive demand medical assessment is associated with the applicant’s application(s).

If the medical officer determines that the applicant, principal applicant, accompanying family member or non-accompanying family member is still reasonably expected to cause excessive demand, the migration officer should do both of the following:

  1. Complete all application processing steps, including any outstanding admissibility or eligibility assessments, other than the assessment of medical admissibility and final decision.
  2. Transfer the application to HMID-NF for continued processing and a final decision.

MHB medical assessment

When a review of immigration medical examination (IME) results shows that the foreign national (principal applicant, accompanying family member or non accompanying family member) is potentially inadmissible on health grounds, the MHB medical officer responsible for the file must complete all medical assessments, based on the definition of excessive demand found in subsection R1(1).

Recording excessive demand medical assessments in the Global Case Management System

When it is the finding of the medical officer that the foreign national might reasonably be expected to cause excessive demand based on the definitions of excessive demand found in the IRPA and IRPR, a medical officer rationale (MOF Rationale) must be entered as a note on the “Medicals – HB” screen of the Global Case Management System (GCMS).

This note must be entered by the assessing medical officer and must meet all of the following conditions:

  • list the medical condition or conditions (diagnoses) identified during the IME that are related to the findings of likely inadmissibility
  • provide a detailed summary, including the costs (where available), indicating why the foreign national might reasonably be expected to cause excessive demand on publicly funded health and social services in Canada (and, if applicable, whether the foreign national is likely to be a danger to public health or public safety) based on the definitions found in the IRPA and IRPR
  • in the rationale, list the following, as defined by subsection R1(1):
    • the health and social services likely required by the applicant over a period of 5 consecutive years immediately following the most recent medical examination required under paragraph 16(2)(b) of the IRPA
    • the cost of these services, if applicable, and the total cost of all health and social services and/or whether these services would add to existing waiting lists and would increase the rate of mortality and morbidity in Canada as a result of an inability to provide timely services to Canadian citizens or permanent residents
    • where applicable, whether the client is likely to have a condition that may pose a danger to public health and safety in addition to excessive demand

Whenever the medical officer finds that the foreign national is likely inadmissible on health grounds, the following information must be recorded by the medical officer in the Assessment Details applet of the “Medicals – HB > IME” screen of the GCMS:

Medical code

One of the following medical codes must be entered to denote the medical officer’s assessment that the foreign national is likely inadmissible on health grounds, in whole or in part due to an excessive demand on health or social services:

  • M5: The foreign national’s condition might reasonably be expected to cause excessive demand on health or social services under the definition of excessive demand found in subsection R1(1).
  • M4/5: The foreign national’s condition might reasonably be expected to cause excessive demand on health or social services under the definition of excessive demand found in subsection R1(1), and the foreign national is likely to be a danger to public health based on the findings of the medical assessment.
  • M5/6: The foreign national’s condition might reasonably be expected to cause excessive demand on health or social services under the definition of excessive demand found in subsection R1(1), and the foreign national is likely to be a danger to public safety based on the findings of the medical assessment.

Reason

The medical officer must enter 1 or more of the medical assessment reasons below to denote which section of the IRPA is being applied to the medical assessment. If more than 1 reason exists, all must be entered.

In cases where the foreign national is found likely to present both an excessive demand and a danger to either public health (M4/5) or public safety (M5/6), or in cases where more than 1 type of potential excessive demand applies (M5), all applicable reasons must be entered.

  • Health services, paragraph A38(1)(c): The applicant’s condition might reasonably be expected to cause excessive demand on health services to such an extent that the applicant is inadmissible under paragraph A38(1)(c).
  • Social services, paragraph A38(1)(c): The applicant has a condition that might reasonably be expected to cause excessive demand on social services to such an extent that the applicant is inadmissible under paragraph A38(1)(c).
  • Displacement of Canadian on waiting list: The applicant has a condition that might reasonably be expected to cause displacement of Canadians who are on a waiting list and have a negative impact on the morbidity and mortality of Canadians.
  • Health condition, paragraph A38(1)(a): The applicant has a condition that is likely to be a danger to public health to such an extent that the applicant is inadmissible under paragraph A38(1)(a).
  • Health condition, paragraph A38(1)(b): The applicant has a condition that is likely to be a danger to public safety to such an extent that the applicant is inadmissible under paragraph A38(1)(b).

Surveillance code

The medical officer must enter one surveillance code to record whether the applicant requires medical surveillance after entering Canada and, if applicable, which type of surveillance applies.

Diagnosis code

A medical officer must enter 1 or more diagnosis codes. These codes exist as a list in the GCMS. All diagnoses (and associated codes) included in the medical officer’s rationale must be populated in this section of the medical assessment.

Application processing instructions

Once the MHB has recorded that the foreign national is likely inadmissible on health grounds, this information is automatically populated in any permanent or temporary residence application records to which the medical assessment is linked in the GCMS.

When the IME is completed as an upfront medical examination or is initially associated with a different application, the migration officer may need to associate the medical results into the application record using the instructions in Medical assessment coding.

Note: For IMEs assessed from June 1, 2018, to March 15, 2022, under the Temporary Public Policy Regarding Excessive Demand on Health and Social Services, follow the instructions below.

  • Determine if the applicant is admissible under the Temporary Public Policy Regarding Excessive Demand on Health and Social Services or if a danger to public safety is present. If a likely danger to public health or public safety does not exist, the migration officer should record an application note advising that excessive demand has been addressed by the application of the public policy provisions and do all of the following:
    • Update the medical admissibility status activity for the excessive demand individual from “Ready to be Assessed” to “Passed.”
      • Note: The migration officer with the GCMS responsibility of “Manager” may need to complete this step. In such cases, the officer should ask their manager to complete this step.
    • Record the final decision on the application in the GCMS.
    • Complete the final processing steps, including the issuance of any documents.
      • Note: The validity of some documents, such as the confirmation of permanent residence (COPR), is based on the validity date of the IME results. Because an M5 medical assessment has no validity date, the migration officer should use a date of 1 year from the date of the most recent medical assessment or the expiry of the applicant’s passport, whichever comes first.
  • If there is a likely danger to public health or public safety present, the processing officer should initiate procedural fairness for the danger to public health or public safety only and proceed with processing. These applications will not be centralized at the HMID-NF. See the procedural fairness instructions for danger to public health and public safety for more information.

For IMEs assessed from June 1, 2018, to March 15, 2022, under the Temporary Public Policy Regarding Excessive Demand on Health and Social Services, where the public policy does not overcome excessive demand findings, the migration officer should follow the IRCC processing instructions for IN, CN and DN offices.

Processing at a port of entry

Border services officers should follow the current instructions for referring processing of foreign nationals with medical conditions (section 7.7 of ENF 4 (PDF, 1.58 MB)).

If the foreign national is referred for an IME, the MHB medical officer provides the medical officer rationale and enters their assessment of the foreign national’s admissibility on health grounds into the GCMS.

If the medical officer finds that the foreign national is likely inadmissible on health grounds, the border services officer should go to the Assessment Details applet of the “Medicals – HB > IME” screen in GCMS. On this screen, the completed assessment by the medical officer should include all of the following:

Finally, the border services officer reviews and ensures that temporary residence and permanent residence applications are coded correctly in the GCMS, according to the steps outlined in the IRCC processing network instructions. The border services officer must ensure that the foreign national has no inadmissibility concerns before allowing them to enter Canada.

IRCC processing instructions for IN, CN and DN offices

Once the GCMS application has been updated to reflect the MHB assessment that the foreign national might reasonably be expected to cause excessive demand (and, if applicable, is also likely to be a danger to public health or public safety), the migration officer responsible for the application must complete the following steps:

  1. Complete all outstanding application processing steps (eligibility, security and criminality assessments) with the exception of assessing medical admissibility and recording a final decision on the application.
  2. Apply the following GCMS special program code to the application: XSD.
  3. Initiate an application file transfer and complete the file transfer to the HM Niagara Falls (3950).

Note: If there is a likely danger to public health or public safety, the migration officer should initiate procedural fairness proceedings for the danger to public health or public safety only, and proceed with processing. These applications will not be centralized at the HMID-NF. See the procedural fairness instructions for danger to public health and public safety for more information.

Procedural fairness instructions (HMID-NF)

Once the transfer of the application from the processing network office to HMID-NF is complete, HMID-NF must do all of the following:

  • Review the application to determine which medical inadmissibility grounds exist. These should always include an excessive demand finding and, in some cases, may also include a finding of a danger to public health or public safety.
  • Prepare and send a procedural fairness letter specific to the findings of the associated medical assessment.
  • Review any response the applicant provided to the procedural fairness request.

For permanent residence applications only: If the applicant is requesting an exemption from the medical inadmissibility based on humanitarian and compassionate (H&C) grounds or, in the absence of a specific request, if facts in the application suggest that an exemption from the medical inadmissibility is being requested by the applicant, the migration officer should consider H&C grounds before proceeding.

See more information about reviewing and assessing H&C considerations and about assessing H&C considerations when no exemption has been requested.

In these cases, the officer should do all of the following:

  • Determine if the information provided, including any H&C considerations if applicable (see above), overcomes medical admissibility concerns.
  • If the migration officer is satisfied that there are sufficient H&C grounds, refer the file to the delegated decision maker (PM-05). The migration officer cannot grant an exemption to section A38.
  • Render a final decision on the application, based on available information.

Excessive demand procedural fairness letter templates

Once the HMID-NF officer has determined that procedural fairness should be initiated, the HMID-NF must use the appropriate template packages (available on the T drive).

Each package includes the following:

  • a letter template
  • an instructions template

Once the appropriate package is selected, the HMID-NF must do all of the following:

  1. Open both the letter and instructions template.
  2. Populate the appropriate information from the drop-down menus.
  3. Save a template copy of the letter and instructions with the populated information to a local drive or desktop.
  4. Attach the template to the appropriate GCMS activity in the “Correspondence > Outgoing” section of the GCMS application screen. This will populate the other fields in the template.

Response to procedural fairness letters

Once a procedural fairness response is received from the applicant, the HMID-NF contacts the responsible regional medical office by email to request a review of the submission. Once this request is received, the medical officer should do the following:

  • Review all the medical documents submitted in response to the procedural fairness letter.
  • If applicable, review the medical applicability of the submitted mitigation plan in the context of the Canadian health care system.
  • Prepare a medical officer consideration letter. This should reflect the impact that information included in the procedural fairness response may have on the medical assessment, including
    • changes to medical diagnoses, prognoses or services required
    • other information that may impact the assessing officer’s medical admissibility decision
  • Record the medical officer consideration letter in the IME notes section of the GCMS.
  • Send a copy of the medical officer consideration letter to the HMID-NF by responding to the email sent by the HMID-NF advising that a response to procedural fairness was received.

Response to procedural fairness letter is not received

If a procedural fairness response is not received within the time frame given to the applicant (including any extensions), the HMID-NF officer will do all of the following:

  • Change the status of the applicable GCMS medical activity from “Ready to be Assessed” to “Failed.”
  • Record that an applicant has been found to be non-compliant in the “Other Requirements” section in the GCMS.
  • Enter all appropriate medical inadmissibility refusal information in the GCMS. This should include details of excessive demand findings and, if applicable, information related to medical inadmissibility due to a likely danger to public health or public safety. This must also include any refusal information related to the non-compliance.
  • Prepare and send a refusal letter that details all relevant refusal grounds.
  • Record a final decision in GCMS.

Response to procedural fairness letter is received

If a procedural fairness response is received, the HMID-NF officer should do all of the following:

  • Digitize the procedural fairness response and record the documents in the GCMS (if required). These documents should be placed in the “IMM > Correspondence > Incoming” section of the GCMS.
  • Prepare a detailed annex of the procedural fairness submission.
  • Request that the medical officer review and assess whether the information received addresses concerns from a medical perspective and await a response. This request can be made by sending an email to the responsible Regional Medical Office (RMO).
  • This email must include the following:
    • a subject line using the following format, which includes a reference to the IME number and the application number impacted: IME <number>, App <number>, Procedural fairness
    • attachments with the procedural fairness response
    • the GCMS eDocs numbers of the procedural fairness response attachments
  • The medical officer will assess whether the procedural fairness response addresses medical inadmissibility concerns and will provide a detailed response to the migration officer with one of the following assessments.
    1. The initial inadmissible assessment is withdrawn by the medical officer and is replaced by a new admissible assessment.
    2. The initial inadmissible assessment is maintained by the medical officer, with one of the two following possibilities:
      1. The procedural fairness response does not provide any new evidence that would allow the medical officer to change their opinion.
      2. The procedural fairness response contains a credible and viable mitigation plan that addresses all inadmissibility elements; the inadmissibility assessment is maintained by the medical officer and the client’s admissibility will depend on the migration officer’s assessment of the client’s ability and intent to adhere to their mitigation plan.
    3. Further information is required; the medical officer will re-open the IME and create a furtherance request for additional information before providing a procedural fairness assessment.

Note: The RMOs outside of Canada do not have access to GCDocs. Documents sent to these offices must be sent as email attachments.

Final decision on the application instructions

The procedural fairness letter response is received, and the applicant is medically admissible after a review (including H&C considerations) of the response.

If a procedural fairness letter response is received and after consulting with the medical officer, it is the migration officer’s assessment that the information provided addresses all medical admissibility concerns, the HM Niagara Falls officer should do the following:

  • Update the medical admissibility status activity for the excessive demand individual from “Ready to be Assessed” to “Passed.”
  • Note: Inadmissibility may only be overcome by H&C considerations for permanent residence applications. See more information about reviewing and assessing H&C considerations and about assessing H&C considerations when no exemption has been requested.
  • If the applicant has requested an exemption from the medical inadmissibility based on H&C grounds or, in the absence of a specific request, if facts in the application suggest that an exemption from the medical inadmissibility has been requested by the applicant and there are sufficient H&C grounds to overcome inadmissibility, apply H&C considerations to overcome medical inadmissibility by doing the following:
    • updating the medical activity status for the applicant from “Ready to be Assessed” to “Failed”
    • creating a new activity line in the “Other Reqs > H&C” section of the GCMS application for the applicant who has been assessed as being otherwise inadmissible
    • selecting “Type H&C – Medical”
    • changing the status of this activity from “Not Started” to “Passed” or “Passed H&C"
  • Enter an application note advising that medical admissibility concerns have been addressed. This note must detail how concerns were addressed (e.g. medical assessment updated, viable and credible mitigation plan in place, there are sufficient H&C factors to overcome medical inadmissibility due to…).
  • Note: The delegation to grant an exemption to A38 on H&C grounds (Other Reqs) rests with the delegation authority (PM­05 Manager).
  • Record the final decision on the application in the GCMS.
  • Complete final processing steps, including the issuance of any documents.

Important: The validity of some documents, such as the COPR, is based on the validity date of the IME results. Because an M5 medical assessment has no validity date, the migration officer should use a date of 1 year from the date of the most recent medical assessment or the expiry of the applicant’s passport, whichever is sooner.

The procedural fairness letter response is received, and the applicant remains medically inadmissible after a review of the response.

If a procedural fairness response is received, but the submitted documents do not address the inadmissibility findings, even with the application of H&C considerations to overcome medical inadmissibility, the migration officer should do the following:

  • Enter an application note advising that the medical admissibility concerns have not been addressed.
  • Update the medical admissibility status activity for the excessive demand individual from “Ready to be Assessed” to “Failed.”
  • Note: H&C grounds may only be considered for permanent residence applications. See more information about reviewing and assessing H&C considerations and about assessing H&C considerations when no exemption has been requested.
  • If the applicant has requested an exemption from the medical inadmissibility based on H&C grounds or, in the absence of a specific request, if facts in the application suggest that an exemption from the medical inadmissibility has been requested by the applicant, and there are insufficient H&C grounds to overcome inadmissibility
    • update the medical activity status for the applicant from “Ready to be Assessed” to “Failed”
  • Record the final decision on the application in the GCMS.
  • Prepare and send a refusal letter that details all relevant refusal grounds. This letter must specify all reasons that the applicant has been found inadmissible including, if required (see above), an acknowledgement that the application of H&C considerations did not overcome inadmissibility.

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