Excessive demand on health services and on social services

This section contains policy, procedures and guidance used by Immigration, Refugees and Citizenship Canada staff. It is posted on the Department’s website as a courtesy to stakeholders.

Part of the immigration application review and decision making process is Immigration, Refugees, and Citizenship Canada (IRCC) decision makers determining if 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 would likely exceed 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), unless there is evidence that significant costs are likely to be incurred beyond that period, in which case the period is no more than 10 consecutive years
  • 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

On June 1, 2018, the Temporary Public Policy Regarding Excessive Demand on Health and Social Services (public policy) was established, pursuant to authorities under section A25.2. This public policy allows officers to exempt individuals who meet the specific eligibility criteria set out by the Minister from paragraph A38(1)(c) (excessive demand).

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 or applications.

The officer responsible for the application (or, if there is more than 1 application, each application) at the time the medical assessment is made weighs if the public policy overcomes the medical assessment finding made by the MHB.

If the officer determines that provisions of the public policy overcome excessive demand inadmissibility concerns, the officer should apply the public policy to overcome the medical inadmissibility and render a final decision on the application.

If, after weighing provisions of the public policy, the officer determines that the applicant (principal applicant or family member) is still reasonably expected to cause excessive demand, the officer should do both of the following:

  • complete all application processing steps, including any outstanding admissibility or eligibility assessments, other than the assessment of medical admissibility and final decision
  • transfer the application to the Humanitarian Migration and Integrity Division at the IRCC Niagara Falls office (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, responsibility for final assessment of the IME is transferred to the MHB Centralized Medical Admissibility Unit (CMAU) in Ottawa.

Once the IME is accepted for continued processing by the CMAU, MHB medical officers should 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 CMAU 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 must be entered as a note in 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), of why the foreign national might reasonably be expected to cause excessive demand on publicly funded health and social services in Canada (and, if also applicable, if 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
  • write the note in a way that enables final decision makers to interpret clearly which parts of the medical assessment findings can or cannot be addressed by the application of the public policy. Therefore, the medical officer rationale must list the following, as defined by subsection R1(1):
    • the health and social services required by the applicant
    • the cost of these services, if applicable, and the total cost of all health and social services

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 GCMS.

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

Delegated officers: applying eligibility criteria and conditions of the public policy

Once an IME is completed, officers delegated to overcome an excessive demand inadmissibility finding, through the consideration and application of the public policy and under the authority of section A25.2, may grant an exemption from paragraph A38(1)(c) (medical inadmissibility due to excessive demand on health services and on social services) to the foreign national (principal applicant or their accompanying or non-accompanying dependent family members) who meets the criteria and conditions of the public policy.

Under the terms of the public policy, the average Canadian per capita health and social services costs are $6,604, and 3 times that average is $19,812.

In considering the costs of health and social services, under the public policy, the Minister’s delegates should calculate the health and social services below only when determining if the foreign national might reasonably be expected to pose an excessive demand.

Social services

Social services are closely related to health services, including the following services provided by a health professional and the provision of devices related to all of the following services:

  • home care by a nurse, physiotherapist, respiratory therapist or other care provider
  • palliative care
  • psychological counseling
  • medical aids, appliances and prostheses
  • social services that provide constant supervision and care for those who are not able to integrate into society, such as:
    • residential facilities, including long-term care and substance abuse services
    • day facilities providing constant supervision, for example respite care

Health services

Officers should include the following costs related to health services when determining the threshold that must be overcome:

  • physician services
  • nursing services
  • laboratory and diagnostic services
  • pharmaceuticals and pharmaceutical services
  • hospital services
  • chemotherapy and radiotherapy
  • dialysis
  • psychiatric services
  • supplies related to these services

Processing at a port of entry

Border services officers have the authority to invoke this new public policy. Medical officers are still using the current provisions and definitions in the IRPR to assess excessive demand.

Border services officers should follow the current instructions for referring processing of foreign nationals with medical conditions (section 7.8 of ENF 4).

When determining if a foreign national will cause excessive demand on publicly funded health and social services in Canada (and, if also applicable, if the foreign national is likely to be a danger to public health or public safety), the border services officer needs to calculate which costs are covered by the public policy and the total of the costs that are not covered by the public policy. See Delegated officers: applying eligibility criteria and conditions of the public policy.

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

As a result of this public policy, officers need to read the narrative of the medial officer rationale to determine if the foreign national fits within the public policy parameters. The medical officer should include all necessary details in the narrative of the medical officer rationale to provide the border services officer with enough information to make a decision to invoke the public policy, and the border services officer should not need to collect additional information.

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

IRCC processing network instructions

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

Public policy overcomes excessive demand findings

The officer should do all of the following:

  • Determine if the applicant is now admissible to Canada or if a danger to public health or public safety is also present.
    • If a likely danger to public health or public safety does not exist, the officer should record an application note advising that excessive demand has been addressed by application of the public policy provisions.
    • 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.

Public policy does not overcome excessive demand findings

The officer should do all of the following:

  • Complete all outstanding application processing steps with the exception of assessing medical admissibility and recording a final decision on the application.
  • Initiate an application file transfer and complete the file transfer to the HMID-NF.

HMID-NF instructions

Once the officer has determined that application of the public policy does not overcome the excessive demand finding, and the transfer of the application from the processing network office to the HMID-NF is complete, the 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 provided by the applicant 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 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), overcome medical admissibility concerns.
  • Render a final decision on the application, based on available information.

Procedural fairness instructions (HMID-NF and CMAU)

Once the transfer of the application to the HMID-NF is complete, procedural fairness must be initiated to give applicants the opportunity to respond to the officer’s concerns.

HMID-NF procedural fairness instructions

Once the officer has determined that the applicant is likely inadmissible to Canada, due to excessive demand (and, if applicable, also due to a likely danger to public health or public safety), the HMID-NF officer prepares and sends a procedural fairness letter.

For applications where an applicant requests an extension of time to submit a procedural fairness response, the officer should use their discretion in determining if extra time should be provided, based on reasons given by the applicant. A decision regarding the amount of time given for the extension should be exercised on a case by case basis.

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

  • Enter all appropriate medical inadmissibility refusal information in GCMS. This should include details of excessive demand findings and, if also 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.

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

  • Digitize the procedural fairness response and record documents in GCMS (if required).
  • Prepare a detailed annex of the procedural fairness submission.
  • Request that the CMAU review and assess if the information received addresses concerns from a medical perspective and await a response. This request can be made by sending an email to the MHB CMAU.
  • Assess if the procedural fairness response addresses medical inadmissibility.

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 it is the officer’s assessment, after consulting with the CMAU, that the information provided addresses all medical admissibility concerns, the officer should do the following:

  • Enter an application note advising that medical admissibility concerns have been addressed. This note must detail how concerns were addressed, including if provisions of the public policy were used to overcome inadmissibility (in whole or in part).
  • or (if inadmissibility is overcome on H&C grounds)

  • 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.
  • Record the final decision on the application in GCMS.
  • Complete final processing steps, including the issuance of any documents.

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 inadmissibility findings, even with the application of H&C considerations to overcome medical inadmissibility, the officer should do the following:

  • Enter an application note advising that medical admissibility concerns have not been addressed.
  • and (if inadmissibility is not overcome on H&C grounds)

  • 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.

  • Record the final decision on the application in GCMS.
  • Complete outstanding processing steps.
  • 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 application of H&C considerations did not overcome inadmissibility.

CMAU procedural fairness instructions

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

  • Review all the 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 revised medical officer rationale. 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 medical admissibility decision of the assessing officer
  • Send a copy of the revised medical officer rationale to the HMID-NF by responding to the email sent by the HMID-NF that advised a response to procedural fairness was received.
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