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R.R.O. 1990, Reg. 552: GENERAL

under Health Insurance Act, R.S.O. 1990, c. H.6

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Health Insurance Act
Loi sur l’assurance-santé

R.R.O. 1990, REGULATION 552

Amended to O. Reg. 6/04

GENERAL

Historical version for the period February 9, 2004 to Mar 11, 2004.

Disclaimer: This consolidation is not an official copy of the law because it is affected by one or more retroactive provisions which have not been incorporated into it. For information about the retroactive provisions, see O. Reg. 374/05, subsection 3 (3).

This Regulation is made in English only.

Skip Table of Contents

CONTENTS

 

 

Sections

 

Definitions

1-1.1

 

Health Card

2-2.3

 

Applications

3

 

Information with Respect to Eligibility

3.1

 

Miscellaneous

4-6

 

Insured Hospital Services in Canada

7-11

 

Extended Care Services

12-14

 

Insured Ambulance Services

15

 

Specified Health Care Services

16-23

 

Exclusions

24-27

 

Hospital Services

28

 

Out of Country Services

28.1-28.6

 

Health Services

29-33

 

Designated Hospitals and Health Facilities

34-35

 

Information to be Furnished by Designated Hospitals

36-37

 

Physician Services

37.1-37.6

 

Billing and Payment for Insured Services

38-38.6

 

Subrogation (Procedural)

39

Table 2

 

 

Table 4

 

 

Table 5

 

 

Table 6

 

 

Schedule 1

 

 

Schedule 2

Federal hospitals

 

Schedule 4

Hospitals for psychiatric illnesses and for alcoholism and drug addiction

 

Schedule 5

Approved physiotherapy facilities

 

Schedule 6

Rehabilitation and crippled children’s centres

 

Schedule 7

Ambulance service operators

 

Schedule 8

Public health laboratories approved as related health facilities

 

Schedule 12

 

 

Schedule 16

Schedule of benefits for out of province services nuclear medicine — in vivo

 

Schedule 17

Medications for the treatment of cystic fibrosis

 

Schedule 18

Medications for the treatment of thalassemia

 

Schedule 22

Laboratory tests authorized by registered nurse in the extended class

 

Schedule 23

Optometry services

 

Definitions

1. (1) In this Regulation,

“benefit period” means the period of time during which an insured person is entitled to insured services;

“dental surgeon” means a person entitled to practise dentistry in the place where dental services are rendered by the surgeon;

“extended class nursing staff” means those registered nurses in the extended class in a hospital,

(a) who are employed by the hospital and are authorized to diagnose, prescribe for or treat out-patients in the hospital, and

(b) who are not employed by the hospital and to whom the governing body or authority of the hospital has granted privileges to diagnose, prescribe for or treat out-patients in the hospital;

“hospital” means any hospital that is designated under this Regulation to participate in the Plan;

“in-patient” means a person admitted to and assigned a bed in a hospital in-patient area;

“midwife” means a member of the College of Midwives of Ontario;

“nursing home” means a nursing home operated or maintained under the authority of a licence issued under the Nursing Homes Act;

“oral and maxillofacial surgeon” means,

(a) with respect to dental services rendered in Ontario, a dental surgeon who holds a specialty certificate of registration from the Royal College of Dental Surgeons of Ontario authorizing the surgeon to practise oral and maxillofacial surgery in Ontario,

(b) with respect to dental services rendered elsewhere in Canada, a person who holds a designation from a professional regulatory body in the Canadian province or territory outside of Ontario where the services are rendered that, in the opinion of the General Manager, is equivalent to the designation referred to in clause (a), or

(c) with respect to dental services rendered outside Canada, a person who is authorized to practise oral and maxillofacial surgery in the jurisdiction outside Canada where the services are rendered and holds, in the opinion of the General Manager, a designation equivalent to the designation referred to in clause (a);

“out-patient” means a person who receives out-patient services and is not admitted to an in-patient area;

“prescribed form” means the form prescribed by the General Manager for the purpose;

“registered nurse in the extended class” means a member of the College of Nurses of Ontario who is a registered nurse and who holds an extended certificate of registration under the Nursing Act, 1991;

“same-sex partner” means a person of the same sex with whom the person is living, in a conjugal relationship outside marriage, if the two persons,

(a) have cohabited for at least one year,

(b) are together the parents of a child, or

(c) have together entered into a cohabitation agreement under section 53 of the Family Law Act;

“schedule of benefits” means the document published by the Ministry of Health and Long-Term Care titled “Schedule of Benefits — Physician Services under the Health Insurance Act (July 1, 2003)” and includes the following amendments, but does not include the “[Commentary…]” portions of the document:

1. Amendments dated August 1, 2003.

2. Amendments dated September 1, 2003;

“schedule of laboratory benefits” means the document published by the Ministry of Health and Long-Term Care titled “Schedule of Benefits for Laboratory Services”, dated April 1, 1999, together with the following documents:

1. The Ministry of Health document titled “Addendum Dated April 1, 2001 to Schedule of Benefits for Laboratory Services”.

Note:  On April 1, 2004, the definition of “schedule of laboratory benefits” is amended by adding the following paragraph:

2. The Ministry of Health and Long-Term Care document titled “Addendum Dated April 1, 2004 to Schedule of Benefits for Laboratory Services”;

See:  O. Reg. 6/04, ss. 1, 3 (2).

“spouse” means a person of the opposite sex,

(a) to whom the person is married, or

(b) with whom the person was living, in a conjugal relationship outside marriage, if the two persons,

(i) have cohabited for at least one year,

(ii) are together the parents of a child, or

(iii) have together entered into a cohabitation agreement under section 53 of the Family Law Act;

“standard ward accommodation” means,

(a) a bed in a hospital area designated by the hospital in accordance with Regulation 794 of the Revised Regulations of Ontario, 1990 under the Ministry of Health Act as a standard ward, or

(b) Revoked:  O. Reg. 375/93, s. 1.

R.R.O. 1990, Reg. 552, s. 1; O. Reg. 616/91, s. 1 (1); O. Reg. 214/93, s. 1; O. Reg. 375/93, s. 1; O. Reg. 794/93, s. 1; O. Reg. 488/94, s. 1; O. Reg. 114/96, s. 1; O. Reg. 409/96, s. 1 (1); O. Reg. 410/96, s. 1; O. Reg. 502/97, s. 1 (1); O. Reg. 44/98, s. 1; O. Reg. 147/98, s. 1; O. Reg. 375/98, s. 1 (1); O. Reg. 376/98, s. 1; O. Reg. 378/98, s. 1; O. Reg. 478/98, s. 1; O. Reg. 178/99, s. 1 (1-5); O. Reg. 201/99, s. 1; O. Reg. 482/99, s. 1; O. Reg. 67/00, s. 1; O. Reg. 322/00, s. 1; O. Reg. 368/00, s. 1 (1); O. Reg. 617/00, s. 1; O. Reg. 66/01, s. 1; O. Reg. 250/01, s. 1 (1); O. Reg. 272/01, s. 1 (1); O. Reg. 345/01, s. 1; O. Reg. 415/01, s. 1; O. Reg. 56/02, s. 1 (1); O. Reg. 169/02, s. 1 (1); O. Reg. 302/02, s. 1 (1); O. Reg. 361/02, s. 1 (1); O. Reg. 18/03, s. 1; O. Reg. 50/03, s. 1; O. Reg. 62/03, s. 1; O. Reg. 203/03, s. 1; O. Reg. 221/03, s. 1; O. Reg. 265/03, s. 1 (1); O. Reg. 266/03, s. 1; O. Reg. 350/03, s. 1.

(2) A reference to the schedule of benefits in relation to a service is a reference to the schedule of benefits set out in the definition in force at the time the service was rendered.  O. Reg. 616/91, s. 1 (2).

(3) Appendices A, B, C and F of the document titled “Schedule of Benefits — Physician Services under the Health Insurance Act (July 1, 2000)” do not form part of the schedule of benefits for the purposes of this Regulation.  O. Reg. 368/00, s. 1 (2).

(4) Revoked:  O. Reg. 265/03, s. 1 (2).

1.1 (1) For the purposes of the Act,

“resident” means an individual,

(a) who is present in Ontario by virtue of an employment authorization issued under the Caribbean Commonwealth and Mexican Seasonal Agricultural Workers Programme administered by the federal Department of Citizenship and Immigration, or

(b) who is ordinarily resident in Ontario and who is one of the following:

1. A Canadian citizen or a landed immigrant under the Immigration Act (Canada).

2. A person who is registered as an Indian under the Indian Act (Canada).

3. A Convention refugee as defined in the Immigration Act (Canada).

4. A person who has submitted an application for landing under the Immigration Act (Canada), who has not yet been granted landing and who has been confirmed by the federal Department of Citizenship and Immigration as having satisfied the medical requirements for landing.

5. Revoked:  O. Reg. 87/95, s. 1.

6. A person who has finalized a contract of employment or an agreement of employment with a Canadian employer situated in Ontario and who, at the time the person makes his or her application to become an insured person, holds an employment authorization under the Immigration Act (Canada) which,

i. names the Canadian employer,

ii. states the person’s prospective occupation, and

iii. has been issued for a period of at least six months.

7. The spouse, same-sex partner or dependent child under the age of 19 years of a person referred to in paragraph 6 if the Canadian employer provides the General Manager with written confirmation of the employer’s intention to employ the person referred to in paragraph 6 for a period of three continuous years.

8. A member of the clergy of any religious denomination who has finalized an agreement of employment to minister on a full-time basis to a religious congregation in Ontario for a period of not less than six consecutive months and whose duties will consist mainly of preaching doctrine, presiding at liturgical functions and spiritual counselling.

9. The spouse or same-sex partner and the dependent children under the age of 19 years of a member of the clergy referred to in paragraph 8 if the religious congregation provides the General Manager with written confirmation that it intends to employ the member for a period of at least three consecutive years.

10. A person granted a minister’s permit under section 37 of the Immigration Act (Canada) which indicates on its face that the person is a member of an inadmissible class designated as case type 86, 87, 88 or 89 or, if the permit is issued for the purpose of an adoption by an insured person, as case type 80.

11. A person granted an employment authorization under the Live-in Care Givers in Canada Programme or the Foreign Domestic Movement administered by the federal Department of Citizenship and Immigration.  O. Reg. 490/94, s. 1; O. Reg. 87/95, s. 1; O. Reg. 67/00, s. 2 (1, 2).

(2) For the purposes of subsection (1), a person is ordinarily resident in Ontario only if,

(a) in the case of an insured person or of a person who comes to Ontario from another province or territory in which that person was insured by the provincial or territorial health insurance authority, the person,

(i) makes his or her permanent and principal home in Ontario, and

(ii) subject to subsections (3), (4), (5) and (6), is present in Ontario for at least 153 days in any 12-month period; and

(b) in the case of a person who is applying to be an insured person for the first time or who is re-establishing his or her entitlement after having been uninsured for a period of time, other than a person who comes to Ontario from another province or territory in which that person was insured by the provincial or territorial health insurance authority, the person,

(i) intends to make his or her permanent and principal home in Ontario, and

(ii) is present in Ontario for at least 153 days immediately following the application.  O. Reg. 490/94, s. 1; O. Reg. 85/99, s. 1 (1, 2).

(3) A person referred to in clause (2) (a) is exempt from the requirement of subclause (2) (a) (ii) if the person provides the General Manager with evidence that he or she meets one of the following criteria:

1. The person’s employment requires the person to travel frequently outside of Ontario.

2. The General Manager has approved, under section 28.4, payment for a treatment to be provided to the person outside Canada.

3. The person,

i. leaves Ontario for a reason mentioned in subsection (4),

ii. met the requirement of subclause (2) (a) (ii) for at least two consecutive 12-month periods immediately before leaving, and

iii. intends to return to make his or her permanent and principal home in Ontario.

4. The person,

i. is the spouse or same-sex partner of, or a dependent child who is under 19 years of age of, a person who is exempt under paragraph 3,

ii. leaves Ontario to accompany the exempt person referred to in subparagraph i,

iii. met the requirement of subclause (2) (a) (ii) for at least two consecutive 12-month periods immediately before leaving, and

iv. intends to return to make his or her permanent and principal home in Ontario.  O. Reg. 85/99, s. 1 (3); O. Reg. 67/00, s. 2 (3).

(4) For the purposes of paragraph 3 of subsection (3), the reasons for which a person leaves Ontario are as follows:

1. To work in a place outside Canada which constitutes the person’s primary place of employment.

2. To attend a full-time educational program at an institution outside Canada that is accredited by the government of that jurisdiction.

3. To engage in missionary work outside Canada that is sponsored by a religious denomination in Ontario.  O. Reg. 85/99, s. 1 (3).

(5) A person who is exempt from the requirement of subclause (2) (a) (ii) under paragraph 3 of subsection (3) shall no longer be exempt from the requirement if,

(a) after having left Ontario for one of the reasons mentioned in subsection (4), the person is absent from Ontario for one of the other reasons mentioned in that subsection without having first returned to Ontario and met the requirement of subclause (2) (a) (ii) for at least two consecutive 12-month periods; and

(b) in the case of a person who leaves to work in a place outside Canada under paragraph 1 of subsection (4), the person fails to meet the requirement of subclause (2) (a) (ii) for more than five consecutive 12-month periods.  O. Reg. 85/99, s. 1 (3).

(6) In addition to any exemption under subsection (3), a person referred to in clause (2) (a) who leaves Ontario for an extended vacation or for any other reason is exempt from the requirement of subclause (2) (a) (ii) for two consecutive or separate 12-month periods if,

(a) the person previously met the requirements of clause (2) (a) for at least two consecutive 12-month periods;

(b) the person intends to return to make his or her permanent and principal home in Ontario; and

(c) the person has not previously been exempted from the requirement of subclause (2) (a) (ii) under this subsection.  O. Reg. 85/99, s. 1 (3).

Health Card

2. (1) The General Manager shall issue a health card to each insured person.  R.R.O. 1990, Reg. 552, s. 2 (1); O. Reg. 177/95, s. 1 (2).

(2) A health card is nontransferable.  R.R.O. 1990, Reg. 552, s. 2 (2); O. Reg. 177/95, s. 1 (3).

(3) An insured person shall present his or her health card upon the request of the hospital, physician or practitioner from whom the person receives insured services.  R.R.O. 1990, Reg. 552, s. 2 (3); O. Reg. 177/95, s. 1 (4).

(4) A health card shall be in the form approved by the Minister.  O. Reg. 177/95, s. 1 (5).

2.1 Revoked:  O. Reg. 172/98, s. 1.

2.2 The following information is prescribed as personal information that may be collected, used or disclosed under clause 2 (3) (b) of the Act:

1. A photograph of the insured person.

2. A copy of an insured person’s signature.  O. Reg. 177/95, s. 2.

2.3 (1) An insured person shall surrender his or her health card to the General Manager upon ceasing to be a resident.  O. Reg. 218/95, s. 1.

(2) An insured person who intends to surrender a card under subsection (1) by mailing it or by delivering it to the General Manager in a way other than by personal delivery shall deface the card in the manner approved by the General Manager before mailing or otherwise delivering the card.  O. Reg. 218/95, s. 1.

Applications

3. (1) A resident who is not otherwise an insured person may become an insured person by submitting an application to the General Manager.  R.R.O. 1990, Reg. 552, s. 3 (1); O. Reg. 177/95, s. 3 (1).

(1.1) An application under subsection (1) shall be in the form approved by the Minister.  O. Reg. 177/95, s. 3 (2).

(2) A resident making an application under subsection (1), shall be present in Ontario at the time of submitting the application.  R.R.O. 1990, Reg. 552, s. 3 (2).

(3) A resident who makes an application under subsection (1) shall only be enrolled as an insured person three months after the day the person becomes a resident.  O. Reg. 491/94, s. 2.

(4) The three-month waiting period referred to in subsection (3) does not apply to the following persons who are residents and who apply to become insured persons:

1. A child under the age of 16 who is adopted by an insured person.

2. A newborn born in Ontario to an insured person.

3. A person who satisfies the General Manager that he or she has been resident in Ontario for at least three months at the time of his or her application to become an insured person.

4. A member of the Canadian Forces who was an insured person immediately before becoming a member and is discharged from the Canadian Forces.

5. A member of the Royal Canadian Mounted Police who had been appointed to a rank therein and who was an insured person immediately before becoming a member and is discharged.

6. A Canadian diplomat who returns to Ontario after a posting to a place outside Canada and who was an insured person immediately before the posting.

7. The spouse, same-sex partner or dependent child under 19 years of age, of a Canadian diplomat referred to in paragraph 6 who was an insured person immediately before the posting of the Canadian diplomat.

8. An inmate at a penitentiary as defined in the Corrections and Conditional Release Act (Canada) who is released.

9. An inmate at a correctional institution established or designated under Part II of the Ministry of Correctional Services Act who is released.

10. A person who,

i. takes up residence in Ontario directly from elsewhere in Canada where the person was insured under a government health plan or a hospital insurance plan, and

ii. upon taking up residence in Ontario, becomes a resident of an approved charitable home for the aged under the Charitable Institutions Act, a home under the Homes for the Aged and Rest Homes Act or a nursing home under the Nursing Homes Act.

11. A Convention refugee as defined in the Immigration Act (Canada).

12. A person who has made a claim to be a Convention refugee under the Immigration Act (Canada) and in respect of whom,

i. a senior immigration officer has determined that the person is eligible to have his or her claim determined by the Refugee Division, and

ii. a removal order, as defined in the Immigration Act (Canada), has not been executed.

13. A person granted a Minister’s permit under section 37 of the Immigration Act (Canada) which indicates on its face that the person is a member of an inadmissible class designated as case type 86, 87, 88 or 89 or, if the permit is issued for the purpose of an adoption by an insured person, as case type 80.

14. A person who is present in Ontario by virtue of an employment authorization issued under the Caribbean Commonwealth and Mexican Seasonal Agricultural Workers Programme administered by the federal Department of Citizenship and Immigration.

15. A pregnant woman who became pregnant before April 1, 1994 and who applied to become an insured person during the course of that pregnancy.

16. A pregnant woman who,

i. has submitted an application for landing under the Immigration Act (Canada) and has not yet been granted landing,

ii. became pregnant before April 1, 1994, and applied to become an insured person during the course of that pregnancy, and

iii. has been confirmed by the federal Department of Citizenship and Immigration as having satisfied,

A. all the medical requirements for landing, or

B. all the medical requirements for landing except for the requirement to submit to an x-ray.  O. Reg. 491/94, s. 2; O. Reg. 67/00, s. 3.

Information with Respect to Eligibility

3.1 (0.1) The General Manager may require an insured person to provide information or evidence relating to eligibility as a condition to continuing as an insured person.  O. Reg. 177/95, s. 4.

(0.2) Information or evidence required under subsection (0.1) shall be provided in the form approved by the Minister.  O. Reg. 177/95, s. 4.

(1) The General Manager may require the following information as a condition for an insured person to continue as an insured person:

1. In cases where the insured person’s name is changed to a name other than the one indicated on the person’s health card, the person’s health number, former name and new name.

2. In cases where the insured person’s address is changed to an address other than the one indicated on the person’s application to become an insured person, the person’s health number, former address and new address.

3. In cases where the insured person’s citizenship or immigration status is changed to a status other than that indicated on the person’s application to become an insured person, the person’s health number, former status and present status.  O. Reg. 490/94, s. 2.

(2) If an insured person is under 16 years of age, the General Manager may require that the information referred to in subsection (1) relating to the change of name, address or citizenship or immigration status of the child be provided by the parent of the child who has custody of the child, or by any other insured person who has custody of the child.  O. Reg. 490/94, s. 2.

Miscellaneous

4. Revoked:  O. Reg. 87/98, s. 1.

5. The benefit period of an insured person who, upon ceasing to be a resident of Ontario, immediately establishes residence in another province or territory of Canada shall be continued for three months after the date the person ceases to be a resident under the Act.  O. Reg. 490/94, s. 3.

6. Revoked:  O. Reg. 496/96, s. 1.

Insured Hospital Services in Canada

7. Subject to section 10, the in-patient services to which an insured person is entitled without charge are all of the following services:

1. Accommodation and meals at the standard or public ward level.

2. Necessary nursing service, except for the services of a private duty nurse who is not engaged and paid by the hospital.

3. 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.

4. Drugs, biologicals and related preparations that are prescribed by an attending physician, oral and maxillofacial surgeon or midwife in accordance with accepted practice and administered in a hospital, but not including any proprietary medicine as defined from time to time by the regulations made under the Food and Drugs Act (Canada).

5. Use of operating room, obstetrical delivery room and anaesthetic facilities, including necessary equipment and supplies.  R.R.O. 1990, Reg. 552, s. 7; O. Reg. 794/93, s. 2; O. Reg. 345/01, s. 2.

8. (1) The out-patient services to which an insured person is entitled without charge are all of the following services:

1. Laboratory, radiological and other diagnostic procedures, together with the necessary interpretations.

2. The use of radiotherapy facilities where available in a hospital in Canada when prescribed by a physician.

2.1 The use of occupational therapy and physiotherapy facilities where available in a hospital in Canada when prescribed by a physician or a registered nurse in the extended class.

3. The use of speech therapy facilities where available in a hospital in Canada when prescribed by a physician, by an oral and maxillofacial surgeon or by a registered nurse in the extended class.

4. The use of diet counselling services when prescribed by a physician or a registered nurse in the extended class.

5. The hospital component of all other out-patient services, including the use of an operating room and anaesthetic facilities, surgical supplies, necessary nursing service, meals required during a treatment program and the supplying of drugs, biologicals and related preparations that are prescribed in accordance with accepted practice by a physician on the medical staff, a midwife on the midwifery staff, an oral and maxillofacial surgeon on the dental staff or a registered nurse in the extended class on the extended class nursing staff of the hospital and that are administered in the hospital, but not including,

i. the provision of any proprietary medicine as defined from time to time by the regulations made under the Food and Drugs Act (Canada),

ii. the provisions of medications for the patient to take home,

iii. diagnostic services performed to satisfy the requirements of third parties such as employers and insurance companies, and

iv. visits solely for the administration of drugs, vaccines, sera or biological products.

6. Use of home renal dialysis medications where available in a hospital in Canada and prescribed by a physician on the medical staff of that hospital.

6.1 Use of home renal dialysis equipment and supplies where available in a hospital in Canada and prescribed by a physician on the medical staff of that hospital or by a registered nurse in the extended class on the extended class nursing staff of that hospital.

7. Use of home hyperalimentation medications where available in a hospital in Ontario and prescribed by a physician on the medical staff of that hospital.

7.1 Use of home hyperalimentation equipment and supplies where available in a hospital in Ontario and prescribed by a physician on the medical staff of that hospital or by a registered nurse in the extended class on the extended class nursing staff of that hospital.

8. The provision to haemophiliac patients, for use in the home, of equipment and supplies for the emergency treatment of, or the prevention of, haemorrhage where the equipment and supplies are available in a hospital in Ontario and prescribed by a physician on the medical staff of that hospital.

8.1 The provision to haemophiliac patients, for use in the home, of equipment and supplies other than blood products where the equipment and supplies are available in a hospital in Ontario and prescribed by a registered nurse in the extended class on the extended class nursing staff of that hospital.

9.-16.  Revoked:  O. Reg. 175/95, s. 1 (2).

R.R.O. 1990, Reg. 552, s. 8; O. Reg. 794/93, s. 3; O. Reg. 175/95, s. 1 (1, 2); O. Reg. 345/01, s. 3; O. Reg. 62/03, s. 2 (1-6).

(1.1) Despite paragraph 1 of subsection (1), a laboratory, radiological or other diagnostic procedure ordered by a registered nurse in the extended class is not an out-patient service to which an insured person is entitled without charge unless it is a laboratory, radiological or diagnostic procedure described in subsection (1.2).  O. Reg. 44/98, s. 2.

(1.2) For the purposes of subsection (1.1), the following laboratory, radiological and diagnostic procedures are, when ordered by a registered nurse in the extended class who is on the extended nursing staff of a hospital, out-patient services to which an insured person is entitled without charge:

1. A mammogram.

2. An X-ray of a chest, ribs, arm, wrist, hand, leg, ankle or foot.

3. A diagnostic ultrasound of the abdomen, pelvis or breast.

4. A laboratory test referred to in Schedule 22.  O. Reg. 44/98, s. 2; O. Reg. 62/03, s. 2 (7).

(1.3) Revoked:  O. Reg. 62/03, s. 2 (8).

(2) Despite subparagraph ii of paragraph 5 of subsection (1), the provision of a medication listed in Column 1 of the Table to this subsection to an out-patient, for use in the home, is an out-patient service to which an insured person is entitled without charge if the medication is provided in the circumstances described in Column 2 of the Table:

TABLE

 

Item

Column 1

Column 2

 

Medication Provided

Condition of Insured Service

1.

A medication for the emergency treatment of, or the prevention of, a haemorrhage

  1. The medication must be available in a hospital in Ontario.

 

 

  2. The medication must be prescribed by a physician on the medical staff of that hospital.

 

 

  3. The medication must be provided to a patient with haemophilia.

2.

cyclosporine

  1. The medication must be prescribed by a physician on the medical staff of a hospital graded, under the Public Hospitals Act, as a Group O hospital.

 

 

  2. The medication must be provided to a solid organ or bone marrow transplant patient.

3.

zidovudine, commonly called “AZT”

  1. The medication must be prescribed by a physician.

 

 

  2. The medication must be provided to a patient with HIV infection.

4.

A biosynthetic human growth hormone

  1. The medication must be prescribed by a physician on the medical staff of a hospital graded, under the Public Hospitals Act, as a Group S hospital.

 

 

  2. The medication must be provided to a patient with endogenous growth hormone deficiency.

5.

A medication for treatment of cystic fibrosis that is listed in Schedule 17

  1. The medication must be prescribed by a physician on the medical staff of a hospital graded, under the Public Hospitals Act, as a Group T hospital.

6.

A medication for the treatment of thalassemia that is listed in Schedule 18

  1. The medication must be prescribed by a physician on the medical staff of a hospital graded, under the Public Hospitals Act, as a Group U hospital.

7.

erythropoietin

  1. The medication must be prescribed by a physician on the medical staff of a hospital.

 

 

  2. The medication must be provided to a patient with anaemia of end-stage renal disease.

8.

alglucerase

  1. The medication must be prescribed by a physician.

 

 

  2. The use of the medication must be recommended by the Gaucher Disease Review Committee.

 

 

  3. The medication must be provided to a patient with Gaucher disease.

9.

clozapine

  1. The medication must be prescribed by a physician on the medical staff of a hospital.

 

 

  2. The use of the medication must be recommended by a regional co-ordinator of a provincial psychiatric hospital.

 

 

  3. The medication must be provided to a patient with treatment-resistant schizophrenia.

10.

didanosine, commonly called “ddI”

  1. The medication must be prescribed by a physician.

 

 

  2. The medication must be provided to a patient with HIV infection.

11.

zalcitabine, commonly called “ddC”

  1. The medication must be prescribed by a physician.

 

 

  2. The medication must be provided to a patient with HIV infection.

12.

pentamidine

  1. The medication must be prescribed by a physician.

 

 

  2. The medication must be provided to a patient with HIV infection.

O. Reg. 175/95, s. 1 (3); O. Reg. 253/00, s. 1; O. Reg. 322/01, s. 1.

(2.1) Despite subparagraph 5 ii of subsection (1), the provision of verteporfin to an out-patient on or after June 15, 2002, for use in the home, is an out-patient service to which an insured person is entitled without charge if the verteporfin is provided in the following circumstances:

1. The verteporfin is provided in the course of ocular photodynamic therapy for the treatment of predominantly classic subfoveal choroidal neovascularization secondary to age-related macular degeneration or pathologic myopia.

2. The area of classic subfoveal choroidal neovascularization is equal to or greater than 50 per cent of the total lesion, as determined by fluorescein angiography.

3. The first treatment is commenced within 30 months after the initial diagnosis of predominantly classic subfoveal choroidal neovascularization secondary to age-related macular degeneration or pathologic myopia.

4. The patient’s visual acuity is 20/40 or worse.  O. Reg. 169/02, s. 2.

(3) Despite subparagraph iv of paragraph 5 of subsection (1), the following visits to a hospital are out-patient services to which an insured person is entitled without charge:

1. A visit that is solely for the administration of a rabies vaccine.

2. A visit that is solely for the administration of a medication listed in Column 1 of the Table to subsection (2) if the conditions listed in Column 2 of the Table are satisfied.  O. Reg. 175/95, s. 1 (3).

8.1 (1) Despite paragraph 3 of section 7 and paragraph 1 of subsection 8 (1), a laboratory, radiological or other diagnostic procedure ordered by an oral and maxillofacial surgeon and rendered in a hospital is not an in-patient or out-patient service to which an insured person is entitled without charge unless,

(a) in the case of a radiological or diagnostic procedure, it is a procedure described in subsection (2); and

(b) the laboratory, radiological or other diagnostic procedure is rendered,

(i) in connection with a dental surgical procedure provided by an oral and maxillofacial surgeon in a hospital and it is medically necessary for the person to receive the dental surgical procedure in a hospital, or

(ii) on the order of an oral and maxillofacial surgeon who has reasonable grounds to believe that a dental surgical procedure, performed by an oral and maxillofacial surgeon, will be required in connection with the laboratory, radiological or other diagnostic procedure and that it will be medically necessary for the person to receive the dental surgical procedure in a hospital.  O. Reg. 345/01, s. 4.

(2) The following radiological and diagnostic procedures are the procedures to which an insured person is entitled without charge for the purposes of clause (1) (a):

1. Nuclear medicine bone and labeled leukocyte scintigraphy.

2. Plain X-ray of the head, neck, chest, pelvis and tibia.

3. Computed tomography of the head.

4. Fistula or sinus radiology examination.

5. Radiology sialograms.

6. Ultrasound of the face and sinuses.

7. Pulmonary function studies.

8. Electrocardiograms.  O. Reg. 345/01, s. 4.

9. (1) Subject to section 10 and subsection 11 (1), an insured person is entitled to in-patient services and out-patient services in the following hospitals, without paying any charge to the hospital for such services:

1. A hospital listed in Schedule 2.

2. A hospital graded, under the Public Hospitals Act, as a Group A, B, C, E, F, G, J or R hospital.

3. Revoked:  O. Reg. 322/01, s. 2 (1).

O. Reg. 253/00, s. 2 (1); O. Reg. 322/01, s. 2 (1).

(2) Subject to section 10 and subsection 11 (1), an insured person is entitled to receive, in a hospital listed in Schedule 1, such in-patient and out-patient services as are available in the hospital without paying any charge to the hospital for the services.  R.R.O. 1990, Reg. 552, s. 9 (2).

(3) Subject to section 10, where the attending physician, oral and maxillofacial surgeon or midwife certifies in writing that an insured person’s condition is such that the person requires immediate admission as an in-patient, and standard ward accommodation in an approved hospital is not available because all such accommodation is occupied or where the attending physician, oral and maxillofacial surgeon or midwife certifies in writing that an insured person’s condition is such that for the person’s own good or for the good of other patients it is necessary that the person be supplied with private or semi-private accommodation, the person shall be provided by the hospital with private or semi-private accommodation without paying any charge to the hospital for such services.  R.R.O. 1990, Reg. 552, s. 9 (3); O. Reg. 794/93, s. 4; O. Reg. 496/96, s. 2; O. Reg. 345/01, s. 5.

(4) Subject to section 10 and to subsection 11 (1), an insured person is entitled to receive, in a hospital listed in Schedule 4, those insured services that are in accordance with the type of care and treatment designated in the Schedule for that hospital without paying any charge for such services.  R.R.O. 1990, Reg. 552, s. 9 (4); O. Reg. 111/98, s. 1.

(5) Subject to subsection 11 (2), an insured person is entitled to receive, as an out-patient in a rehabilitation centre or crippled children’s centre listed in Schedule 6, the insured services indicated in the Schedule without paying any charge to the centre for such services.  R.R.O. 1990, Reg. 552, s. 9 (5).

(6) Subject to subsection 11 (1), an insured person is entitled to receive computerized axial tomography scanning services in a hospital graded, under the Public Hospitals Act, as a Group M hospital without paying any charge to the hospital for such services.  O. Reg. 322/01, s. 2 (2).

(7) Revoked:  O. Reg. 253/00, s. 2 (3).

(8) It is a condition of payment by the Plan to a hospital for the performance of a computerized axial tomography scan that the scan be performed by and on the premises of a hospital graded, under the Public Hospitals Act, as a Group M hospital.  O. Reg. 322/01, s. 2 (3).

10. (1) A co-payment for accommodation and meals that are insured services shall be made by or on behalf of an insured person who, in the opinion of the attending physician, requires chronic care and is more or less permanently resident in a hospital or other institution.  O. Reg. 496/96, s. 3.

(2) This section applies only with respect to an insured person receiving,

(a) insured in-patient services provided in a hospital listed in Part II of Schedule 1, Part II of Schedule 2 or Part II of Schedule 4 or a hospital graded, under the Public Hospitals Act, as a Group F, G or R hospital; or

(b) insured in-patient services provided in a hospital graded, under the Public Hospitals Act, as a Group A, B or C hospital if the insured person is awaiting placement in a hospital referred to in clause (a) or another institution.  O. Reg. 322/01, s. 3.

(3) Co-payments shall be paid to the hospital providing the services.  O. Reg. 496/96, s. 3.

(4) The amount of the co-payment is the amount charged by the hospital subject to the following restrictions:

1. The amount charged may not exceed the maximum amount of the co-payment under subsections (6) to (9).

2. The amount charged may not be increased unless the hospital has given the insured person at least 30 days written notice of the increase.  O. Reg. 496/96, s. 3.

(5) Paragraph 2 of subsection (4) does not apply to an increase in the amount of a co-payment that was reduced pursuant to an application under subsection (7), if the increase results from,

(a) a determination under subsection (8) pursuant to a reapplication under subsection (7); or

(b) a failure to reapply under subsection (7) at the end of the period for which the reduction was in effect.  O. Reg. 496/96, s. 3.

(6) Subject to subsections (7) to (9), the maximum amount of the co-payment is,

(a) for each calendar month that services are received on every day of the month by a person in a category set out in Column 2 of Table 2, the amount prescribed opposite in Column 3 for the period the services are received in Column 1; and

(b) for each day, other than a day that is part of a month referred to in clause (a), that services are received by a person in a category set out in Column 2 of Table 2, the amount prescribed opposite in Column 4 for the period the services are received in Column 1.  O. Reg. 496/96, s. 3.

(7) The insured person or the insured person’s spouse or same-sex partner may make an application to the hospital for a reduction in the maximum amount of the co-payment if,

(a) the insured person has a spouse or same-sex partner who was cohabiting with the insured person immediately before the insured person was admitted to the hospital where he or she is receiving insured in-patient services or, if the insured person has been in more than one hospital or institution continuously, immediately before the insured person was first admitted to such a hospital or institution;

(b) the spouse or same-sex partner is receiving benefits under the Old Age Security Act (Canada) or the Ontario Guaranteed Annual Income Act; and

(c) the spouse or same-sex partner lives outside an approved charitable home for the aged under the Charitable Institutions Act, a home under the Homes for the Aged and Rest Homes Act, a nursing home under the Nursing Homes Act or a hospital or other facility that is government-funded.  O. Reg. 496/96, s. 3; O. Reg. 67/00, s. 4 (1).

(8) If an application is made under subsection (7), the amount of the reduction shall be determined in accordance with the Application for Reduction of Assessed Co-Payment Fees dated February 28, 2000 and published by and available from the Ministry of Health.  O. Reg. 496/96, s. 3; O. Reg. 67/00, s. 4 (2).

(9) A reduction determined under subsection (8) shall take effect on the first day of the month in which the application for the reduction was made and ends on the earliest of the following dates:

1. The first June 30 following the first day of the month in which the application for the reduction was made.

2. The last day of the month immediately preceding the month in which the next application is made under subsection (7) in respect of the same insured person.  O. Reg. 496/96, s. 3.

(10) This section does not apply with respect to,

(a) a child who is under 18 years of age;

(b) a person who was receiving benefits under the General Welfare Assistance Act or the Family Benefits Act, income support under the Ontario Disability Support Program Act, 1997, or income assistance under the Ontario Works Act, 1997 on the day before the insured person was admitted to the hospital where they are receiving insured in-patient services.  O. Reg. 496/96, s. 3; O. Reg. 221/03, s. 2.

(11) In this section, and in Table 2,

“dependant” means,

(a) a spouse or same-sex partner who is not receiving benefits under the Old Age Security Act (Canada) or the Ontario Guaranteed Annual Income Act and who was cohabiting with the insured person immediately before the insured person was admitted to the hospital where they are receiving insured in-patient services or, if the insured person has been in more than one hospital or institution continuously, immediately before they were first admitted to such a hospital or institution, or

(b) a child who is under 18 years of age;

“estimated income” means the average monthly income of any nature or kind whatsoever, so long as it is taxable under the Income Tax Act (Canada), of an insured person or of a dependant of an insured person, as estimated by the insured person or the insured person’s representative, and including,

(a) payments made under an Act of the Parliament of Canada or by Ontario,

(b) income from salaries and wages,

(c) income from an interest in or operation of a business, less expenses incurred in earning such gross income, and

(d) income from investments, less expenses incurred in earning such income.  O. Reg. 496/96, s. 3; O. Reg. 197/97, s. 1; O. Reg. 67/00, s. 4 (3, 4).

11. (1) An insured person is not entitled to insured services in a hospital unless the person has been,

(a) admitted as an in-patient on the order of a physician;

(b) received in the hospital and examined as an out-patient by a physician and treated as an out-patient, if necessary;

(c) referred to the hospital as an out-patient by,

(i) a physician, for any of the services designated in section 8,

(ii) an osteopath or chiropractor, for X-rays, or

(iii) an oral and maxillofacial surgeon, for any laboratory, radiological or diagnostic procedure described in section 8.1;

(c.1) admitted as an in-patient or registered as an out-patient on the order or under the authority of an oral and maxillofacial surgeon;

(d) admitted as an in-patient or registered as an out-patient on the order or under the authority of a midwife; or

(e) registered as an out-patient on the order or under the authority of a registered nurse in the extended class.  R.R.O. 1990, Reg. 552, s. 11 (1); O. Reg. 794/93, s. 5; O. Reg. 44/98, s. 3; O. Reg. 345/01, s. 6; O. Reg. 62/03, s. 3.

(2) An insured person is not entitled to receive insured services in a centre listed in Schedule 6 unless he or she has been,

(a) received in the centre, and examined as an out-patient by a physician; or

(b) referred to the centre as an out-patient by a physician.  R.R.O. 1990, Reg. 552, s. 11 (2).

Extended Care Services

12. RevokedO. Reg. 375/93, s. 3.

13. (1) In this section,

“home care facility” means,

(a) a local board of health of a municipality or a health unit, or

(b) an agency,

approved by the Minister to provide home care services;

“home care services” means,

(a) the services that are provided, on a visitation basis, by a nurse or a nursing assistant,

(b) the services provided, on a visiting basis, by a physiotherapist, occupational therapist, speech therapist, social worker or nutritionist,

(c) the provision of dressings and medical supplies,

(d) the provision of diagnostic and laboratory services,

(e) the provision of hospital and sickroom equipment,

(f) the provision of transportation services to and from the home to a hospital, health facility or the attending physician’s office, as the case may be;

“nurse” means a nurse who holds a certificate of registration under Part IV of the Health Disciplines Act;

“nursing assistant” means a nursing assistant who holds a certificate of registration under Part IV of the Health Disciplines Act;

“professional service” means nursing, physiotherapy, occupational therapy and speech therapy services.  R.R.O. 1990, Reg. 552, s. 13 (1).

(2) Each home care facility is prescribed as a health facility under the Act and is designated as a health facility for the purpose of section 34.  R.R.O. 1990, Reg. 552, s. 13 (2).

(3) Home care services provided by a home care facility to an insured person in his or her home are prescribed as insured services.  R.R.O. 1990, Reg. 552, s. 13 (3).

(4) It is a condition of payment for insured services under subsection (3) that,

(a) Revoked:  O. Reg. 173/95, s. 1 (1).

(b) the services are necessary to enable the insured person to remain in his or her home or to make possible the insured person’s return to his or her home from a hospital or other institution;

(c) the needs of the insured person cannot be met on an out-patient basis;

(d) the insured person is in need of at least one professional service, if the service for which payment is sought is described in clause (c), (d), (e) or (f) of the definition of “home care services” in subsection (1);

(e) the services are provided in the insured person’s home where such has been approved by the Minister as being suitable to enable the required care to be given;

(f) the services are available in the area where the insured person resides; and

(g) the services are reasonably expected to result in progress towards rehabilitation.  R.R.O. 1990, Reg. 552, s. 13 (4); O. Reg. 173/95, s. 1 (1, 2).

(5) Physiotherapy, occupational therapy and speech therapy provided by a home care facility to an insured person who,

(a) is a resident in a nursing home;

(b) is a resident in a home for the aged, established and maintained under the Homes for the Aged and Rest Homes Act; or

(c) is a resident in a charitable institution approved under the Charitable Institutions Act,

are prescribed as insured services.  R.R.O. 1990, Reg. 552, s. 13 (5); O. Reg. 375/93, s. 4.

(6) It is a condition of payment for insured services under subsection (5) that,

(a) Revoked:  O. Reg. 173/95, s. 1 (3).

(b) Revoked:  O. Reg. 173/95, s. 1 (3).

(c) the needs of the insured person cannot be met on an out-patient basis;

(d) the services are available in the area of the facility in which the insured person is a resident; and

(e) the services are reasonably expected to result in progress toward rehabilitation.  R.R.O. 1990, Reg. 552, s. 13 (6); O. Reg. 173/95, s. 1 (3).

14. Revoked:  O. Reg. 493/00, s. 1.

Insured Ambulance Services

15. (1) Ambulance services are insured services if,

(a) they are provided by an ambulance service operator listed in Schedule 7 or by an ambulance service operated by the Province of Ontario;

(b) the hospital to or from which the services are required is listed in Schedule 1 or 4 or is graded, under the Public Hospitals Act, as a Group A, B, C, E, F, G, J or R hospital; and

(c) the insured person pays a co-payment of $45 to that hospital.  O. Reg. 253/00, s. 4; O. Reg. 322/01, s. 4.

(2) Where ambulance services are provided by air or by rail, including where applicable any ambulance service required to connect with the air or rail facilities, an insured person shall pay as his or her share of the ambulance charges an amount of $45 a trip by way of co-payment.  R.R.O. 1990, Reg. 552, s. 15 (2); O. Reg. 329/92, s. 1 (2).

(3) An ambulance service is not an insured service if it is not medically necessary.  O. Reg. 329/92, s. 1 (3).

(4) Revoked:  O. Reg. 329/92, s. 1 (4).

(5) Revoked:  O. Reg. 329/92, s. 1 (4).

(6) The co-payment prescribed in subsections (1) and (2) does not apply to a person,

(a) who receives benefits under the Family Benefits Act, income support under the Ontario Disability Support Program Act, 1997, or income assistance under the Ontario Works Act, 1997;

(b) who is transferred from a hospital to another hospital;

(c) who is transferred from a hospital to a facility listed in Schedule 6;

(d) who is transferred from a hospital to a facility listed in Schedule 8;

(e) who is transferred from a hospital to a medical laboratory licensed under the Laboratory and Specimen Collection Centre Licensing Act;

(f) who is transferred from a hospital to a facility registered under the Healing Arts Radiation Protection Act for the purpose of radiological examination or treatment;

(g) who is transferred from one part of a hospital to any other part of the same hospital;

(h) who is receiving home care services under section 13;

(i) who is residing in an approved home under section 12 of the Mental Hospitals Act;

(j) who is a resident of a home for special care licensed under the Homes for Special Care Act;

(k) who is a resident of a nursing home operated or maintained under the authority of a licence issued under the Nursing Homes Act;

(l) who is a resident of a home for the aged or a rest home under the Homes for the Aged and Rest Homes Act; or

(m) who is a resident of an approved charitable home for the aged under the Charitable Institutions Act.  R.R.O. 1990, Reg. 552, s. 15 (6); O. Reg. 375/93, s. 5; O. Reg. 221/03, s. 3.

Specified Health Care Services

16. (1) The services rendered by dental surgeons that are prescribed as insured services are the services set out in Column 1 of Parts I, II and III of the schedule of dental benefits.  O. Reg. 86/03, s. 2.

(2) It is a condition for the performance and for payment of the insured services set out in the schedule of dental benefits, that they be performed in a hospital by a dental surgeon who has been appointed to the dental staff by the hospital on the recommendation of the chief of the surgical staff and the agreement of the Medical Advisory Committee of the hospital.  O. Reg. 86/03, s. 2.

(3) It is a condition for the performance and for payment of the insured services set out in Part II of the schedule of dental benefits that they be performed in conjunction with one or more of the insured services set out in Part I or III of that schedule.  O. Reg. 86/03, s. 2.

(4) It is a condition for the performance and for payment of the insured services set out in Part III of the schedule of dental benefits that,

(a) hospitalization is medically necessary; and

(b) there is prior approval by the General Manager of the provision of the service.  O. Reg. 86/03, s. 2. 

(5) The amount payable by the Plan for a service set out in Column 1 of Part I, II or III of the schedule of dental benefits is the amount set out opposite the service in Column 2 where the service is performed by a dental surgeon or the amount set out opposite the service in Column 3 where the service is performed by an oral and maxillofacial surgeon.  O. Reg. 86/03, s. 2. 

(5.1) The amount that would otherwise be payable by the Plan for an insured service is increased by,

(a) 1 per cent if the service was rendered on or after April 1, 2002, but before April 1, 2003; and

(b) 3 per cent if the service was rendered on or after April 1, 2003, but before January 1, 2004.  O. Reg. 442/03, s. 1 (1).

(5.2) Each dental surgeon who provided insured services during the period that commenced on April 1, 2002 and ended on March 31, 2003 is entitled to a payment calculated using the formula,

P = (A/B) × $300,000

in which,

“P” =  the amount of the payment,

“A” =  the total amount otherwise paid by the Plan to the dental surgeon for insured services rendered on or after April 1, 2002 but before April 1, 2003, and

“B” =  the total amount paid by the Plan for all dental services rendered on or after April 1, 2002 but before April 1, 2003.

O. Reg. 442/03, s. 1 (1).

(5.3) Each dental surgeon who provided insured services during the period that commenced on April 1, 2003 and ended on December 31, 2003 is entitled to a payment calculated using the formula,

P = (A/B) × $225,000

in which,

“P” =  the amount of the payment,

“A” =  the total amount otherwise paid by the Plan to the dental surgeon for insured services rendered on or after April 1, 2003 but before January 1, 2004, and

“B” =  the total amount paid by the Plan for all dental services rendered on or after April 1, 2003 but before January 1, 2004.

O. Reg. 442/03, s. 1 (2).

(6) The following services are prescribed as insured services under the Plan:

1. All services rendered by a hospital in connection with dental surgical procedures not specified in subsection (1), (3) or (5).  O. Reg. 86/03, s. 2. 

(7) It is a condition for the performance and for payment of the insured services prescribed under subsection (6) that hospitalization is medically necessary.  O. Reg. 86/03, s. 2.

(8) In this section,

“schedule of dental benefits” means the document published by the Ministry of Health and Long-Term Care titled “Schedule of Benefits — Dental Services under the Health Insurance Act (January 1, 2004)”.  O. Reg. 442/03, s. 1 (3).

(9) This section, as it read immediately before April 1, 2003, continues to apply with respect to payments for services rendered before April 1, 2003.  O. Reg. 86/03, s. 2.

17. (1) The following services rendered by an optometrist are prescribed as insured services:

1. A periodic oculo-visual assessment described in subsections (2) and (3), subject to subsections (4) and (5).

2. An oculo-visual minor assessment described in subsection (6.1) and (6.2).  O. Reg. 145/98, s. 1.

(2) A periodic oculo-visual assessment is an assessment of the eye conducted to determine refractive errors due to myopia, hypermetropia, presbyopia, anisometropia and astigmatism and, if necessary, to provide a written refractive prescription.  O. Reg. 145/98, s. 1.

(3) A periodic oculo-visual assessment shall include the performance of refraction and may include the following elements:

1. The history of the complaint.

2. The patient’s medical history.

3. A visual acuity examination.

4. An ocular mobility examination.

5. Slit lamp examination of the anterior segment.

6. Ophthalmoscopy.

7. Tonometry.

8. Advice or instructions to patient.  O. Reg. 145/98, s. 1.

(3.1) Revoked:  O. Reg. 145/98, s. 1.

(3.2) Revoked:  O. Reg. 145/98, s. 1.

(4) A periodic oculo-visual assessment rendered by an optometrist is not an insured service unless,

(a) in the case of an assessment of a patient who is 19 years of age or younger or who is 65 years of age or older, it has been at least one year since a previous periodic oculo-visual assessment was rendered by an optometrist or physician;

(b) in the case of an assessment of a patient who is older than 19 and younger than 65, it has been at least two years since a previous periodic oculo-visual assessment was rendered by an optometrist or physician.  O. Reg. 145/98, s. 1.

(4.1) Revoked:  O. Reg. 145/98, s. 1.

(4.2) Revoked:  O. Reg. 145/98, s. 1.

(5) Despite clause (4) (b), one additional periodic oculo-visual assessment of a patient described in that clause is an insured service if,

(a) it is performed during the second year that follows the periodic oculo-visual assessment referred to in clause (4) (b); and

(b) it is required to correct a refractive error equal to or greater than a 0.5 diopters spherical equivalent that is directly attributable to a trauma or disease suffered by the patient.  O. Reg. 145/98, s. 1.

(6) Myopia, hypermetropia, presbyopia, anisometropia or astigmatism shall not constitute a disease for the purposes of clause (5) (b).  O. Reg. 145/98, s. 1.

(6.1) An oculo-visual minor assessment is conducted in order to provide a re-assessment following a periodic oculo-visual assessment or in order to assess an oculo-visual disorder other than a refractive error due to a condition referred to in subsection (2).  O. Reg. 145/98, s. 1.

(6.2) An oculo-visual minor assessment may include any diagnostic and therapeutic procedures.  O. Reg. 145/98, s. 1.

(6.3) The basic fee payable for an insured service described in subsection (1) is the amount set out opposite the service in Schedule 22 to the Regulation.  O. Reg. 145/98, s. 1.

(6.4) It is a condition for payment for an insured service rendered to a patient that the claim for payment include the diagnostic code that relates to the patient’s condition and is specified for the condition by the Plan.  O. Reg. 145/98, s. 1.

(7) Revoked:  O. Reg. 86/95, s. 1 (3).

(8) Optometry is designated as a discipline for the purpose of section 16 of the Act.  R.R.O. 1990, Reg. 552, s. 17 (8).

(9) An optometrist who does not submit accounts directly to the Plan may commence to bill the Plan by giving written notice to the General Manager that he or she intends to bill the Plan directly and the notification becomes effective the first day of the third month following the month in which the General Manager receives the notification but may become effective on an earlier date as ordered by the General Manager.  R.R.O. 1990, Reg. 552, s. 17 (9).

18. (1) The following services rendered by chiropractors are prescribed as insured services under the Plan:

1. Initial service (office or institutional).

2. Subsequent service.

3. Home service.

4. Radiographic examination of the cervical spine — minimum of antero-posterior and lateral views.

5. Radiographic examination of the thoracic spine — minimum of antero-posterior and lateral views.

6. Radiographic examination of the lumbar spine — minimum of antero-posterior and lateral views.

7. Radiographic examination of the pelvis and sacrum — minimum of antero-posterior and lateral views.

8. Radiographic examination of the antero-posterior full spine — one view.

9. Radiographic examination of the antero-posterior full spine plus one additional view.

10. Radiographic examination of the antero-posterior full spine plus two additional views.

11. Radiographic examination of the ribs — minimum of antero-posterior and lateral views.

12. Radiographic examination of any extremity — minimum of two views.

13. Special added view of any of the above.  R.R.O. 1990, Reg. 552, s. 18 (1).

(2) Subject to subsections (2.1), (3) and (4), the amount payable by the Plan for the services prescribed under subsection (1) is, where the services are provided to an insured person on or after the 1st day of July 1989, as follows:

 

1.

Initial service (office or institutional)

$11.75

2.

Subsequent service

9.65

3.

Home service

12.00

4.

Radiographic examination of the cervical spine — minimum of antero-posterior and lateral views

16.00

5.

Radiographic examination of the thoracic spine — minimum of antero-posterior and lateral views

16.00

6.

Radiographic examination of the lumbar spine — minimum of antero-posterior and lateral views

16.00

7.

Radiographic examination of the pelvis and sacrum — minimum of antero-posterior and lateral views

16.00

8.

Radiographic examination of the antero-posterior full spine — one view

16.00

9.

Radiographic examination of the antero-posterior full spine plus one additional view

28.00

10.

Radiographic examination of the antero-posterior full spine plus two additional views

35.00

11.

Radiographic examination of the ribs — minimum of antero-posterior and lateral views

16.00

12.

Radiographic examination of any extremity — minimum of two views

16.00

13.

Special added view of any of the above — per view

8.00

R.R.O. 1990, Reg. 552, s. 18 (2); O. Reg. 888/93, s. 1.

(2.1) The amounts payable by the Plan under subsection (2) for insured services rendered by chiropractors shall be reduced by,

(a) 10 per cent for services rendered on or after October 1, 1993 but before January 1, 1994;

(b) 12.5 per cent for services rendered on or after January 1, 1994 but before April 1, 1994;

(c) 8.6465 per cent for services rendered on or after April 1, 1994 but before April 1, 1995;

(d) 12.5 per cent for services rendered on or after April 1, 1995 but before October 1, 1995;

(e) 5 per cent for services rendered on or after October 1, 1995 but before April 1, 1996; or

(f) 5 per cent for services rendered on or after March 1, 1999.  O. Reg. 589/94, s. 1 (1); O. Reg. 172/96, s. 3; O. Reg. 58/99, s. 1.

(3) The maximum amount payable by the Plan for the radiographic services prescribed in subsection (1) is, where the services are provided to an insured person on or after the 1st day of July, 1985, in respect of each insured person, $40 per twelve-month period.  R.R.O. 1990, Reg. 552, s. 18 (3).

(4) The maximum amount payable by the Plan for the services prescribed in subsection (1) is, where the services are provided to an insured person on or after April 1, 1999, in respect of each insured person, $150 per twelve-month period.  O. Reg. 59/99, s. 1 (1).

(5) Despite subsection (2.1), the maximum amount payable under subsections (3) and (4) shall be calculated using the amounts set out in subsection (2).  O. Reg. 888/93, s. 2.

(6) For the purposes of subsections (3) and (4), the 12-month period to which the maximum amount applies is, with respect to insured services rendered on or after April 1, 1994, the period beginning on April 1 of each year and ending on March 31 of the following year.  O. Reg. 589/94, s. 1 (2).

(7) The following apply with respect to services prescribed in subsection (1) provided on or after April 1, 1998 but before April 1, 1999:

1. This paragraph applies to services provided to an insured person on or after April 1, 1998 but before February 12, 1999.  The maximum amount payable by the Plan for the services is, in respect of each insured person, $220.

2. This paragraph applies to services provided to an insured person on or after February 12, 1999 but before April 1, 1999.  The maximum amount payable by the Plan for the services is, in respect of each insured person, $150 minus the amounts payable for services provided to the insured person on or after April 1, 1998 but before February 12, 1999.  If that calculation would result in a negative number, the maximum amount is zero.

3. Despite subsection (2.1), the maximum amount payable under paragraph 2 shall be calculated using the amounts set out in subsection (2).  O. Reg. 59/99, s. 1 (2).

19. (1) The following services rendered by osteopaths are prescribed as insured services under the Plan:

1. Initial service (office or institutional).

2. Subsequent service.

3. Home service.

4. Radiographic examination.  R.R.O. 1990, Reg. 552, s. 19 (1).

(2) The amount payable by the Plan for the services prescribed in subsection (1) is, where the services are provided to an insured person on or after the 1st day of July, 1989, as follows:

 

1.

Initial service (office or institutional)

$12.00

2.

Subsequent service

9.00

3.

Home service

15.00

4.

Radiographic examination

10.00

R.R.O. 1990, Reg. 552, s. 19 (2).

(2.1) Despite paragraph 2 of subsection (2), where a subsequent service is provided to an insured person on or after the 1st day of July, 1990, the amount payable by the Plan is $9.50.  O. Reg. 42/91, s. 1.

(3) The maximum amount payable by the Plan for the radiographic services prescribed in subsection (1) is, in respect of each insured person, $25 per twelve-month period.  R.R.O. 1990, Reg. 552, s. 19 (3).

(4) The maximum amount payable by the Plan for the services prescribed in subsection (1) is, where the insured services are provided to an insured person on or after the 1st day of July, 1989, in respect of each insured person, $155 per twelve-month period.  R.R.O. 1990, Reg. 552, s. 19 (4).

(5) For the purposes of subsections (3) and (4), the 12-month period to which the maximum amount applies is, with respect to insured services rendered on or after July 1, 1989 and before July 1, 1993, the period beginning on July 1 of each year and ending on June 30 of the following year.  O. Reg. 589/94, s. 2.

(6) For the purposes of subsections (3) and (4), the period beginning on July 1, 1993 and ending on March 31, 1994 shall be deemed to be a 12-month period and the maximum amounts prescribed in subsections (3) and (4) apply to services rendered within that period.  O. Reg. 589/94, s. 2.

(7) For the purposes of subsections (3) and (4), the 12-month period to which the maximum amount applies is, with respect to insured services rendered on or after April 1, 1994, the period beginning on April 1 in any year and ending on March 31 of the following year.  O. Reg. 589/94, s. 2.

20. (1) The following are insured services:

1. Chiropody services rendered by a member of the College of Chiropodists of Ontario who is a podiatrist.

2. Podiatrist services rendered by a podiatrist who practises outside Ontario.  O. Reg. 787/94, s. 1.

(2) The amounts payable by the Plan for services prescribed as insured services in subsection (1) and rendered on or after the 1st day of February, 1990 are as follows:

 

1.

Initial office visit

$16.40

2.

Subsequent office visit

11.45

3.

Home visit

14.00

4.

Institution visit

7.00

5.

X-ray of foot — antero-posterior and lateral views

11.00

6.

X-ray of feet, including one view of each foot

11.00

7.

Oblique or special view of foot

5.50

R.R.O. 1990, Reg. 552, s. 20 (2).

(3) The maximum amount payable by the Plan for the services set out in subsection (2), excluding radiographic examinations, and rendered in a 12-month period in respect of an insured person is $135.  O. Reg. 589/94, s. 3.

(4) The maximum amount payable by the Plan for radiographic examinations set out in subsection (2) and carried out in a 12-month period in respect of an insured person is $30.  O. Reg. 589/94, s. 3.

(5) For the purposes of subsections (3) and (4), the 12-month period to which the maximum amount applies is, with respect to services rendered on or after July 1, 1990, the period beginning on July 1 of each year and ending on June 30 of the following year.  O. Reg. 589/94, s. 3.

21. (1) Physiotherapy services are insured services where ordered by a physician and provided by a physiotherapist in a physiotherapy facility listed in Part I of Schedule 5.  R.R.O. 1990, Reg. 552, s. 21 (1).

(2) The amount payable by the Plan for an insured service referred to in subsection (1) is, for service provided to the insured person on or after the 1st day of October, 1990, $12.20.  R.R.O. 1990, Reg. 552, s. 21 (2); O. Reg. 754/91, s. 1 (1).

(2.1) The amount payable by the Plan under subsection (2) is increased by,

(a) 1.3376 per cent if the service is rendered on or after April 1, 1993 but before April 1, 1994; or

(b) 3.3563 per cent if the service is rendered on or after April 1, 1994 but before April 1, 1995.  O. Reg. 172/96, s. 4 (1).

(2.2) The amount payable by the Plan under subsection (2) is decreased by 10 per cent if the service is rendered on or after November 1, 1998.  O. Reg. 60/99, s. 1 (1).

(3) Physiotherapy services are insured services where the services are ordered by a physician and are provided to an insured person in his or her home by a physiotherapist who works in a physiotherapy facility listed in Part I or II of Schedule 5.  R.R.O. 1990, Reg. 552, s. 21 (3).

(4) The amount payable by the Plan for an insured service referred to in subsection (3) is, for service provided to the insured person on or after the 1st day of October, 1990, $24.40.  R.R.O. 1990, Reg. 552, s. 21 (4); O. Reg. 754/91, s. 1 (2).

(4.0.1) The amount payable by the Plan under subsection (4) is increased by,

(a) 1.3376 per cent if the service is rendered on or after April 1, 1993 but before April 1, 1994; or

(b) 3.3563 per cent if the service is rendered on or after April 1, 1994 but before April 1, 1995.  O. Reg. 172/96, s. 4 (2).

(4.0.2) The amount payable by the Plan under subsection (4) is decreased by 10 per cent if the service is rendered on or after November 1, 1998.  O. Reg. 60/99, s. 1 (2).

(4.1) If one or more physiotherapists who work in a physiotherapy facility provide services referred to in subsection (3) at the same site on the same day, then, despite subsection (4), the amounts payable by the plan for the services are,

(a) for the first insured service billed, the amount payable under subsection (4); and

(b) for the rest of the insured services, the amounts that would be payable under subsection (2).  O. Reg. 754/91, s. 1 (3); O. Reg. 219/95, s. 2 (2).

(4.2) Subsection (4.1) applies to services rendered on or after the 15th day of December, 1991.  O. Reg. 754/91, s. 1 (3).

(5) Payment for an insured physiotherapy service may only be made,

(a) to the physiotherapy facility which performed the service;

(b) upon the physiotherapy facility submitting an account therefor to the Plan; and

(c) if the physiotherapy facility accepts the payment as constituting payment in full for the service.  R.R.O. 1990, Reg. 552, s. 21 (5).

22. (1) A laboratory service is an insured service where the laboratory service is a test within the meaning of section 5 of the Laboratory and Specimen Collection Centre Licensing Act and,

(a) the test,

(i) is specifically authorized, on a form approved by the Minister, by a physician or a midwife who has clinically assessed the patient to whom the test relates, or

(ii) is a test referred to in Schedule 22 and is specifically authorized, on a form approved by the Minister, by a registered nurse in the extended class who has clinically assessed the patient to whom the test relates; and

(b) the test is performed in a laboratory, other than a hospital laboratory, licensed under the Laboratory and Specimen Collection Centre Licensing Act to perform the test for which payment is claimed.  R.R.O. 1990, Reg. 552, s. 22 (1); O. Reg. 794/93, s. 6 (1); O. Reg. 44/98, s. 4 (1).

(2) Laboratory services are insured services,

(a) if the services are authorized by a medical director of a laboratory;

(b) if the results of the tests authorized by a physician, midwife or registered nurse in the extended class who has clinically assessed a patient yield abnormal findings or information that, without the laboratory services, would be incomplete or insufficient or meaningless to the physician, midwife or registered nurse in the extended class; and

(c) if the services are performed in a laboratory, other than a hospital laboratory, licensed under the Laboratory and Specimen Collection Centre Licensing Act to perform the laboratory services for which payment is claimed.  R.R.O. 1990, Reg. 552, s. 22 (2); O. Reg. 794/93, s. 6 (2); O. Reg. 44/98, s. 4 (2).

(3) A laboratory service is not an insured service unless, in addition to meeting the requirements of subsection (1) or (2), the service is listed in the schedule of laboratory benefits.  O. Reg. 511/00, s. 1.

(4) The amount payable by the Plan for an insured service rendered by a medical laboratory on or after the 1st day of October, 1989 is 51.7 cents multiplied by the applicable individual unit value for such service set out opposite the service in the schedule of laboratory benefits.  R.R.O. 1990, Reg. 552, s. 22 (4); O. Reg. 2/98, s. 1 (2); O. Reg. 201/99, s. 2 (1).

(5) Despite subsection (4), the amount payable by the Plan for an insured service rendered by a medical laboratory in a time period set out in Column 1 of Table 4 is,

(a) where the service is authorized by a physician who has clinically assessed the patient; and

(b) Revoked:  O. Reg. 2/98, s. 1 (4).

(c) where the total individual unit values for the services authorized by the physician during the period set out opposite thereto in Column 2 of Table 4 are greater than 150,000 but less than 200,001,

the amount arrived at by multiplying the applicable individual unit value for such service set out opposite the service in the schedule of laboratory benefits by the amount calculated by,

(d) multiplying the first 150,000 individual unit values by the amount set out opposite thereto in Column 3 of Table 4;

(e) multiplying the excess by the amount set out opposite thereto in Column 4 of Table 4;

(f) adding the amounts arrived at under clauses (d) and (e); and

(g) dividing the amount arrived at under clause (f) by the total individual unit values.  R.R.O. 1990, Reg. 552, s. 22 (5); O. Reg. 291/91, s. 1 (2); O. Reg. 2/98, s. 1 (3, 4); O. Reg. 201/99, s. 2 (2).

(6) Despite subsection (4), the amount payable by the Plan for an insured service rendered by a medical laboratory in a time period set out in Column 1 of Table 5 is,

(a) where the service is authorized by a physician who has clinically assessed the patient; and

(b) Revoked:  O. Reg. 2/98, s. 1 (6).

(c) where the total individual unit values for the services authorized by the physician during the period set out opposite thereto in Column 2 of Table 5 are greater than 200,000,

the amount arrived at by multiplying the applicable individual unit value for such service set out opposite the service in the schedule of laboratory benefits by the amount calculated by,

(d) multiplying the first 150,000 individual unit values by the amount set out opposite thereto in Column 3 of Table 5;

(e) multiplying the next 50,000 individual unit values by the amount set out opposite thereto in Column 4 of Table 5;

(f) multiplying the excess by the amount set out opposite thereto in Column 5 of Table 5;

(g) adding the amounts arrived at under clauses (d), (e) and (f); and

(h) dividing the amount arrived at under clause (g) by the total individual unit values.  R.R.O. 1990, Reg. 552, s. 22 (6); O. Reg. 291/91, s. 1 (3); O. Reg. 2/98, s. 1 (5, 6); O. Reg. 201/99, s. 2 (3).

(7) Revoked:  O. Reg. 2/98, s. 1 (7).

(8) Despite subsection (4), if the amount paid by the Plan for insured services rendered by a medical laboratory during the period set out in Column 1 of Table 6 is less than the product obtained by multiplying the total individual unit values for insured services rendered by the medical laboratory during the period set out in Column 1 by 51.7 cents, the amount payable by the Plan for an insured service rendered by the medical laboratory during the period set out in Column 2 of Table 6 is the amount arrived at according to the following formula:

where,

a = the amount payable by the Plan,

b = the amount paid by the Plan for insured services rendered by the medical laboratory during the period set out in Column 1 of Table 6,

c = the product obtained by multiplying the total individual unit values for insured services rendered by the medical laboratory during the period set out in Column 1 of Table 6 by 51.7 cents,

d = the product obtained by multiplying the applicable individual unit value for the insured service set out opposite the service in the schedule of laboratory benefits by 51.7 cents.

O. Reg. 126/92, s. 1; O. Reg. 2/98, s. 1 (8); O. Reg. 201/99, s. 2 (4).

(9) RevokedO. Reg. 291/91, s. 1 (4).

(10) Payment for an insured service provided by a medical laboratory is subject to the following conditions:

1. The medical laboratory shall not accept payment for the service from any other person.

2. The medical laboratory must be a party to a written verification agreement with the General Manager at the time the service was rendered.  O. Reg. 676/00, s. 1.

(11) In subsection (10),

“verification agreement” means an agreement between a medical laboratory and the General Manager in which the medical laboratory authorizes the General Manager or a person designated by the General Manager to examine records in the medical laboratory’s possession, on such terms as the parties may agree to, in order to verify that,

(a) all insured services for which accounts were submitted to the Plan were in fact performed by the medical laboratory,

(b) all insured services performed by the medical laboratory were authorized by a physician, midwife or registered nurse in the extended class, and

(c) the Plan has not paid more for an insured service performed by the medical laboratory than the amount payable for the service under the Plan.  O. Reg. 676/00, s. 1.

22.1 (1) In sections 22.2 to 22.11,

“base year amount” means, in relation to a medical laboratory, the amount calculated in accordance with section 22.5;

“fiscal year” means the 12-month period beginning on April 1;

“over-threshold laboratory” means a medical laboratory that has a threshold amount for a fiscal year (determined without regard to the operation of section 22.4) that is less than the total amount payable to it under section 22 for insured services provided during the year;

“receiving laboratory” means a medical laboratory that performs tests referred to it by a referring laboratory;

“referring laboratory” means a medical laboratory that refers to a receiving laboratory tests that it is not licensed to perform;

“threshold amount” means, in relation to a medical laboratory, the amount calculated in accordance with section 22.3;

“under-threshold laboratory” means a medical laboratory that has a threshold amount for a fiscal year (determined without regard to the operation of section 22.4) that is greater than the total amount payable to it under section 22 for insured services provided during the year.  O. Reg. 2/98, s. 2.

(2) Two or more medical laboratories are jointly engaged in providing insured services if they provide the services as a joint undertaking on a fully-integrated basis, whether as partners or otherwise.  O. Reg. 2/98, s. 2.

(3) Sections 22.2 to 22.11 do not apply with respect to hospital laboratories.  O. Reg. 2/98, s. 2.

22.2 (1) For the purposes of subsections 17.1 (6) and 17.2 (4) of the Act,

(a) all insured services provided by a medical laboratory are prescribed insured services;

(b) the prescribed period for a medical laboratory is a fiscal year; and

(c) the prescribed amount for a medical laboratory is its threshold amount for the fiscal year.  O. Reg. 2/98, s. 2.

(2) If the total amount payable under section 22 for insured services provided by a medical laboratory during a fiscal year equals or exceeds its threshold amount, the fee payable for each insured service it performs during the fiscal year is decreased by the percentage that is calculated as follows:

1. Calculate the medical laboratory’s threshold amount for the fiscal year.

2. Subtract the threshold amount from the total amount payable to the medical laboratory for the fiscal year.

3. Express the amount calculated under paragraph 2 as a percentage of the total amount payable to the medical laboratory for the fiscal year.  O. Reg. 2/98, s. 2.

22.3 (1) A medical laboratory’s threshold amount for a fiscal year is the amount calculated as follows:

1. Calculate the medical laboratory’s base year amount.

2. Express the base year amount as a percentage of the base year amounts of all medical laboratories.

3. Multiply the provincial cap for the fiscal year by the percentage calculated under paragraph 2.

4. Add the amounts, if any, calculated under section 22.4.  O. Reg. 2/98, s. 2.

(2) The provincial cap applicable for the purposes of calculating threshold amounts for medical laboratories is,

(a) $418,297,741 for the 1997/98 fiscal year;

(b) $424,697,741 for the 1998/99 fiscal year;

(c) $451,297,741 for the 1999/2000 fiscal year; and

(d) $455,603,360 for the 2000/01 fiscal year and subsequent fiscal years.  O. Reg. 2/98, s. 2; O. Reg. 415/01, s. 2; O. Reg. 6/04, s. 2.

22.4 (1) This section applies if one or more medical laboratories are under-threshold laboratories for a fiscal year.  O. Reg. 2/98, s. 2.

(2) For each over-threshold laboratory that is jointly engaged in providing insured services with an under-threshold laboratory, the threshold amount for the fiscal year is increased in accordance with subsection (4).  O. Reg. 2/98, s. 2.

(3) The threshold amount for a fiscal year for each over-threshold laboratory is increased in accordance with subsection (5).  Increases under this subsection are calculated after any increases required by subsection (2) are made.  O. Reg. 2/98, s. 2.

(4) The amount of the increase described in subsection (2) for an over-threshold laboratory is calculated as follows:

1. Subtract the total amount payable to the under-threshold laboratory under section 22 for insured services provided during the fiscal year from its threshold amount for the year.

2. Allocate the amount calculated under paragraph 1 among the over-threshold laboratories jointly engaged with the under-threshold laboratory in providing insured services during the fiscal year.  The allocation is to be made in proportion to their respective threshold amounts for the year (determined without regard to the operation of this section).

3. Increase the threshold amount of each over-threshold laboratory by the lesser of,

i. the amount allocated to the laboratory under paragraph 2, or

ii. the amount that results in the threshold amount being equal to the total amount payable to the laboratory under section 22 for insured services provided by it during the fiscal year.

4. If the threshold amount of one or more over-threshold laboratories is increased by the amount described in subparagraph ii of paragraph 3, for each such laboratory subtract the amount of the increase from the amount allocated to the laboratory under paragraph 2.

5. Add the amounts calculated under paragraph 4.

6. Allocate the amount calculated under paragraph 5 among the over-threshold laboratories whose threshold amount was increased by the amount described in subparagraph i of paragraph 3, in proportion to their respective threshold amounts (determined without regard to the operation of this section).

7. Paragraphs 3 to 6 apply, with necessary modifications, with respect to the allocation of amounts calculated under paragraph 5 until,

i. all such amounts are allocated, or

ii. the threshold amount of every over-threshold laboratory equals the total amount payable to the laboratory under section 22 for insured services provided by it during the fiscal year.  O. Reg. 2/98, s. 2.

(5) The amount of the increase described in subsection (3) for an over-threshold laboratory is calculated as follows:

1. For each under-threshold laboratory that is not jointly engaged in providing insured services with an over-threshold laboratory, subtract the total amount payable to it under section 22 for insured services provided during the fiscal year from its threshold amount for the year.

2. Add all amounts calculated under paragraph 5 of subsection (4) that remain unallocated under paragraph 7 of that subsection.

3. Add the amounts calculated under paragraphs 1 and 2.

4. Allocate the amount calculated under paragraph 3 among the over-threshold laboratories that are entitled to an increase under subsection (3), in proportion to their respective threshold amounts (determined without regard to the operation of this subsection).

5. Increase the threshold amount of each over-threshold laboratory by the lesser of,

i. the amount allocated to the laboratory under paragraph 4, or

ii. the amount that results in the threshold amount being equal to the total amount payable to the laboratory under section 22 for insured services provided by it during the fiscal year.

6. If two or more over-threshold laboratories that are entitled to an increase under subsection (3) were jointly engaged with each other in providing insured services during the fiscal year and the threshold amount of one or more of them is increased by the amount described in subparagraph ii of paragraph 5, for each such laboratory subtract the amount of the increase from the amount allocated to the laboratory under paragraph 4.

7. Add the amounts calculated under paragraph 6.

8. Allocate the amount calculated under paragraph 7 among the over-threshold laboratories who were jointly engaged with a laboratory described in paragraph 6 and whose threshold amounts were increased by the amount described in subparagraph i of paragraph 5, in proportion to their respective threshold amounts (determined without regard to the operation of this subsection).

9. Paragraphs 5 to 8 apply, with necessary modifications, until,

i. all amounts calculated under paragraph 7 are allocated, or

ii. the threshold amount of each laboratory receiving an allocated amount under paragraph 8 equals the total amount payable to the laboratory under section 22,

whichever occurs first.

10. If the threshold amount of every jointly engaged over-threshold laboratory to which amounts are allocated under paragraph 8 equals its total amount payable under section 22, determine the amount, if any, that remains unallocated.

11. If the threshold amount of one or more over-threshold laboratories, other than a jointly engaged over-threshold laboratory described in paragraph 6, is increased by an amount described in subparagraph ii of paragraph 5, for each such laboratory subtract the amount of the increase from the amount allocated to the laboratory under paragraph 4.

12. Add the amounts calculated under paragraph 11 and any amount determined under paragraph 10.

13. Allocate the amount calculated under paragraph 12 among the over-threshold laboratories whose threshold amounts were increased by the amount described in subparagraph i of paragraph 5, other than any jointly engaged over-threshold laboratory that ceases to be over-threshold as a result of an allocation under paragraph 8, in proportion to their respective threshold amounts (determined without regard to the operation of this subsection).

14. Paragraphs 5 and 11 to 13 apply, with necessary modifications, until all such amounts are allocated.  O. Reg. 2/98, s. 2.

22.5 (1) The base year amount for a medical laboratory is calculated as follows:

1. For each physician who authorized insured services that were performed by the medical laboratory during the 1995/96 fiscal year, calculate the total amount payable under section 22 to all laboratories for insured services authorized by the physician for that fiscal year.

2. Express the total amount payable to the medical laboratory for insured services authorized by each physician as a percentage of the amount calculated under paragraph 1 in respect of the physician.

3. For each physician, calculate the total individual unit values of all insured services authorized by him or her and performed by all laboratories during the 1995/96 fiscal year.

4. For each physician, reduce the amount calculated under paragraph 3 by 8.5737 per cent.

5. For each physician, calculate the amount that would have been payable under section 22 for all insured services authorized by him or her and performed by all medical laboratories during the 1995/96 fiscal year.  The calculation is to be based upon the total individual unit values for the insured services, as reduced under paragraph 4.

6. For each physician, multiply the amount calculated under paragraph 5 by the percentage calculated under paragraph 2 for the physician.

7. Add the amounts calculated under paragraph 6 for every physician that authorized the insured services that the medical laboratory performed during the 1995/96 fiscal year.

8. For the following medical laboratories, add the amount indicated:

i. Canadian Medical Laboratories Ltd., $397,922.

ii. Flemingdon Medical Laboratories, $1,537,136.

iii. Hospital-In-Common Laboratory Inc., $182,750.

iv. MDS Inc., $2,108,864.

v. Med-Chem Health Care Ltd., $922,003.

9. Add or subtract (as the case may be) the amounts, if any, calculated under sections 22.6 to 22.12.  O. Reg. 2/98, s. 2.

(2) Despite subsection (1), if no amount was payable under the Plan to the medical laboratory for performing insured services before January 1, 1997, the base year amount for the medical laboratory is calculated as follows:

1. Multiply by four an amount equal to 85 per cent of the total individual unit values for insured services, if any, performed by the medical laboratory from January 1 to March 31, 1997.

2. Add or subtract (as the case may be) the amounts, if any, calculated under sections 22.6 to 22.11.  O. Reg. 2/98, s. 2.

(3) Except where otherwise provided, a change in a medical laboratory’s base year amount made under sections 22.6 to 22.11 applies with respect to the calculation of the threshold amount for the fiscal year in which the change is made and for every subsequent fiscal year.  O. Reg. 2/98, s. 2.

22.6 (1) This section applies if one or more medical laboratories are under-threshold laboratories for a fiscal year after the 1996/97 fiscal year.  O. Reg. 2/98, s. 2.

(2) The base year amount of each under-threshold laboratory is decreased by the amount calculated using the formula,

in which,

  “A” equals the total of the base year amounts of all medical laboratories for the fiscal year (calculated without regard to the operation of this section),

  “B” equals the amount by which the threshold amount for the laboratory in the fiscal year exceeds the total amount payable under section 22 to the laboratory for insured services provided during the fiscal year, and

  “C” equals the provincial cap set out in subsection 22.3 (2) for the fiscal year.

O. Reg. 2/98, s. 2.

(3) The base year amount of each medical laboratory that is an over-threshold laboratory for the fiscal year is increased by the amount calculated using the formula,

in which,

  “A” and “C” have the same meaning as in subsection (2), and

  “D” equals the amount by which the threshold amount for the fiscal year for the over-threshold laboratory is increased under section 22.4.

O. Reg. 2/98, s. 2.

(4) A change in base year amounts made under this section applies with respect to the calculation of threshold amounts for the fiscal year following the year in which the circumstance described in subsection (1) exists, and for every subsequent fiscal year.  O. Reg. 2/98, s. 2.

22.7 (1) The base year amount for a medical laboratory is increased by the amount calculated under subsection (2) if the laboratory becomes licensed to perform, and begins to perform, one or more of the following tests during the 1995/96 or 1996/97 fiscal year:

1. Antithrombin III assay (L373).

2. C-peptide Immunoreactivity (L346).

3. Dehydroepiandrosterone Sulphate (L347).

4. Free T-3 (L607).

5. Free Testosterone (L608).

6. 1,25 Dihydroxy Vitamin D (L605).

7. 25 Hydroxy Vitamin D (L606).

8. Immunoperoxidase technique (L731).

9. Leukocyte phenotyping by monoclonal antibodies (L685 or L686).

10. Methenalbumin (L171).

11. Oxalic Acid — U (L184).

12. Plasminogen assay (L433).

13. Total Haemolytic complement (CH 50 non-kit) (L530).

14. Thyroglobulin (L609).  O. Reg. 2/98, s. 2.

(2) The amount of the increase is calculated using the formula,

in which,

  “A” is the total individual unit values (based on the unit values in effect on April 1, 1997) for all the tests listed in subsection (1) that were performed by or on behalf of the Hospital-in-Common Laboratory Inc. during the 1995/96 fiscal year, and

  “B” is the total individual unit values of the tests listed in subsection (1) performed by the medical laboratory from April 1 until June 30, 1997 expressed as a percentage of the total individual unit values of the tests performed during that period by all medical laboratories entitled to an increase under subsection (1).

O. Reg. 2/98, s. 2.

22.8 (1) This section applies with respect to a referring laboratory and a receiving laboratory,

(a) if during the 1995/96 fiscal year the referring laboratory referred certain tests to the receiving laboratory; and

(b) if during the 1995/96 or 1996/97 fiscal year,

(i) the referring laboratory becomes licensed to perform those tests and begins to perform them instead of referring them to the receiving laboratory, or

(ii) the referring laboratory begins referring the tests to a related laboratory instead of the receiving laboratory.  O. Reg. 2/98, s. 2.

(2) The base year amount for the referring laboratory is increased, and the base year amount for the receiving laboratory is decreased, by 85 per cent of the total amount that would have been payable under subsection 22 (4) for tests referred by the referring laboratory that were performed by the receiving laboratory during the 1995/96 fiscal year.  O. Reg. 2/98, s. 2.

(3) A change in the base year amount made under this section applies with respect to the calculation of threshold amounts for the 1996/97 fiscal year and for every subsequent fiscal year.  O. Reg. 2/98, s. 2.

(4) For the purposes of subsection (1), two medical laboratories are related if they are controlled (within the meaning of subsection 1 (5) of the Business Corporations Act) by the same person.  O. Reg. 2/98, s. 2.

22.9 (1) This section applies with respect to a referring laboratory and a receiving laboratory,

(a) if, during the 1995/96 fiscal year, the receiving laboratory performed tests that were referred by the referring laboratory;

(b) if, on or after April 1, 1997, the receiving laboratory ceases to perform some or all of the tests referred by the referring laboratory; and

(c) if neither the referring laboratory nor a related laboratory is licensed to perform the tests when the receiving laboratory ceases to perform some or all of them.  O. Reg. 2/98, s. 2.

(2) The base year amount for the receiving laboratory is decreased, and the base year amount for all of the medical laboratories described in subsection (3) is increased, by the amount calculated as follows:

1. With respect to the type of test that the receiving laboratory ceases to perform, determine the total amount that would have been payable under subsection 22 (4) for tests of that type referred by the referring laboratory that were performed by the receiving laboratory during the 1995/96 fiscal year.

2. Multiply the amount calculated under paragraph 1 by 85 per cent.  O. Reg. 2/98, s. 2.

(3) The increase is apportioned among the following medical laboratories as follows:

1. If the referring laboratory refers the tests to other medical laboratories and one receiving laboratory performs all the tests referred, the base year amount for the receiving laboratory is increased by the amount calculated under subsection (2).

2. If the referring laboratory refers the tests to other medical laboratories and two or more medical laboratories perform the tests, the amount calculated under subsection (2) is allocated between them, and the base year amount of each is increased, in proportion to the total amount payable to each of them respectively for the tests.  O. Reg. 2/98, s. 2.

22.10 (1) This section applies if a written agreement in effect between two medical laboratories provides that,

(a) one of them (the “managing laboratory”) will manage and operate all or part of the laboratory business of the other of them (the “contracting laboratory”); or

(b) one of them (the “managing laboratory”) will perform insured services referred by the other of them (the “contracting laboratory”).  O. Reg. 2/98, s. 2.

(2) The agreement must have been in effect on March 31, 1996 or it must replace such an agreement, although the replacement agreement may involve a different managing laboratory than the one that was a party to the agreement in effect on March 31, 1996.  O. Reg. 2/98, s. 2.

(3) If the agreement terminates on March 31, upon its termination the base year amount for the managing laboratory that was a party to the agreement in effect on March 31, 1996 is decreased in the fiscal year after the agreement is terminated, and the base year amount for the contracting laboratory is increased, by the amount calculated as follows:

1. Calculate 85 per cent of the total amount that would have been payable under subsection 22 (4) to the managing laboratory for insured services performed during the 1995/96 fiscal year by the managing laboratory under the agreement then in effect.

2. Calculate 85 per cent of the total amount that would have been payable under subsection 22 (4) to the contracting laboratory for all insured services performed by it during the 1995/96 fiscal year.

3. If the amount calculated under paragraph 1 is greater than or equal to the amount calculated under paragraph 2, the amount calculated under paragraph 1 is the amount of the increase or decrease, as the case may be, in the base year amount.  O. Reg. 2/98, s. 2.

(4) If the agreement terminates on a date other than March 31, upon its termination the base year amount for the managing laboratory that was a party to the agreement in effect on March 31, 1996 is decreased in the fiscal year in which the agreement is terminated and in the following fiscal year, and the base year amount for the contracting laboratory is increased in each of those years, by the amounts calculated as follows:

1. Calculate the amount of the increase or decrease that would be payable if the agreement terminated on March 31.

2. Multiply the amount calculated under paragraph 1 by the following fraction:

The resulting amount is the amount of the increase or decrease, as the case may be, in the fiscal year in which the agreement is terminated.

3. Subtract the amount calculated under paragraph 2 from the amount calculated under paragraph 1.  The resulting amount is the amount of the increase or decrease, as the case may be, in the following fiscal year.  O. Reg. 2/98, s. 2.

(5) Despite subsections (3) and (4), if the contracting party enters into an agreement with another medical laboratory within 60 days after the expiry of the agreement referred to in subsection (1),

(a) the base year amount for the contracting laboratory shall not be increased as provided by subsection (3) or (4); and

(b) the base year amount for the other medical laboratory shall be increased by the amount that the base year amount for the contracting laboratory would have been increased under subsection (3) or (4).  O. Reg. 2/98, s. 2.

(6) Upon the termination of an agreement described in subsection (5), the base year amount for the contracting laboratory is increased and the base year amount for the other medical laboratory is decreased as provided by subsection (3) or (4).  O. Reg. 2/98, s. 2.

22.11 (1) This section applies,

(a) when one medical laboratory (the “transferring laboratory”) transfers its interest in one or more laboratories (the “transferred facilities”) licensed under the Laboratory and Specimen Collection Centre Licensing Act to another medical laboratory (the “acquiring laboratory”) and ceases to hold a licence under that Act for the transferred facilities;

(b) when one medical laboratory becomes controlled (within the meaning of subsection 1 (5) of the Business Corporations Act) by another medical laboratory or two medical laboratories become controlled by the same person;

(c) when two or more medical laboratories amalgamate; or

(d) when the trustee in bankruptcy or receiver and manager appointed over a medical laboratory (the “trustee”) sells assets of the medical laboratory.  O. Reg. 2/98, s. 2; O. Reg. 232/99, s. 1 (1).

(2) In the circumstances described in subsection (1) (a) and only if both medical laboratories agree, the base year amount for the acquiring laboratory is increased and the base year amount for the transferring laboratory is decreased by the amount calculated as follows:

1. Calculate 85 per cent of the total amount payable under subsection 22 (4) to the transferring laboratory for insured services performed at the transferred facilities in the fiscal year before the transfer of interest in the facilities occurs.

2. Calculate 85 per cent of the total amount payable under subsection 22 (4) to the transferring laboratory for the same fiscal year.

3. Express the amount calculated under paragraph 1 as a percentage of the amount calculated under paragraph 2.

4. Multiply the base year amount of the transferring laboratory by the percentage calculated under paragraph 3.  O. Reg. 2/98, s. 2.

(3) In the circumstances described in clause (1) (b) and only if both medical laboratories agree,

(a) the base year amount for one of the medical laboratories is increased by the amount of the base year amount for the other medical laboratory; and

(b) the base year amount for the other medical laboratory is reduced to zero.  O. Reg. 2/98, s. 2.

(4) When two or more medical laboratories amalgamate and only if the amalgamating laboratories agree,

(a) the base year amount for the amalgamated laboratory is increased by the base year amount for each of the amalgamating laboratories; and

(b) the base year amount for each of the amalgamating laboratories is reduced to zero.  O. Reg. 2/98, s. 2.

(4.1) In the case of the sale of assets described in clause (1) (d),

(a) the base year amount for the medical laboratory whose base year amount is to be increased under the terms of the agreement of purchase and sale is increased by an amount equal to the base year amount of the medical laboratory whose assets are being sold; and

(b) the base year amount for the medical laboratory whose assets are being sold is reduced to zero.  O. Reg. 232/99, s. 1 (2).

(5) The base year amount is transferred as of April 1 in the fiscal year in which the event described in subsection (2), (3), (4) or (4.1) occurs.  O. Reg. 232/99, s. 1 (3).

(6) Subsection (2) does not apply to the transfer of interests in facilities that are part of a sale of assets described in clause (1) (d).  O. Reg. 232/99, s. 1 (3).

23. (1) In this section,

“birth centre” means a place where one or more members of the public receive labour and delivery care;

“labour and delivery care” includes the post-partum care given to a woman and the care of her newborn during their stay at the birth centre immediately following delivery.  O. Reg. 486/94, s. 1.

(2) The following services rendered by a member of the College of Midwives of Ontario are prescribed as insured services under the Plan:

1. Pre-natal care rendered during visits to a birth centre during pregnancy.

2. Labour and delivery care at a birth centre.

3. Post-partum care of a woman during visits to a birth centre after labour and delivery.

4. Care to the newborn that is ancillary to the birth and received during visits of a newborn to a birth centre after birth.  O. Reg. 486/94, s. 1.

(3) No amount shall be payable by the Plan for any of the services prescribed as insured services under subsection (2).  O. Reg. 486/94, s. 1.

(4) The provision of premises, equipment, supplies and personnel incidental to the provision of insured services prescribed under subsection (2) are deemed not to be part of the insured services.  O. Reg. 486/94, s. 1.

Exclusions

24. (1) The following services rendered by physicians or practitioners are not insured services and are not part of insured services unless, in the case of services rendered by physicians, they are specifically listed as an insured service or as part of an insured service in the schedule of benefits:

1. Travelling to visit an insured person outside the usual geographical area of practice of the person making the visit.

2. Toll charges for long distance telephone calls.

3. Preparing or providing a device that is not implanted by means of an incision and that is used for therapeutic purposes unless,

i. the device is used to permit or facilitate a procedure or examination, or

ii. the device is a cast for which there is a fee listed in the schedule of benefits.

4. Preparing or providing,

i. a drug, antigen, antiserum or other substance used for treatment that is not used to facilitate a procedure or examination, or

ii. a drug to promote ovulation.

5. Advice given by telephone to an insured person at the request of the person or the person’s representative.

6. An interview or case conference in respect of an insured person that,

i. lasts more than twenty minutes, and

ii. includes a professional, none of whose services are insured services.

7. The preparation and transfer of an insured person’s health records when this is done because the care of the person is being transferred at the request of the person or the person’s representative.

8. A service, including an annual health or annual physical examination, received wholly or partly for the production or completion of a document or the transmission of information to which paragraph 8.1 or 8.2 applies regardless of whether the document or information was requested before, at the same time as or after the service was received.

8.1 The production or completion of a document, or the transmission of information to any person other than the insured person, if the document or transmission of information is required by legislation of any government or is to be used to receive anything under, or to satisfy a condition under, any legislation or program of a government.

8.2 The production or completion of a document, or the transmission of information to any person other than the insured person, if the document or the transmission of the information relates to,

i. admission to or continued attendance in a day care or pre-school program or a school, community college, university or other educational institution or program,

ii. admission to or continued attendance in a recreational or athletic club, association or program or a camp,

iii. an application for, or the continuation of, insurance,

iv. an application for, or the continuation of, a licence,

v. entering or maintaining a contract,

vi. an entitlement to benefits, including insurance benefits or benefits under a pension plan,

vii. obtaining or continuing employment,

viii. an absence from or return to work,

ix. legal proceedings.

9. The providing of a prescription to an insured person if the person or the person’s personal representative requests the prescription and no concomitant insured service is provided.

10. A service that is solely for the purpose of altering or restoring appearance.

11. An anaesthetic service rendered by a physician in connection with,

i. a service rendered by a practitioner that is provided outside a hospital, or

ii. a dental service that is not insured, is provided in a hospital and involves only the removal of impacted teeth.

12. The fitting of contact lenses other than for,

i. aphakia,

ii. myopia greater than 9 dioptres,

iii. irregular astigmatism resulting from post corneal grafting or corneal scarring from disease, or

iv. keratoconus.

13. An acupuncture procedure.

14. Psychological testing.

15. A service that is part of a group screening program.

16. An examination or procedure for the purpose of a research or survey program other than an assessment that is necessary to determine if an insured person is suitable for the program.

17. Treatment for a medical condition that is generally accepted within Ontario as experimental.

18. Psychotherapy that is a requirement for the patient to obtain a diploma or degree or to fulfil a course of study.

19. A missed appointment or procedure.

20. Destruction of hair follicles.

21. Circumcision, except if medically necessary.

22. Reversal of sterilization.

23. In vitro fertilization other than the first three treatment cycles of in vitro fertilization that are intended to address infertility due to complete bilateral anatomical fallopian tube blockage that did not result from sterilization.

24. Counselling, therapy or any other service rendered for the purpose of weight loss for the benefit of a patient other than a patient,

i. who has a medical condition that is attributable to, or aggravated by, excess weight, or

ii. who suffers from obesity and whose obesity puts the patient at an increased risk of developing a medical condition that is attributable to, or aggravated by, excess weight.

25. A service or treatment, including immunization or the administration of any drug, rendered to an insured person in connection with, and for the sole purpose of, travelling to a country outside Canada.

26. Sex-reassignment surgery.

27. The fitting or evaluation of hearing aids and tinnitus maskers.  R.R.O. 1990, Reg. 552, s. 24 (1); O. Reg. 617/91, s. 1; O. Reg. 785/92, s. 1 (1); O. Reg. 488/94, s. 2 (1, 2); O. Reg. 790/94, s. 1; O. Reg. 176/95, s. 1 (1); O. Reg. 146/98, s. 1 (1, 2); O. Reg. 377/98, s. 1 (1); O. Reg. 528/98, s. 2 (1); O. Reg. 617/00, s. 2; O. Reg. 250/01, s. 2 (1); O. Reg. 272/01, s. 2 (1, 2).

(1.0.1) Subparagraph 4 i of subsection (1) does not apply with respect to the preparation or provision of verteporfin on or after June 15, 2002 if all of the following conditions exist:

1. The verteporfin is provided in the course of ocular photodynamic therapy for the treatment of predominantly classic subfoveal choroidal neovascularization secondary to age-related macular degeneration or pathologic myopia.

2. The area of classic subfoveal choroidal neovascularization is equal to or greater than 50 per cent of the total lesion, as determined by fluorescein angiography.

3. The first treatment is commenced within 30 months after the initial diagnosis of predominantly classic subfoveal choroidal neovascularization secondary to age-related macular degeneration or pathologic myopia.

4. The patient’s visual acuity is 20/40 or worse.  O. Reg. 169/02, s. 3.

(1.1) Paragraphs 8, 8.1 and 8.2 of subsection (1) do not apply to:

1. Keeping or maintaining appropriate physician or practitioner records.

2. Conferring with or providing advice, direction, information or records to physicians or other professionals concerned with the health of the insured person.

3. Producing or completing documents or transmitting information,

i. required to satisfy a condition of being admitted to, or receiving health services in, a hospital, nursing home, a home as defined in the Homes for the Aged and Rest Homes Act, a home for retarded persons as defined in the Homes for Retarded Persons Act or a charitable institution as defined in the Charitable Institutions Act,

ii. required in relation to an annual health or annual physical examination of a patient or resident of any facility mentioned in subparagraph i,

iii. required to receive anything under a program administered by the Minister of Health,

iv. required to receive welfare or social assistance benefits provided by a government or vocational rehabilitation services under the Vocational Rehabilitation Services Act,

v. required by or for a health facility as defined in the Independent Health Facilities Act,

vi. respecting the health status of a child who,

A. is in the supervision, or under the care, custody or control of a children’s aid society,

B. resides in a place of secure custody, a place of open custody or a place of temporary detention, within the meaning of Part IV of the Child and Family Services Act, or

C. resides in a children’s residence licensed under Part IX of the Child and Family Services Act,

vii. required, as evidence of immunization status, for admission to or continued attendance in a day care or pre-school program or a school, community college, university or other educational institution or program,

viii. required as evidence of disability, for the purposes of eligibility for a benefit, related to transportation, under any legislation or program of a government, or

ix. to obtain consents to the performance of insured services.

4. A service received wholly or partly for the production or completion of a document or the transmission of information to which paragraph 3 applies.

5. An examination rendered and documents produced or completed or information transmitted under the Mental Health Act.

6. An examination rendered and documents produced or completed or information transmitted for the purpose of an investigation or confirmation of an alleged sexual assault in accordance with the requirements of the Ministry of the Attorney General and the Ministry of the Solicitor General.  O. Reg. 785/92, s. 1 (2).

(1.2) Paragraph 8 of subsection (1) does not apply to a service that is, in the opinion of the physician or practitioner, medically necessary and that is received wholly or partly for the production or completion of a document or the transmission of information that relates to any of the following:

1. The receipt of disability or sickness benefits or the satisfaction of a condition relating to disability or sickness benefits.

2. A return to a day care or pre-school program after a temporary absence.

3. A condition relating to fitness to continue employment other than a condition that requires an examination or assessment to be conducted on an annual or other periodic basis.

4. An absence from or return to work.

5. Legal proceedings.  O. Reg. 785/92, s. 1 (2).

(1.3) For the purpose of subparagraph ii of paragraph 24 of subsection (1), a person, other than a person referred to in subsection (1.4), suffers from obesity if the person’s body mass index is equal to or greater than 27.  O. Reg. 146/98, s. 1 (3).

(1.4) For the purpose of subparagraph ii of paragraph 24 of subsection (1), the following persons suffer from obesity if it is the opinion of the physician who renders the service referred to in paragraph 24 that they suffer from obesity:

1. A pregnant or lactating female.

2. A person of muscular build.

3. A person who is under the age of 20 or over the age of 65.  O. Reg. 146/98, s. 1 (3).

(1.5) In subsection (1.3),

“body mass index” means, with respect to a person, the ratio of the person’s mass (measured in kilograms) to the square of his or her height (measured in metres).  O. Reg. 146/98, s. 1 (3).

(2) The following are deemed not to be insured services:

1. Revoked:  O. Reg. 111/96, s. 1.

2. A service provided by a laboratory, physician or hospital that supports a service that is deemed, under paragraph 1 of this subsection or paragraph 8, 8.1, 8.2, 10, 13, 15, 16, 17, 21, 22, 23, 25, 26 or 27 of subsection (1), not to be an insured service.

3. A service provided by a laboratory and ordered by a dental surgeon, osteopath, chiropractor or chiropodist.  R.R.O. 1990, Reg. 552, s. 24 (2); O. Reg. 785/92, s. 1 (3); O. Reg. 488/94, s. 2 (3); O. Reg. 176/95, s. 1 (2); O. Reg. 111/96, s. 1; O. Reg. 377/98, s. 1 (2); O. Reg. 528/98, s. 2 (2); O. Reg. 250/01, s. 2 (2); O. Reg. 272/01, s. 2 (3, 4); O. Reg. 345/01, s. 8.

(3) Despite paragraph 26 of subsection (1) and the reference to paragraph 26 of subsection (1) in paragraph 2 of subsection (2), sex-reassignment surgery and any supporting services for such surgery are insured services if performed on a person who, as of October 1, 1998,

(a) has completed the Gender Identity Clinic Program operated by the Centre for Addiction and Mental Health in Toronto; and

(b) has been recommended for the surgery by the Gender Identity Clinic, upon completion of the program.  O. Reg. 528/98, s. 2 (3).

(4) The following services rendered by physicians are deemed not to be insured services:

1. Physical therapy and therapeutic exercise, including thermal therapy, light therapy, ultrasound therapy, hydrotherapy, massage therapy, electrotherapy, magnetotherapy, transcutaneous nerve stimulation and biofeedback.  O. Reg. 272/01, s. 2 (6).

25. (1) The following services rendered outside of Ontario by physicians shall be deemed not to be insured services in respect of insured persons who are under the age of sixteen years:

1. Ligation, cauterization or removal of vas deferens — uni or bilateral (vasectomy).

2. Hysterectomy or ligation, cauterization or removal of fallopian tubes — uni or bilateral by abdominal or vaginal approach, including laparoscopy, culdoscopy, or hysteroscopy — for sterilization (any method).  R.R.O. 1990, Reg. 552, s. 25 (1).

(2) All services rendered outside of Ontario by hospitals in connection with the services specified in subsection (1) shall be deemed not to be insured services in respect of insured persons who are under the age of sixteen years.  R.R.O. 1990, Reg. 552, s. 25 (2).

(3) Subsections (1) and (2) do not apply where the surgeon or the attending physician believes that the surgical operation is medically necessary for the protection of the physical health of the insured person.  R.R.O. 1990, Reg. 552, s. 25 (3).

26. (1) In this section,

“patient” means a patient as defined in section 1 of the Mental Health Act;

“psychiatric facility” means a psychiatric facility as defined in section 1 of the Mental Health Act;

“psychiatrist” means a psychiatrist as defined in section 1 of the Mental Health Act.  R.R.O. 1990, Reg. 552, s. 26 (1).

(2) The following services are not insured services under the Plan:

1. Any service or examination for the purpose of legal requirements or proceedings, other than an examination rendered,

i. by a psychiatrist, who is not a member of the medical staff of a psychiatric facility in which a patient is detained, for the purpose of clause 49 (4) (b) of the Mental Health Act,

ii. and documentation prepared by a physician for the purpose of an investigation or confirmation of an alleged sexual assault.  R.R.O. 1990, Reg. 552, s. 26 (2).

26.1 Services rendered by a podiatrist or by a chiropractor are prescribed for the purposes of clause 14 (1) (c) of the Act.  O. Reg. 339/96, s. 1.

27. Revoked:  O. Reg. 173/96, s. 1.

Hospital Services

28. (1) An insured person who receives treatment in a hospital outside Ontario but within Canada as an in-patient or an out-patient may be reimbursed by the Plan for all or part of the cost of insured services received, on presentation to the General Manager of a detailed receipt from the hospital for payment made to the hospital by the person, or the General Manager may cause payment to be made directly to the hospital for insured services received by the insured person, where,

(a) the hospital that supplied the care and treatment is approved by the General Manager for the purpose of the Plan;

(b) the hospital that supplied the care and treatment is licensed or approved as a hospital by the governmental hospital licensing authority in whose jurisdiction the hospital is situated;

(c) in the case of services to an in-patient, the hospital certifies to the General Manager,

(i) that the insured person was admitted with, the date of admission,

(ii) the diagnosis of the condition for which the insured person was admitted,

(iii) the date of discharge or death of the insured person,

(iv) the nature of any complication, complications, or sequelae, if any, that warrant a longer than average stay in hospital of a person with the disease or condition from which the insured person was suffering,

(v) the kind and number of any laboratory, radiological or other special diagnostic tests performed on or for the insured person,

(vi) the nature of any special treatment procedures or surgery that were performed on the insured person,

(vii) the discharge diagnosis or cause of death, as the case may be, and

(viii) such other information as is required or requested by the General Manager; and

(d) the accommodation and services received do not constitute, in the opinion of the General Manager, the domiciliary type of care provided in a home for the aged, an infirmary or other institution of a similar character.  R.R.O. 1990, Reg. 552, s. 28 (1); O. Reg. 31/92, s. 2 (1); O. Reg. 375/93, s. 6.

(2) If an insured person receives treatment in a hospital outside Ontario but within Canada for an acute attack of tuberculosis, the Plan may reimburse the insured person for the cost of the treatment for a period not exceeding sixty days and subsection (1) applies.  O. Reg. 31/92, s. 2 (2).

(3) RevokedO. Reg. 31/92, s. 2 (2).

Out of Country Services

28.1 Licensed facilities outside Canada where medical or surgical services are rendered are prescribed as health facilities for the purposes of the Act.  O. Reg. 31/92, s. 3.

28.2 (1) Out-patient services described in the Table to this section and rendered outside Canada are prescribed as insured services if,

(a) they are medically necessary;

(b) they are rendered by persons other than chiropractors, dental surgeons, optometrists, osteopaths, physicians or podiatrists;

(c) they are rendered,

(i) in a hospital that is licensed or approved as a hospital by the government in whose jurisdiction the hospital is situated, or

(ii) in a health facility that is licensed by the government in whose jurisdiction the health facility is situated and in which medical or surgical services are routinely rendered on an out-patient basis; and

(d) they are rendered in connection with an illness, disease, condition or injury that,

(i) is acute and unexpected,

(ii) arose outside Canada, and

(iii) requires immediate treatments.  O. Reg. 31/92, s. 3; O. Reg. 596/93, s. 1 (1); O. Reg. 345/01, s. 9 (1).

(2) Subsection (1) does not apply to an out-patient service that is,

(a) the provision of a drug or other substance for the insured person to take away from the hospital or facility;

(b) a visit solely to administer a drug or other substance;

(c) a physiotherapy, radiotherapy, speech therapy, occupational therapy or diet counselling service; or

(d) a laboratory service.  O. Reg. 31/92, s. 3.

(3) The Table to this section sets out the amounts payable by the Plan for insured services prescribed in subsection (1).  O. Reg. 31/92, s. 3.

(4) The amounts in the Table are daily amounts that cover all the out-patient services rendered during the day by persons other than chiropractors, dental surgeons, optometrists, osteopaths, physicians or podiatrists.  O. Reg. 31/92, s. 3; O. Reg. 345/01, s. 9 (2).

(5) An amount payable under this section for out-patient services shall be reduced by any amount paid or payable under section 28.3 for in-patient services rendered to the insured person on the same day.  O. Reg. 31/92, s. 3.

(6) If the amount payable under this section is more than the amount that would be payable under the Act and this Regulation if the services were rendered in Ontario, then only that latter amount is payable.  O. Reg. 31/92, s. 3.

(7) Subsection (6) does not apply if no amount would be payable under the Act and this Regulation if the services were rendered in Ontario.  O. Reg. 31/92, s. 3.

(8) The amount payable under this section for renal dialysis rendered outside of Canada on or after the 1st day of October, 1991 but before the 1st day of May, 1992 is the cost of the dialysis to the patient and subsections (2) to (7) do not apply with respect to such dialysis.  O. Reg. 343/92, s. 1.

TABLE
OUT OF COUNTRY OUT-PATIENT RATES

 

1.

Services not described below that are,

 

 

 

(a) rendered in a hospital; or

 

 

 

(b) rendered in a health facility and that are necessary for the provision of a service that is set out in the schedule of benefits and preceded in the schedule by the symbol “#”

$50.00

 

2.

Services that include Magnetic Resonance Imaging (one scan) prescribed by a physician

50.00

 

3.

Services that include renal dialysis

210.00

 

4.

Services that include cancer chemotherapy prescribed by a physician

50.00

 

5.

Services that support a surgical procedure that is ordinarily rendered in an operating room and ordinarily requires the services of an anaesthetist

50.00

 

6.

Services that include a Computerized Axial Tomography scan prescribed by a physician

50.00

 

7.

Services that include either lithotripsy or Magnetic Resonance Imaging (more than one scan), prescribed by a physician

50.00

 

Note:  If a day’s services are described by more than one item, the applicable amount is the highest amount payable.

O. Reg. 489/94, s. 1.

28.3 (1) In-patient services rendered outside Canada in an eligible hospital or health facility are prescribed as insured services if,

(a) the services are medically necessary;

(b) it is medically necessary that the services be provided on an in-patient basis;

(c) in Ontario, the insured person would ordinarily have been admitted as an in-patient of a public hospital to receive the services; and

(d) the services are rendered in connection with an illness, disease, condition or injury that,

(i) is acute and unexpected,

(ii) arose outside Canada, and

(iii) requires immediate treatment.  O. Reg. 31/92, s. 3; O. Reg. 596/93, s. 2.

(2) In subsection (1),

“eligible hospital or health facility” means,

(a) a hospital licensed or approved as a hospital by the government in whose jurisdiction the hospital is situated in which complex medical and complex surgical procedures are routinely performed, or

(b) a health facility licensed by the government in whose jurisdiction the health facility is situated in which complex medical and complex surgical procedures are routinely performed.  O. Reg. 31/92, s. 3.

(3) Despite subsection (1), if all the services rendered during a day are part of a domiciliary type of care that, in Ontario, would ordinarily be provided in a nursing home or a home for the aged, the services are not prescribed as insured services.  O. Reg. 31/92, s. 3; O. Reg. 375/93, s. 7.

(4) The amount payable by the Plan for in-patient services prescribed in subsection (1) is the amount actually billed to a maximum of,

(a) $400 per day for the higher level of care described in subsection (5); or

(b) $200 per day for any other kind of care.  O. Reg. 392/95, s. 1.

(5) The higher level of care referred to in subsection (5) is care for a condition for which the primary treatment ordinarily provided in Ontario is provided in a public hospital in any of the following:

1. A coronary care unit.

2. An intensive care unit.

3. A neonatal or paediatric special care unit.

4. An operating room.  O. Reg. 392/95, s. 1.

(6) An amount payable under this section covers all the in-patient services rendered during the day including diagnostic procedures or interpretations rendered by physicians but not including any other kind of service rendered by a physician.  O. Reg. 31/92, s. 3.

(7) The amount payable under this section for renal dialysis rendered outside of Canada on or after the 1st day of October, 1991 but before the 1st day of May, 1992 is the cost of the dialysis to the patient and subsections (3) to (6) do not apply with respect to such dialysis.  O. Reg. 343/92, s. 2.

28.4 (1) In this section,

“preferred provider arrangement” means a written agreement between the Minister and the operator of a hospital or health facility outside of Canada for the delivery of specified insured services to insured persons and “preferred provider” means the operator.  O. Reg. 31/92, s. 3.

(2) Services that are part of a treatment and that are rendered outside Canada at a hospital or health facility are prescribed as insured services if,

(a) the treatment is generally accepted in Ontario as appropriate for a person in the same medical circumstances as the insured person; and

(b) either,

(i) that kind of treatment that is not performed in Ontario by an identical or equivalent procedure, or

(ii) that kind of treatment 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.  O. Reg. 31/92, s. 3.

(2.1) Sex reassignment surgery and the supporting services for such surgery are not insured services prescribed by subsection (2).  O. Reg. 528/98, s. 3.

(2.2) Despite subsection (2.1), sex reassignment surgery performed on a person described in subsection (2.3) and any supporting services for such surgery are insured services.  O. Reg. 528/98, s. 3.

(2.3) Subsection (2.2) applies to a person who, as of October 1, 1998,

(a) has completed the Gender Identity Clinic Program operated by the Centre for Addiction and Mental Health in Toronto; and

(b) has been recommended for the surgery by the Gender Identity Clinic, upon completion of the program.  O. Reg. 528/98, s. 3.

(3) If insured services prescribed by subsection (2) are covered by a preferred provider arrangement, the amount payable is the amount provided in the preferred provider arrangement.  O. Reg. 31/92, s. 3.

(4) If insured services prescribed by subsection (2) are not covered by a preferred provider arrangement, the amount payable is the usual and customary amount charged by similar facilities under similar circumstances to major insurers for services provided, to persons they insure, in facilities located in the jurisdiction where the insured services are provided.  O. Reg. 31/92, s. 3.

(5) The following are conditions of payment of amounts for services prescribed in this section:

1. An application for approval of payment must be submitted to the General Manager by a physician who practices medicine in Ontario on behalf of the insured person and the application must contain a written confirmation from that physician that, in the opinion of the physician, one of the conditions set out in clause 2 (2) (b) is satisfied.

2. The General Manager must give written approval of the payment of the amount under this section before the services for which approval has been sought are rendered.

3. The services must be received within the time limit set out in the approval described in paragraph 2.

4. If the services are covered by a preferred provider arrangement, they must be received from a preferred provider.  O. Reg. 31/92, s. 3; O. Reg. 489/94, s. 3.

28.5 (1) A therapeutic laboratory service or diagnostic laboratory test that is performed outside Canada is prescribed as an insured service if that kind of service or test is not performed in Ontario but the service or test is generally accepted in Ontario as appropriate for a person in the same circumstances as the insured person.  O. Reg. 31/92, s. 3.

(2) Despite subsection (1), a service or test is not prescribed as an insured service if the service or test is experimental or the service or test is performed for research purposes.  O. Reg. 31/92, s. 3.

(3) The amount payable by the Plan for a service or test prescribed by subsection (1) is the amount determined by the General Manager.  O. Reg. 31/92, s. 3.

(4) It is a condition of payment of an amount for a service or test prescribed by subsection (1) that written approval of the payment is obtained from the General Manager before the service or test is performed.  O. Reg. 31/92, s. 3.

(5) A payment under this section may only be made directly to the person who performed the service or test.  O. Reg. 31/92, s. 3.

28.6 (1) For in-patient services, it is a condition of the payment of any amount under section 28.3 or 28.4 that the General Manager receive, from the hospital or health facility where the services were rendered, a written statement showing,

(a) the day the insured person was admitted;

(b) the diagnosis of the condition for which the insured person was admitted;

(c) the date of discharge or death of the insured person;

(d) the nature of any complications, if any, that warranted a stay in the hospital or health facility that was longer than the average stay of persons with the same condition or disease as the insured person;

(e) the kind and number of any laboratory, radiological or other diagnostic tests performed;

(f) the nature of any treatment, procedure or surgery that was performed;

(g) the discharge diagnosis or cause of death, as the case may be; and

(h) any other information required by the General Manager.  O. Reg. 31/92, s. 3.

(2) For out-patient services, it is a condition of the payment of any amount under section 28.2 or 28.4 that the General Manager receive, from the hospital or health facility where the services were rendered, a written statement showing,

(a) the diagnosis of the condition for which the insured person was treated;

(b) the kind and number of any laboratory, radiological or other diagnostic tests performed;

(c) the nature of any treatment, procedure or surgery that was performed;

(d) the date or dates when the insured person was treated; and

(e) any other information required by the General Manager.  O. Reg. 31/92, s. 3.

(3) It is a condition of payment of any amount for services under section 28.2, 28.3 or 28.4 that the General Manager receive,

(a) for payments to the insured person, a detailed receipt; or

(b) for payments directly to the person billing for the services, a detailed invoice in a form specified by the General Manager and a written direction from the insured person authorizing payment to the person billing for the services.  O. Reg. 31/92, s. 3.

(4) It is a condition for the payment of any amount for services under section 28.5 that the General Manager receive from the hospital or health facility where the service or test was performed,

(a) a written statement showing the kind and number of service or test performed and any other information required by the General Manager; and

(b) a detailed invoice in a form specified by the General Manager.  O. Reg. 31/92, s. 3.

Health Services

29. (1) The amount payable by the Plan for an insured service rendered by a physician outside Ontario to an insured person on or after the 22nd day of April, 1990 is the lesser of,

(a) the amount actually billed by the physician; or

(b) the amount payable for the service in the schedule of benefits or 51.7 cents multiplied by the applicable individual unit value for such service set out opposite the service in the schedule of laboratory benefits, as the case may be.  R.R.O. 1990, Reg. 552, s. 29 (1); O. Reg. 178/99, s. 2 (1); O. Reg. 201/99, s. 3.

(2) Despite subsection (1), the amount payable by the Plan for an insured service rendered by a physician outside Ontario to an insured person on or after the 22nd day of April, 1990 is, for the services Vital capacity, FEV1, FEV1/FVC with or without MMEFR (FEF 25-75) calculation, Repeat J301 after bronchodilator, Flow volume loop (FVC, FEV1, FEV1/FVC, V50, V25), and Repeat J304 after bronchodilator listed under the heading of “Pulmonary Function Studies” of the schedule of benefits, is the lesser of,

(a) the amount actually billed by the physician; or

(b) the amount calculated by adding the amount payable for the service in Column P and the amount payable for the service in Column T.  R.R.O. 1990, Reg. 552, s. 29 (2); O. Reg. 178/99, s. 2 (2).

(3) Despite subsections (1) and (2), if the services Vital capacity, FEV1, FEV1/FVC with or without MMEFR (FEF 25-75) calculation and Flow volume loop (FVC, FEV1, FEV1/FVC, V50, V25) are rendered together by a physician outside Ontario to an insured person on or after the 22nd day of April, 1990, the amount payable by the Plan for the services is the lesser of,

(a) the amount actually billed by the physician; or

(b) $31.50.  R.R.O. 1990, Reg. 552, s. 29 (3).

(4) Despite subsection (1), the amount payable by the Plan for an insured service rendered by a physician outside Ontario to an insured person on or after the 22nd day of April, 1990 and listed under the heading “Nuclear Medicine — In Vivo”, “Diagnostic Radiology”, “Diagnostic Ultrasound” or “Pulmonary Function Studies” of Schedule 16 is the lesser of,

(a) the amount actually billed by the physician; or

(b) the amount calculated by adding the amount payable for the service and, for a service listed under the heading,

(i) “Nuclear Medicine — In Vivo”,

(A) for visual inspection of imaging studies, the amount, or

(B) for visual inspection of imaging studies and quantification or data manipulation, 130 per cent of the amount,

payable for the service in Column P1 or P2 of the schedule of benefits, as the case may be, except for Tomography (SPECT), Myocardial wall motion studies, and Myocardial wall motion studies with ejection fraction, in which case, the amount payable for the service in Column P1 or P2, as the case may be, or

(ii) “Diagnostic Radiology”, “Diagnostic Ultrasound” or “Pulmonary Function Studies”, the amount payable for the service in Column P of the schedule of benefits.  R.R.O. 1990, Reg. 552, s. 29 (4); O. Reg. 178/99, s. 2 (3).

(5) Despite subsection (4), if the services Bone scintigraphy — general survey and Bone scintigraphy — single site are rendered together by a physician outside Ontario to an insured person on or after the 22nd day of April, 1990, the amount payable by the Plan for the services is the lesser of,

(a) the amount actually billed by the physician; or

(b) the amount calculated by adding $98.80 and,

(i) for visual inspection of imaging studies, the amount, or

(ii) for visual inspection of imaging studies and quantification or data manipulation, 130 per cent of the amount,

payable for Bone scintigraphy — general survey in Column P1 or P2 of the schedule of benefits, as the case may be.  R.R.O. 1990, Reg. 552, s. 29 (5); O. Reg. 178/99, s. 2 (4).

(6) Despite subsection (4), if the services Bone scintigraphy — general survey or Bone scintigraphy — single site and First transit with blood pool images are rendered together by a physician outside Ontario to an insured person on or after the 22nd day of April, 1990, the amount payable by the Plan for the services is the lesser of,

(a) the amount actually billed by the physician; or

(b) the amount calculated by adding $15.30, the amount payable for Bone scintigraphy — general survey or Bone scintigraphy — single site, as the case may be, in Schedule 16 and,

(i) for visual inspection of imaging studies, the amounts, or

(ii) for visual inspection of imaging studies and quantification or data manipulation, 130 per cent of the amounts,

payable for First transit without blood pool images and Bone scintigraphy — general survey or Bone scintigraphy — single site, as the case may be, in Column P1 or P2 of the schedule of benefits, as the case may be.  R.R.O. 1990, Reg. 552, s. 29 (6); O. Reg. 178/99, s. 2 (5).

(7) Despite subsection (4), the amount payable by the Plan for an insured service rendered by a physician outside Ontario to an insured person on or after the 22nd day of April, 1990 is for the services Brain scintigraphy, Perfusion lung scintigraphy, Ventilation lung scintigraphy, Perfusion and ventilation scintigraphy — same day, and Liver/spleen scintigraphy listed under the heading “Nuclear Medicine — In Vivo” of Schedule 16, if the service is limited to one view, the lesser of,

(a) the amount actually billed by the physician; or

(b) 50 per cent of the amount calculated by adding the amount payable for the service in Schedule 16 and the amount payable for the service in Column P1 or P2 of the schedule of benefits, as the case may be.  R.R.O. 1990, Reg. 552, s. 29 (7); O. Reg. 178/99, s. 2 (6).

(8) Despite subsection (4), the amount payable by the Plan for an insured service rendered by a physician outside Ontario to an insured person on or after the 22nd day of April, 1990 and listed under the heading “Diagnostic Radiology” of Schedule 16 is, if less than the minimum number of views set out opposite the service is rendered, the lesser of,

(a) the amount actually billed by the physician; or

(b) 75 per cent of the amount calculated by adding the amount payable for the service in Schedule 16 and the amount payable for the service in Column P of the schedule of benefits.  R.R.O. 1990, Reg. 552, s. 29 (8); O. Reg. 178/99, s. 2 (7).

(9) Despite subsection (4), if the services Carbon monoxide diffusing capacity by steady state at rest and Carbon monoxide diffusing capacity by single breath method are rendered together by a physician outside Ontario to an insured person on or after the 22nd day of April, 1990, the amount payable by the Plan for the services is the lesser of,

(a) the amount actually billed by the physician; or

(b) $35.80.  R.R.O. 1990, Reg. 552, s. 29 (9).

(10) Payment for insured services specified in sections 16 to 19 rendered by a practitioner outside Ontario shall be in the amounts actually billed or in the amounts prescribed under sections 16 to 19, whichever is the lesser.  O. Reg. 31/92, s. 4.

(11) It is a condition of payment by the Plan for an insured service rendered outside Canada by a physician or a practitioner that the service is rendered in connection with an illness, disease, condition or injury that,

(a) is acute and unexpected;

(b) arose outside Canada; and

(c) requires immediate treatment.  O. Reg. 596/93, s. 3.

30. (1) Where physiotherapy services are performed in Canada but outside Ontario they are an insured service only when performed on an in-patient or out-patient basis in a hospital.  R.R.O. 1990, Reg. 552, s. 30 (1).

(2) Revoked:  O. Reg. 31/92, s. 5.

31. If an insured person, while outside Ontario, received an insured service rendered by a laboratory on or after the 1st day of October, 1989 that was authorized by a physician practising outside Ontario, the General Manager may cause to be paid to or on behalf of the insured person 51.7 cents multiplied by the applicable individual unit value for such service set out opposite the service in the schedule of laboratory benefits.  R.R.O. 1990, Reg. 552, s. 31; O. Reg. 201/99, s. 4.

32. (1) A private clinic in Canada but outside Ontario that renders renal dialysis services is prescribed as a health facility for the purposes of the Act.  O. Reg. 31/92, s. 6.

(2) Renal dialysis services rendered by private clinics in Canada but outside Ontario are prescribed as insured services.  O. Reg. 31/92, s. 6.

(3) The amount payable by the Plan for the insured services prescribed in subsection (2) is the cost of the insured services to an insured person.  R.R.O. 1990, Reg. 552, s. 32 (3).

33. Revoked:  O. Reg. 31/92, s. 7.

Designated Hospitals and Health Facilities

34. No hospital or health facility in Ontario providing for the care and treatment of the sick, injured or disabled, other than a hospital or health facility designated under the Act and this Regulation, is entitled to payment by the Plan in respect of insured services provided to an insured person in or by such hospital or health facility.  R.R.O. 1990, Reg. 552, s. 34.

35. (1) The following hospitals are designated for the purpose of the Plan:

1. The hospitals listed in Schedule 2.

2. The hospitals graded, under the Public Hospitals Act, as Group A, B, C, E, F, G, J or R hospitals.

3. Revoked:  O. Reg. 322/01, s. 5 (1).

O. Reg. 253/00, s. 5 (1); O. Reg. 322/01, s. 5 (1).

(2) Each hospital listed in Schedule 1 is designated for the purpose of providing such in-patient and out-patient services to insured persons as are available in the hospital.  R.R.O. 1990, Reg. 552, s. 35 (2).

(3) Each hospital graded, under the Public Hospitals Act, as a Group M hospital is designated for the purpose of performing computerized axial tomography scans.  O. Reg. 322/01, s. 5 (2).

(4)-(7) RevokedO. Reg. 253/00, s. 5 (3).

(8) Revoked:  O. Reg. 363/02, s. 1.

(9) Each hospital listed in Schedule 4 is designated for the purpose of providing the type of care and treatment designated in the Schedule for that hospital.  R.R.O. 1990, Reg. 552, s. 35 (9).

(10) Each physiotherapy facility listed in Part I of Schedule 5 is designated as a health facility for the purpose of providing office and home physiotherapy treatment to insured persons and each physiotherapy facility listed in Part II of Schedule 5 is designated as a health facility for the purpose of providing home physiotherapy treatment only to insured persons.  R.R.O. 1990, Reg. 552, s. 35 (10).

(11) Each rehabilitation centre or crippled children’s centre listed in Schedule 6 is designated as a hospital for the purpose of providing the insured services indicated in Schedule 6.  R.R.O. 1990, Reg. 552, s. 35 (11).

(12) Each ambulance service operator listed in Schedule 7 is designated as a health facility for the purpose of providing insured ambulance services.  R.R.O. 1990, Reg. 552, s. 35 (12).

(13) Each Public Health Laboratory listed in Schedule 8 is designated as a health facility for the purpose of providing laboratory services.  R.R.O. 1990, Reg. 552, s. 35 (13).

(14) Revoked:  O. Reg. 375/93, s. 8.

Information to be Furnished by Designated Hospitals

36. Every hospital in Ontario designated for the purpose of the Plan shall forward to the General Manager,

(a) within twenty-four hours after an in-patient is admitted, a notification of admission in the prescribed form and if ambulance service has been required, a notification of the name of the ambulance operator listed in Schedule 7 who provided such service, together with the amount of the ambulance service charges;

(b) within ninety-six hours after an in-patient is discharged from or dies in the hospital, a notification of the discharge or death in the prescribed form and if ambulance service was required when the patient was discharged, a notification of the name of the ambulance operator listed in Schedule 7 who provided such service, together with the amount of the ambulance service charges;

(c) as required by the General Manager, a longstay report in the prescribed form;

(d) a list of out-patients in the prescribed form, in duplicate, when the form is filled in, or not later than the twenty-fifth day of each month, whichever is the sooner;

(e) monthly operating statements and financial and statistical returns in the prescribed forms as required by the General Manager; and

(f) within thirty days after an in-patient is admitted as the result of an accident or at the time of discharge, whichever is earlier, and for each subsequent admission, an accident report in the prescribed form.  R.R.O. 1990, Reg. 552, s. 36.

37. (1) A hospital is prescribed as an organization that must provide information to the General Manager for the purposes of subsection 37 (2) of the Act.  O. Reg. 44/98, s. 5.

(2) A hospital shall give the General Manager a written statement regarding the condition of an insured person who received insured services or other treatment in the hospital and the statement shall,

(a) be prepared by the physician, oral and maxillofacial surgeon, midwife or registered nurse in the extended class who attends the insured person in the hospital; and

(b) set out the reasons the insured services and other treatment provided to the insured person during his or her stay in hospital were necessary.  O. Reg. 44/98, s. 5; O. Reg. 345/01, s. 10 (1).

(3) The General Manager may require a hospital to obtain the written statement described in subsection (4) from the insured person’s attending physician, oral and maxillofacial surgeon, midwife or registered nurse in the extended class and to forward it to the General Manager.  O. Reg. 62/03, s. 4.

(4) The written statement, to be prepared by the attending physician, oral and maxillofacial surgeon, midwife or registered nurse in the extended class, is a statement regarding the condition of the insured person and must state the reason that any ambulance services provided to the insured person are necessary.  O. Reg. 62/03, s. 4.

Physician Services

37.1 (1) A service rendered by a physician in Ontario is an insured service if it is referred to in the schedule of benefits and rendered in such circumstances or under such conditions as may be specified in the schedule of benefits.  O. Reg. 111/96, s. 2.

(2) The basic fee payable by the Plan for an insured service prescribed under subsection (1) is the fee payable under the schedule of benefits.  O. Reg. 111/96, s. 2.

(3) A laboratory service set out in the schedule of laboratory benefits and rendered by a physician is an insured service if,

(a) it is rendered for the purposes of diagnosing or treating a patient of the physician who sees the physician for purposes other than the sole purpose of receiving the laboratory service; or

(b) it is rendered in a public hospital.  O. Reg. 111/96, s. 2; O. Reg. 201/99, s. 5 (1).

(4) The basic fee payable by the Plan for a laboratory service set out in the schedule of laboratory benefits and rendered by a physician in the circumstances referred to in clause (3) (a) is 51.7 cents multiplied by the applicable individual unit value for the service set out opposite the service in the schedule of laboratory benefits.  O. Reg. 111/96, s. 2; O. Reg. 201/99, s. 5 (2).

(5) The basic fee payable for a laboratory service set out in the schedule of laboratory benefits and rendered by a physician in a public hospital is nil.  O. Reg. 111/96, s. 2; O. Reg. 201/99, s. 5 (3).

(6) If, under this Regulation or under an agreement to which the Government of Ontario is a party, the fee payable for an insured service set out in the schedule of laboratory benefits is nil, the fee payable for an insured service rendered by a physician in relation to that service is nil.  O. Reg. 111/96, s. 2; O. Reg. 201/99, s. 5 (4).

(7) Despite subsection (6), if a second physician renders a diagnostic laboratory medicine consultation in relation to a laboratory service set out in the schedule of laboratory benefits at the request of another physician, the fee payable to the second physician is the fee set out in the schedule of benefits.  O. Reg. 111/96, s. 2; O. Reg. 201/99, s. 5 (5).

(8) For the purposes of subsection (7), a diagnostic laboratory medicine consultation occurs when a physician who practises laboratory medicine in a hospital gives a written opinion with respect to tissue, slides or specimens that are referred to the physician by a physician practising laboratory medicine in another hospital.  O. Reg. 111/96, s. 2.

37.1.1 (1) Despite subsection 37.1 (1), the following services rendered by an opthalmologist in Ontario on or after April 1, 2002 and before June 15, 2002 are insured services if all of the conditions listed in subsection (2) are met:

1. Ocular photodynamic therapy, including establishment of intravenous access.

2. The provision of verteporfin.

3. The supervision of drug infusion and application of non-thermal diode laser for the activation of verteporfin.  O. Reg. 169/02, s. 4.

(2) These are the conditions that must be met:

1. The service is provided for the treatment of predominantly classic subfoveal choroidal neovascularization secondary to age-related macular degeneration or pathologic myopia.

2. The area of classic subfoveal choroidal neovascularization is equal to or greater than 50 per cent of the total lesion, as determined by fluorescein angiography.

3. The first treatment is commenced within 30 months after the initial diagnosis of predominantly classic subfoveal choroidal neovascularization secondary to age-related macular degeneration or pathologic myopia.

4. The patient’s visual acuity is 20/40 or worse.  O. Reg. 169/02, s. 4.

(3) Despite subsection 37.1 (2), the basic fee payable by the Plan for an insured service described in subsection (1) is the lesser of,

(a) the amount actually paid by the insured person for the service; and

(b) the usual amount charged for the service in Ontario for similar treatment provided in similar circumstances.  O. Reg. 169/02, s. 4.

37.2 Revoked:  O. Reg. 370/00, s. 1.

Note:  Despite its revocation, section 37.2, as it read immediately before January 1, 2000, continues to apply with respect to payments for services rendered before January 1, 2000.  See:  O. Reg. 370/00, s. 5 (2).

37.3 (1) Subject to subsection (2), the basic fee payable for an insured service rendered by a physician in Ontario, as set out in the schedule of benefits, shall be increased by 1.95 per cent if it is rendered on or after April 1, 2000.  O. Reg. 369/00, s. 1.

(2) The increase in the basic fee payable under subsection (1) does not apply to an insured service referred to in Part 2 of Appendix E to the General Preamble to the schedule of benefits, other than a service referred to at the end of that Part of the Appendix under the heading “Other”.  O. Reg. 369/00, s. 1.

37.4 The basic fee payable for an insured service that is rendered in a hospital and set out in Part 2 of Appendix E to the General Preamble to the schedule of benefits shall be decreased by,

(a) 6.7 per cent, if it is rendered before April 1, 1999;

(b) 3 per cent, if it is rendered on or after April 1, 1999 but before October 1, 1999; and

(c) 7 per cent, if it is rendered on or after October 1, 1999.  O. Reg. 177/99, s. 1; O. Reg. 483/99, s. 1.

37.5 (1) The fee payable for an insured service rendered by a physician during a fiscal year referred to in Column 1 of the Table to this section shall be decreased in accordance with subsection (2) if the total amount payable for insured services rendered by the physician between the beginning of the fiscal year and the day the service is rendered exceeds the threshold amount set out opposite the fiscal year in Column 2 of the Table to this section.  O. Reg. 50/03, s. 2.

(2) For the purposes of subsection (1), in the case of an insured service rendered during a fiscal year referred to in Column 1 of the Table to this section, if the total amount payable for insured services rendered by the physician between the beginning of the fiscal year and the day the insured service is rendered is equal to or exceeds the threshold amount set out opposite the fiscal year in Column 2 of the Table, the fee payable for the insured service is one-third of the basic fee otherwise payable.  O. Reg. 50/03, s. 2.

(3) For the purposes of this section, the total amount payable for insured services shall include the amounts payable for all insured services other than the following:

1. A service set out in Appendix E to the General Preamble to the schedule of benefits.

2. A service rendered under the Underserviced Area Program of the Ministry of Health.  O. Reg. 50/03, s. 2.

(4) Despite subsection (1), the fee payable for the following insured services shall not be decreased under this section:

1. A service set out in Appendix E to the General Preamble to the schedule of benefits.

2. A service rendered under the Underserviced Area Program of the Ministry of Health.  O. Reg. 50/03, s. 2; O. Reg. 264/03, s. 1.

(5) In this section,

“fiscal year” means the period from April 1 of each year to and including March 31 of the following year.  O. Reg. 50/03, s. 2.

(6) This section, as it read immediately before April 1, 2002, continues to apply with respect to payments for services rendered before April 1, 2002.  O. Reg. 50/03, s. 2.

TABLE
THRESHOLD AMOUNTS FOR physician providers

 

Column 1

Column 2

Fiscal year

Total amount payable

For the fiscal year beginning April 1, 2002, and any subsequent fiscal year

$455,000

O. Reg. 50/03, s. 2.

37.6 Revoked:  O. Reg. 370/00, s. 3.

Note:  Despite its revocation, section 37.6, as it read immediately before January 1, 2000, continues to apply with respect to payments for services rendered before January 1, 2000.  See:  O. Reg. 370/00, s. 5 (2).

Billing and Payment for Insured Services

38. (1) RevokedO. Reg. 111/96, s. 3.

(2) A physician who does not submit his or her accounts directly to the Plan may commence to bill the Plan by giving written notice to the General Manager that he or she intends to bill the Plan directly and the notification becomes effective the first day of the third month following the month in which the General Manager receives such notification but may become effective on an earlier date as ordered by the General Manager.  R.R.O. 1990, Reg. 552, s. 38 (2).

(3) A physician who does not submit his or her accounts directly to the Plan and who becomes a full-time member of a clinic that is registered with the Plan may give written notice to the General Manager that he or she intends to bill the Plan directly and the notification becomes effective the first day of the month following the month in which the General Manager receives such notification.  R.R.O. 1990, Reg. 552, s. 38 (3).

(4) Subject to subsection (5), the following classes of accounts are exempt from the application of section 15 of the Act:

1. Accounts for the performance of insured services rendered to an insured person who is a recipient of a war veteran’s allowance under the War Veterans Allowance Act (Canada).

2. Accounts for the performance of insured services rendered to an insured Indian who is a member of a band as defined in the Indian Act (Canada).

3. Accounts for the performance of insured services rendered to an insured person in an out-patient or any other clinical department of a public hospital.

4. Accounts for the performance of insured services rendered to an insured person in,

i. a nursing home,

ii. a home for the aged, established and maintained under the Homes for the Aged and Rest Homes Act,

iii. a children’s mental health centre under the Children’s Mental Health Services Act, being chapter 69 of the Revised Statutes of Ontario, 1980,

iv. a hospital established or approved under the Community Psychiatric Hospitals Act,

v. a psychiatric facility under the Mental Health Act,

vi. an institution designated as an approved home under the Mental Hospitals Act,

vii. a designated facility to which the Developmental Services Act applies,

viii. a home for special care, established, approved or licensed under the Homes for Special Care Act, or

ix. an approved charitable home for the aged under the Charitable Institutions Act.

5. Accounts for the performance of insured services rendered to an insured person in a mobile vision or hearing van operated by a non-profit organization to provide eye or ear care in under-serviced areas in Ontario.

6. Accounts for the performance of an examination rendered to an insured person and for documentation prepared for the purpose of an investigation or confirmation of an alleged sexual assault.  R.R.O. 1990, Reg. 552, s. 38 (4); O. Reg. 375/93, s. 9.

(5) Payment for the classes of accounts exempted by paragraphs 3 and 4 of subsection (4) may only be made where,

(a) the physician performing the services is a member of an associate medical group that is registered with the Plan;

(b) the accounts for such services are submitted by the association referred to in clause (a) directly to the Plan; and

(c) the associate medical group referred to in clause (a) and physician accept the payment as constituting payment in full for the services.  R.R.O. 1990, Reg. 552, s. 38 (5).

(6) Revoked:  O. Reg. 86/93, s. 2.

(7) Revoked:  O. Reg. 363/02, s. 2.

(8)-(10) Revoked:  O. Reg. 86/93, s. 2.

(11) The Plan shall pay a designated hospital for insured services provided to an insured person on the day of the person’s admission to the hospital but not on the day of the person’s discharge from the hospital.  R.R.O. 1990, Reg. 552, s. 38 (11).

(12) The Plan shall not make and a hospital shall not accept duplicate payments for any insured services provided by the hospital.  R.R.O. 1990, Reg. 552, s. 38 (12).

38.0.0.1 (1) A physician or practitioner may give a direction under subsection 16.1 (1) of the Act (direction to make payments to prescribed person or entity) to the persons or entities and in the circumstances described in this section.  O. Reg. 422/01, s. 1.

(2) A physician who ordinarily practises with one or more physicians at a department of a public hospital in Ontario (a “physician hospital group”) may direct that payment for the insured services he or she renders at that department be made,

(a) to the physician hospital group or to one or more members of that group;

(b) to the public hospital; or

(c) to a person or partnership with which the physician hospital group has an agreement concerning the provision of insured services at that department.  O. Reg. 422/01, s. 1.

(3) A practitioner who ordinarily practises at a department of a public hospital in Ontario with one or more practitioners who are members of the same regulated health profession (a “practitioner hospital group”) may direct that payment for the insured services he or she renders at that department be made,

(a) to the practitioner hospital group or to one or more members of that group;

(b) to the public hospital; or

(c) to a person or partnership with which the practitioner hospital group has an agreement concerning the provision of insured services at that department.  O. Reg. 422/01, s. 1.

(4) Subject to subsection (6), a physician who ordinarily practises with one or more physicians (a “physician group”) at one or more sites in Ontario may direct that payment for the insured services he or she renders at the site or sites be made,

(a) to the physician group or to one or more members of that group; or

(b) to a person or partnership with which the physician group has an agreement concerning the provision of insured services at those sites. O. Reg. 422/01, s. 1. 

(5) Subject to subsection (6), a practitioner who ordinarily practises at one or more sites in Ontario with one or more practitioners who are members of the same regulated health profession (a “practitioner group”) may direct that payment for the insured services he or she renders at the site or sites be made,

(a) to the practitioner group or to one or more members of that group; or

(b) to a person or partnership with which the practitioner group has an agreement concerning the provision of insured services at those sites.  O. Reg. 422/01, s. 1.

(6) Subsection (4) or (5) applies only if the General Manager assigned an identification number to the physician group or practitioner group before the day Ontario Regulation 422/01 comes into force.  O. Reg. 422/01, s. 1.

(7) A physician who renders insured services to insured persons pursuant to an alternative funding plan arrangement entered into with the Minister (an “AFP physician”) may direct that payment for the insured services he or she renders be made to one of the following or to both of the following as provided for in the direction:

1. The group of AFP physicians that ordinarily renders insured services to insured persons under the same alternative funding plan arrangement as the physician making the direction, or to one or more members of that group.

2. The governance organization responsible for ensuring provision of insured services by AFP physicians under the alternative funding plan arrangement entered into with the Minister.  O. Reg. 441/03, s. 1.

38.0.1 (1) The following circumstances are prescribed for the purposes of paragraph 7 of subsection 18 (2) of the Act:

1. The General Manager is of the opinion that the account for the insured service has not been submitted in accordance with the Act and the regulations.

2. The General Manager is of the opinion that the fee code used by a physician or the amount claimed by a practitioner in the account submitted for payment is incorrect in the circumstances.

3. The General Manager is of the opinion that the insured service for which an account has been submitted was provided in circumstances in which no payment or a reduced payment is to be made, according to the Act, the regulations or the schedule of benefits.

4. The General Manager is of the opinion that the account submitted by a physician for payment includes two or more fee codes that reflect, in whole or in part, the provision of a single insured service rendered to an insured person in circumstances in which the service is more accurately described by only one fee code.

5. The General Manager is of the opinion that the account submitted by a practitioner for payment includes two or more claims that reflect, in whole or in part, the provision of a single insured service rendered to an insured person in circumstances in which the service is more accurately described by only one fee code.

6. The General Manager is of the opinion,

i. that an account submitted for payment by a physician includes a fee code for a service (the “billed service”) that is described in the schedule of benefits as an element of an insured service (the “insured service”), and

ii. that the insured service was rendered by another physician to the same person as the billed service was rendered and with respect to the same medical circumstances.  O. Reg. 344/01, s. 1.

(2) The following circumstances are prescribed for the purposes of paragraph 5 of subsection 39.1 (6) of the Act:

1. The applicable committee is of the opinion that the account for the insured service has not been submitted in accordance with the Act and the regulations.

2. The applicable committee is of the opinion that the fee code used by a physician or the amount claimed by a practitioner in the account submitted for payment is incorrect in the circumstances.

3. The applicable committee is of the opinion that the insured service for which an account has been submitted was provided in circumstances in which no payment is to be made, according to the Act, the regulations or the schedule of benefits.

4. The applicable committee is of the opinion that the account submitted by a physician for payment includes two or more fee codes that reflect, in whole or in part, the provision of a single insured service rendered to an insured person in circumstances in which the service is more accurately described by only one fee code.

5. The applicable committee is of the opinion that the account submitted by a practitioner for payment includes two or more claims that reflect, in whole or in part, the provision of a single insured service rendered to an insured person in circumstances in which the service is more accurately described by only one fee code.

6. The applicable committee is of the opinion,

i. that an account submitted for payment by a physician includes a fee code for a service (the “billed service”) that is described in the schedule of benefits as an element of an insured service (the “insured service”), and

ii. that the insured service was rendered by another physician to the same person as the billed service was rendered and with respect to the same medical circumstances.  O. Reg. 344/01, s. 1.

(3) In this section,

“fee code” means fee schedule code as listed in the schedule of benefits.  O. Reg. 344/01, s. 1.

38.1 (1) For the purposes of clause 18.1 (2) (a) of the Act, a physician may request that a decision of the General Manager under subsection 18 (2) or (5) of the Act be reviewed by a single member of the Medical Review Committee if the amount in dispute is less than $100,000.  O. Reg. 575/98, s. 1; O. Reg. 150/00, s. 1 (1).

(2) For the purposes of clause 18.1 (4) (a) of the Act, a practitioner may request that a decision of the General Manager under subsection 18 (2) or (5) of the Act be reviewed by a single member of the applicable practitioner review committee if the amount in dispute is less than $100,000.  O. Reg. 575/98, s. 1; O. Reg. 150/00, s. 1 (2).

38.2 (1) For the purposes of subsection 18.1 (5) of the Act, the amount that must accompany a request for review shall be equal to 5 per cent of the amount in dispute but in no case shall be more than $2,500 or less than $350.  O. Reg. 256/03, s. 1.

(2) For the purposes of subsection 18.1 (8) of the Act, the amount that must accompany a request for reconsideration shall be $350.  O. Reg. 256/03, s. 1.

38.2.1 (1) For the purposes of subsection 18.1 (14) of the Act, interest on an amount payable by or to a physician or practitioner, that is payable as a result of a direction under subsection 18.1 (10), 18.2 (2) or 39.1 (5), shall be paid at the rate set by the Ministry of Finance under section 10 of the Financial Administration Act.  O. Reg. 575/98, s. 1; O. Reg. 149/00, s. 1; O. Reg. 150/00, s. 3 (1).

(2) For the purposes of subsection 18.1 (14) of the Act, interest on an amount payable by or to a physician or practitioner shall be paid from the date determined in accordance with the following rules:

1. If the review committee directs an amount to be paid after reviewing a decision of the General Manager to refuse to pay for a service or to pay a reduced amount under subsection 18 (2) of the Act, interest is payable from the payment day that is or that follows the day the physician or practitioner receives notice of the General Manager’s decision.

2. If the review committee directs the General Manager to return to a physician or practitioner all or part of a reimbursement that he or she paid after being required to reimburse the Plan under subsection 18 (5) of the Act, interest is payable from the day that the physician or practitioner made the reimbursement.

3. If the review committee confirms the General Manager’s decision to require a physician or practitioner to reimburse the Plan under subsection 18 (5), interest is payable from the day the physician or practitioner receives notice of the General Manager’s decision to require the reimbursement.

4. If a review committee directs an amount to be paid under subsection 18.2 (2) or 39.1 (5), interest is payable from the payment day that follows the end of the review period.  O. Reg. 575/98, s. 1; O. Reg. 150/00, s. 3 (2).

(3) In subsection (2),

“payment day” means the day the Plan makes payments to physicians and practitioners and is the 15th day of each month;

“review period” means, with respect to a review by the Medical Review Committee or a practitioner review committee of the amount payable for services rendered by a physician or practitioner, the period of time during which those services were rendered.  O. Reg. 575/98, s. 1.

38.2.2 (1) For the purposes of subsection 18.1 (15) of the Act, if, as a result of a review or a reconsideration of a review under section 18.1 of the Act, a physician or practitioner is required to reimburse money to the Plan or a direction is made directing the General Manager to pay an amount to a physician or practitioner that is less than the amount of the account submitted, the additional amount for the cost of the review or for the cost of the reconsideration of the review shall be calculated using the following formula:

where,

A is,

(a) where the physician or practitioner is required to reimburse money to the Plan, the amount that is required to be reimbursed, or

(b) where the General Manager is required to pay less than the amount of the account submitted, the portion of the amount the physician or practitioner claimed, in the review or reconsideration, should be paid to him or her that has been refused by the review committee;

B is,

(a) where the physician or practitioner is required to reimburse money to the Plan, the amount that the physician or practitioner claimed he or she should not be required to reimburse in the review or reconsideration, or

(b) where the General Manager is required to pay less than the amount of the account submitted, the amount that the physician or practitioner claimed should be paid to him or her in the review or reconsideration;

C is $1000, in the case of a review or reconsideration conducted by the Medical Review Committee, or $500, in the case of a review or reconsideration conducted by a practitioner review committee;

D is the number of review days in the review or reconsideration, as determined under subsection (5).

O. Reg. 149/00, s. 2.

(2) Despite subsection (1), the additional amount determined under that subsection shall not exceed the lesser of,

(a) the amount that is,

(i) where the physician or practitioner is required to reimburse money to the Plan, the amount that is required to be reimbursed, multiplied by 0.35, or

(ii) where the General Manager is required to pay less than the amount of the account submitted, the portion of the amount the physician or practitioner claimed, in the review or reconsideration, should be paid to him or her that has been refused by the review committee, multiplied by 0.35; and

(b) $1000 for each review day, in the case of a review or reconsideration conducted by the Medical Review Committee, or $500 for each review day, in the case of a review or a reconsideration conducted by a practitioner review committee.  O. Reg. 149/00, s. 2.

(3) For the purposes of subsection 18.1 (15) of the Act, if, as a result of a review or a reconsideration of a review under section 18.1 of the Act, a direction is made confirming the decision of the General Manager to refuse to pay an account for services or if, as a result of a review or a reconsideration of a review under section 18.2 or 39.1 of the Act, a physician or practitioner is required to reimburse money to the Plan, the additional amount for the cost of the review or for the cost of the reconsideration of the review shall be calculated using the following formula:

where,

C is $1000, in the case of a review or reconsideration conducted by the Medical Review Committee, or $500, in the case of a review or reconsideration conducted by a practitioner review committee;

D is the number of review days in the review or reconsideration, as determined under subsection (5).

O. Reg. 149/00, s. 2; O. Reg. 150/00, s. 4 (1).

(4) Despite subsection (3), the additional amount determined under that subsection shall not exceed,

(a) where a direction is made confirming the decision of the General Manager to refuse to pay an account for services, the amount that the physician or practitioner claimed should be paid to him or her in the review or reconsideration, multiplied by 0.35; or

(b) where a physician or practitioner is required to reimburse money to the Plan, the amount that is required to be reimbursed, multiplied by 0.35.  O. Reg. 149/00, s. 2.

(5) For the purposes of subsections (1), (2) and (3), if the direction of the committee is made on or after April 1, 2003 and if the circumstances set out in subsection (5.2) do not apply, the number of review days in a review or reconsideration is the lesser of 15 and the number determined as follows:

1. For each member of the committee, determine the number of days, including any partial days rounded to the first decimal, the member spent working on the review or reconsideration and on related matters after commencing to hear from the physician or practitioner.

2. If the parties agreed to a settlement of the review or reconsideration, determine, for each member, the number of days, including any partial days rounded to the first decimal, the member spent considering and agreeing to the offer to settle after commencing to hear from the physician or practitioner.

3. For each member of the committee, determine the days that are spent by the committee in hearing from the physician or practitioner, including any partial days rounded to the first decimal, to a maximum of two days.

4. For each member, subtract the number of days determined for the member under paragraphs 2 and 3 from the number of days determined for the member under paragraph 1.

5. Add the numbers determined under paragraph 4 for each member to calculate the total number of days all the members of the committee spent working on the review or reconsideration and on related matters. 

6. For the purposes of the calculations in paragraphs 1, 2 and 3, the committee is “hearing from the physician or practitioner” when the physician or practitioner or his or her counsel or agent is in the presence of the committee for the purpose of making representations.  O. Reg. 5/04, s. 1.

(5.1) For the purposes of subsections (1), (2) and (3), if the direction of the committee was made before April 1, 2003 or if the circumstances set out in subsection (5.2) apply, the number of review days in a review or reconsideration shall be determined as follows:

1. For each member of the committee, determine the number of days, including any partial days rounded to the first decimal, the member spent working on the review or reconsideration and on related matters.

2. If the parties agreed to a settlement of the review or reconsideration, determine, for each member, the number of days, including any partial days rounded to the first decimal, the member spent considering and agreeing to the offer to settle.

3. For each member, subtract the number of days determined for the member under paragraph 2 from the number of days determined for the member under paragraph 1.

4. Add the numbers determined under paragraph 3 for each member to calculate the total number of days all the members of the committee spent working on the review or reconsideration and on related matters.  O. Reg. 5/04, s. 1.

(5.2) The following are set out as circumstances for the purposes of subsections (5) and (5.1):

1. In the case of a practitioner, if a direction under subsection 18.1 (10) of the Act has previously been made requiring the practitioner to reimburse money to the Plan or directing the General Manager to pay an amount to the practitioner that is less than the amount of the account submitted.

2. In the case of a physician,

i. if a direction under subsection 18.1 (10) of the Act has previously been made requiring the physician to reimburse money to the Plan or directing the General Manager to pay an amount to the physician that is less than the amount of the account submitted, and

ii. the direction related, in whole or in part, to a claim or claims submitted with regard to one or more of the same schedule of benefits fee codes or classes of fee code as the claim or claims giving rise to the current review or reconsideration.  O. Reg. 5/04, s. 1.

(5.3) The following are classes of fee code for the purposes of paragraph 2 of subsection (5.2):

1. Class 1 — all codes which are in respect of diagnostic tests or services, or the interpretation of a diagnostic test or service.

2. Class 2 — all codes in respect of surgical services.

3. Class 3 — all codes in respect of anesthesia services.

4. Class 4 — all codes other than those contained in any of classes 1 to 3.  O. Reg. 5/04, s. 1.

(6) Despite subsections (1) and (3), the additional amount for the cost of a review or for the cost of a reconsideration of a review shall be a nil amount if the physician or practitioner who is a party to the review or reconsideration made an offer to settle the matter and the offer was refused and,

(a) where the issue in the review or reconsideration related to whether the Plan owed money to the physician or practitioner, the settlement offer provided that the physician or practitioner accept payment of an amount that was equal to or less than the amount that the committee or single member directed that the Plan pay; or

(b) where the issue in the review or reconsideration related to whether the physician or practitioner owed money to the Plan, the settlement offer provided that the physician or practitioner reimburse an amount that was equal to or greater than the amount that the committee or single member directed the member to reimburse.  O. Reg. 149/00, s. 2.

(6.1) Despite subsections (1) to (3), in the case of a review or a reconsideration of a review that, as of March 3, 2000, is before a review committee and in respect of which no direction has been issued, the additional amount for the cost of the review or reconsideration shall be a nil amount if the physician or practitioner made an offer to settle the matter on or before that date, or makes such an offer within 45 days after that date, and the offer is accepted at any time after it is made.  O. Reg. 150/00, s. 4 (2).

(7) Upon the recommendation of the review committee, the General Manager may reduce the additional amount payable for the cost of a review or reconsideration of a review, as determined under subsections (1) to (5), by such amount as is reasonable in the circumstances.  O. Reg. 149/00, s. 2.

(8) The review committee may recommend a reduction of the additional amount payable for the cost of a review or reconsideration of a review if, in the course of the review or reconsideration, either of the following circumstances are found to exist:

1. The review or reconsideration relates to accounts that were submitted to the Plan by a physician or practitioner in accordance with advice received from the General Manager.

2. The General Manager or review committee failed to provide the physician or practitioner with information that was likely to affect either his or her decision to proceed with the review or reconsideration or his or her decision to make an offer to settle the matter.  O. Reg. 149/00, s. 2.

38.2.3 Sections 38.2.1 and 38.2.2 apply to any review or reconsideration of a review under section 18.1 or 39.1 of the Act that is commenced on or after November 5, 1998 or that was commenced before November 5, 1998 but in respect of which a direction had not been issued before that date.  O. Reg. 149/00, s. 2.

38.3 (1) In this section,

“electronic data transfer” means a method approved by the Ministry of Health and Long-Term Care for electronically transferring information.  O. Reg. 362/02, s. 1.

(2) It is a condition of payment that the following claims be submitted by electronic data transfer: 

1. A claim for the cost of an insured service rendered by a physician, practitioner or health facility, if the physician, practitioner or health facility was first assigned an Ontario Health Insurance Plan identification number on or after January 1, 2003.

2. A claim for the cost of a laboratory service that is an insured service under section 22, if the medical director of the laboratory was first assigned an Ontario Health Insurance Plan identification number on or after January 1, 2003.  O. Reg. 362/02, s. 1.

(3) It is a condition of payment that the following claims be submitted in a machine readable form acceptable to the Ministry of Health and Long-Term Care:

1. A claim for the cost of an insured service rendered by a physician, practitioner or health facility, if the physician, practitioner or health facility was assigned an Ontario Health Insurance Plan identification number on or after January 1, 1993 and before January 1, 2003.

2. A claim for the cost of a laboratory service that is an insured service under section 22, if the medical director of the laboratory was assigned an Ontario Health Insurance Plan identification number on or after January 1, 1993 and before January 1, 2003.  O. Reg. 362/02, s. 1.

(4) Subsections (2) and (3) do not apply to a claim for the cost of an insured service rendered by a dental surgeon.  O. Reg. 362/02, s. 1.

(5) A processing fee is payable under the regulations under the Interpretation Act for every claim received after July 13, 1993, unless the claim is submitted by electronic data transfer or in a machine readable form acceptable to the Ministry of Health and Long-Term Care.  O. Reg. 362/02, s. 1.

(6) This section does not apply to a claim for a service rendered to an insured person outside of Ontario.  O. Reg. 362/02, s. 1.

38.4 (1) It is a condition of payment of a claim for an insured service rendered to an insured person in Ontario that the claim include the following information:

1. The Ontario Health Insurance Plan identification number for,

i. the physician or practitioner who rendered the service,

ii. the physiotherapy facility listed in Schedule 5 to this Regulation that rendered the service, or

iii. the medical director of the laboratory in which the service was rendered.

2. If the service was rendered by a physician, practitioner or laboratory,

i. the four characters assigned by the Plan that indicate whether the physician or practitioner practices alone or with one or more other physicians or practitioners or whether the service was provided in a laboratory, and

ii. the two characters assigned by the Plan that indicate the specialty of the physician, if any, or the specialty or profession of the practitioner or laboratory director, if any.

3. The most recently issued 10 digit health number for the insured person to whom the service was provided and any version code that may appear on the person’s health card bearing that number.

4. The date of birth of the insured person to whom the service was rendered.

5. The payment program code “HCP”.

6. Any characters assigned by the Ministry of Health and Long-Term Care that identify the payee as a provider or recipient of the insured service.

7. If the service is a diagnostic radiology procedure in accordance with the schedule of benefits, the Ontario Health Insurance Plan identification number of the referring physician or registered nurse in the extended class.

8. If the service is a laboratory or other diagnostic procedure listed under “Nuclear Medicine”, “Pulmonary Function Studies” or “Diagnostic Ultrasound” in the schedule of benefits, the Ontario Health Insurance Plan identification number of the referring physician, midwife, registered nurse in the extended class or laboratory.

9. If the service is a consultation in accordance with the schedule of benefits, the Ontario Health Insurance Plan identification number of the referring physician.

10. If the service is an assessment requested by a midwife in accordance with the schedule of benefits, the Ontario Health Insurance Plan identification number of the midwife.

11. If the service was rendered in a mobile independent health facility licensed under the Independent Health Facilities Act or if the service consists of the interpretation of the results of a diagnostic procedure performed in that type of facility, the four character service site indicator assigned by the Plan to identify the location at which the service was rendered.

12. If the service was provided to a person who was an in-patient in a hospital, the date of the person’s admission to the hospital.

13. If the service was rendered by a physician who was issued an Ontario Health Insurance Plan identification number after December 16, 1996, the numeric code assigned by the Ministry of Health and Long-Term Care for the location where the service was rendered.

14. The fee code that, in the circumstances in which the service was rendered, correctly describes the service as specified,

i. in the schedule of benefits, if the service was rendered by a physician,

ii. in Schedule 13, 14 or 15 to this Regulation, if the service was rendered by a member of the Royal College of Dental Surgeons of Ontario,

iii. in Schedule 23 to this Regulation, if the service was rendered by a member of the College of Optometrists of Ontario, and

iv. by the Plan, if the service was rendered by a podiatrist who is a member of the College of Chiropodists of Ontario, by a member of the College of Chiropractors of Ontario, by an osteopath or by a member of the College of Physiotherapists of Ontario in a physiotherapy facility listed in Schedule 5 to this Regulation.

15. In the case of a service other than a laboratory service described in section 22, the amount of the fee being claimed.

16. If it is relevant under the schedule of benefits, the number of times the service was rendered or the number of units claimed for the service.

17. The date the service was rendered.

18. If it is required by the Plan, the diagnostic code specified by the Plan for the service that relates to the insured person’s condition.

19. If the service was an X-ray or laboratory or other diagnostic procedure that was provided in a hospital upon the requisition of an oral and maxillofacial surgeon, the Ontario Health Insurance Plan identification number of the referring oral and maxillofacial surgeon.  O. Reg. 362/02, s. 1.

(2) It is a condition of payment of a claim for an insured service rendered in Ontario to a person who is insured by a health insurance scheme provided by another province or territory of Canada applies that the following information be included:

1. The payment program code “RMB”, the health number or other identification number issued to the person by the health insurance scheme in the other province or territory, the person’s first and last names, the person’s sex and the code for the province or territory in which the person is insured, as specified by the Plan.

2. The Ontario Health Insurance Plan identification number for,

i. the physician who rendered the service, or

ii. the medical director of the laboratory in which the service was rendered.

3. If the service was rendered by a physician or laboratory,

i. the four characters assigned by the Plan that indicate whether the physician practices alone or with one or more other physicians or whether the service was provided in a laboratory, and

ii. the two characters assigned by the Plan that indicate the specialty of the physician, if any, or the specialty of the laboratory director, if any.

4. Any characters assigned by the Ministry of Health and Long-Term Care that identify the payee as a provider or recipient of the insured service.

5. If the service is a diagnostic radiology procedure in accordance with the schedule of benefits, the Ontario Health Insurance Plan identification number of the referring physician.

6. If the service is a laboratory or other diagnostic procedure listed under “Nuclear Medicine”, “Pulmonary Function Studies” or “Diagnostic Ultrasound” in the schedule of benefits, the Ontario Health Insurance Plan identification number of the referring physician.

7. If the service is a consultation in accordance with the schedule of benefits, the Ontario Health Insurance Plan identification number of the referring physician.

8. If the service was rendered in a mobile independent health facility licensed under the Independent Health Facilities Act or the service consists of the interpretation of the result of a diagnostic procedure preformed in that type of facility, the four character service site indicator assigned by the Plan to identify the location at which the service was rendered.

9. If the service was provided to a person who was an in-patient in a hospital, the date of the person’s admission to the hospital.

10. If the service was rendered by a physician, the fee code that, in the circumstances in which the service was rendered, correctly describes the service as specified in the schedule of benefits. 

11. In the case of a service other than a laboratory service described in section 22, the amount of the fee being claimed.

12. If it is relevant under the schedule of benefits, the number of times the service was rendered or the number of units claimed for the service.

13. The date the service was rendered.

14. If it is required by the Plan, the diagnostic code specified by the Plan for the services that relates to the insured person’s condition.  O. Reg. 362/02, s. 1.

(3) In the case of a claim submitted in machine readable form, it is a condition of payment that the claim include the following additional information with respect to each service for which payment is claimed:

1. The transaction identifier code “HE”.

2. The appropriate identification code for the record.

3. The identifier code for the technical specification release.

4. The code for the Ministry of Health and Long-Term Care district office where the service provider is registered for the purpose of claims payments.

5. In the case of a claim that is included in a batch of claims, the date on which the batch of claims was created and the sequence number of the batch.

6. The operator number assigned by the Ministry of Health and Long-Term Care to the person authorized to submit the claim by magnetic cartridge or tape.

7. On the last record in each batch of claims, the total number of each of the record identification codes H, R, and T.  O. Reg. 362/02, s. 1.

38.5 In sections 38.3 and 38.4,

“Ontario Health Insurance Plan identification number” means the number issued by the Plan to a physician, practitioner, registered nurse in the extended class, midwife, medical director of a laboratory licensed under the Laboratory and Specimen Collection Centre Licensing Act, hospital or health facility for the purposes of monitoring, processing and paying claims for payment of insured services and of monitoring and controlling the delivery of insured services.  O. Reg. 362/02, s. 1.

38.6 (1) For the purposes of subsection 27.2 (3) of the Act, the General Manager may require a physician or practitioner to submit accounts directly to the Plan if the physician or practitioner owes money to the Plan, has received the notice referred to in subsection (2) and has not paid the amount specified in the notice within 30 days after the day the notice is given.  O. Reg. 14/01, s. 2.

(2) The General Manager shall give a physician or practitioner 30 days written notice of,

(a) the amount owing to the Plan;

(b) the matter in respect of which the amount is owing; and

(c) the intention of the General Manager to require the physician or practitioner to submit accounts directly to the Plan.  O. Reg. 14/01, s. 2.

Subrogation (Procedural)

39. (1) In this section,

“notice” means notice in writing by personal delivery or mailed by registered mail addressed to the latest post office address of the person to whom the notice is sent as shown on the records of the Plan or, where no address is shown for the person on the records of the Plan, addressed to the person at the person’s post office address as shown on the records of the hospital or other provider of the insured services.  R.R.O. 1990, Reg. 552, s. 39 (1).

(2) Where an insured person commences an action referred to in section 31 of the Act, his or her solicitor shall so inform the General Manager forthwith after issuing the writ and shall act as solicitor for the Plan for the purpose of this section unless notified by the General Manager in writing that he or she is no longer acting for the Plan and in such case the General Manager may appoint another solicitor to represent the Plan.  R.R.O. 1990, Reg. 552, s. 39 (2).

(3) Where the insured person and the General Manager cannot agree as to any offer of settlement or where the solicitor receives conflicting instructions from the General Manager and the insured person, the solicitor may so inform the General Manager in writing and thereupon shall cease to act for the Plan and the General Manager may appoint another solicitor for the purpose of this section.  R.R.O. 1990, Reg. 552, s. 39 (3).

(4) Where the General Manager appoints a solicitor under subsection (2) or (3), the solicitor may participate in the action as fully as if acting for a plaintiff and shall be at liberty to appear at the trial of the action and take part therein in such manner and to such extent as the trial judge may direct but, if, upon the application of the defendant or the insured, it appears that such participation may embarrass or delay the trial of the action, the court may order separate trials, or make such other order as may be expedient.  R.R.O. 1990, Reg. 552, s. 39 (4).

(5) Where the insured person and the General Manager cannot agree as to any offer of settlement in the action the insured person may make a settlement of his or her claims and thereafter the General Manager shall have the conduct of the action.  R.R.O. 1990, Reg. 552, s. 39 (5).

(6) Subject to subsection (8), where an insured person obtains a final judgment in an action in which he or she includes a claim on behalf of the Plan, the Plan shall bear the same proportion of the taxable costs otherwise payable by the insured person, whether on a party and party basis or on a solicitor and client basis, as the recovery made on behalf of the Plan bears to the total recovery of the insured person in the action or, where no recovery is made, as the assessed claim of the Plan bears to the total damages of the insured person assessed by the court.  R.R.O. 1990, Reg. 552, s. 39 (6).

(7) Where a claim is settled, the Plan shall bear the same proportion of the taxable costs otherwise payable by the insured person as is set out in subsection (6) in respect of a recovery made.  R.R.O. 1990, Reg. 552, s. 39 (7).

(8) The costs for which the Plan may be liable to bear a portion under subsection (6) are the costs of bringing the action to the conclusion of the trial only and do not include the costs of any other proceeding without the written consent of the General Manager.  R.R.O. 1990, Reg. 552, s. 39 (8).

(9) If no action has been commenced by an insured person for the recovery of damages arising out of injury or disability within eleven months of the last act or omission that caused or contributed to the injury or disability, or thirty days before the expiration of the limitation period for the action, whichever occurs first, the General Manager,

(a) after notice thereof to the insured person, may commence an action in the name of the Plan or in the name of the insured for damages in the amount of the costs of insured services; and

(b) may effect settlement of the claim without prejudice to the right of the insured person to commence an action to recover for his or her injuries or other damages.  R.R.O. 1990, Reg. 552, s. 39 (9).

(10) The insured person, at any time prior to the trial of an action commenced under clause (9) (a), may, subject to the rules of court, join in such action any additional claims arising out of the same occurrence and thereafter the insured person shall have the conduct of the action as if he or she had commenced it under section 31 of the Act.  R.R.O. 1990, Reg. 552, s. 39 (10).

(11) Where the insured person is a minor or under other disability or has died, the General Manager may commence an action in the name of the Plan for the recovery of the cost of insured services rendered to the person and, in that event, shall forthwith give notice of the institution of such action to the parent or guardian of the minor, or to a lawfully authorized substitute decision maker, or to the personal representative, if any, of the deceased person, and subsections (9) and (10) apply with necessary modifications to such action.  R.R.O. 1990, Reg. 552, s. 39 (11); O. Reg. 13/95, s. 1.

(12) This section does not apply to any action arising out of negligence or other wrongful act or omission in the use or operation of a motor vehicle, where,

(a) the accident resulting in the injuries occurred after the 30th day of November, 1978;

(b) at the time of the accident, the owner of the motor vehicle was insured against liability under a motor vehicle liability policy issued by an insurer set out in Schedule 12; and

(c) at the time of the accident, the motor vehicle was the subject of a permit issued under subsection 7 (7) of the Highway Traffic Act.  R.R.O. 1990, Reg. 552, s. 39 (12).

Table 1 Revoked:  O. Reg. 375/93, s. 10.

Table 2

Item

Column 1

Column 2

Column 3

Column 4

Effective Period

Person Receiving Chronic Care Services

Monthly Co-Payment

Daily Co-Payment

1.

On or after the 1st day of November, 1990, but before the 1st day of February, 1991.

Person with no dependants — maximum estimated income $840.02

Estimated income less $100.00

Estimated income less $100.00, divided by 30.4

 

 

Person with one dependant — maximum aggregate estimated incomes $4,700.00

Aggregate estimated incomes less $2,480.00, divided by 3

Aggregate estimated incomes less $2,480.00, divided by 91.2

 

 

Person with two dependants — maximum aggregate estimated incomes $5,055.00

Aggregate estimated incomes less $2,835.00, divided by 3

Aggregate estimated incomes less $2,835.00, divided by 91.2

 

 

Person with three dependants — maximum aggregate estimated incomes $5,377.00

Aggregate estimated incomes less $3,157.00, divided by 3

Aggregate estimated incomes less $3,157.00, divided by 91.2

 

 

Person with four or more dependants — maximum aggregate estimated incomes $5,666.00

Aggregate estimated incomes less $3,446.00, divided by 3

Aggregate estimated incomes less $3,446.00, divided by 91.2

 

 

Person not referred to elsewhere in this item

$740.02

$24.33

2.

On or after the 1st day of February, 1991, but before the 1st day of May, 1991.

Person with no dependants — maximum estimated income $847.71

Estimated income less $100.00

Estimated income less $100.00, divided by 30.4

 

 

Person with one dependant — maximum aggregate estimated incomes $4,723.00

Aggregate estimated incomes less $2,480.00, divided by 3

Aggregate estimated incomes less $2,480.00, divided by 91.2

 

 

Person with two dependants — maximum aggregate estimated incomes $5,078.00

Aggregate estimated incomes less $2,835.00, divided by 3

Aggregate estimated incomes less $2,835.00, divided by 91.2

 

 

Person with three dependants — maximum aggregate estimated incomes $5,400.00

Aggregate estimated incomes less $3,157.00, divided by 3

Aggregate estimated incomes less $3,157.00, divided by 91.2

 

 

Person with four or more dependants — maximum aggregate estimated incomes $5,689.00

Aggregate estimated incomes less $3,446.00, divided by 3

Aggregate estimated incomes less $3,446.00, divided by 91.2

 

 

Person not referred to elsewhere in this item

$747.71

$24.58

3.

On or after the 1st day of May, 1991, but before the 1st day of August, 1991.

Person with no dependants — maximum estimated income $864.02

Estimated income less $100.00

Estimated income less $100.00, divided by 30.4

 

 

Person with one dependant — maximum aggregate estimated incomes $4,772.00

Aggregate estimated incomes less $2,480.00, divided by 3

Aggregate estimated incomes less $2,480.00, divided by 91.2

 

 

Person with two dependants — maximum aggregate estimated incomes $5,127.00

Aggregate estimated incomes less $2,835.00, divided by 3

Aggregate estimated incomes less $2,835.00, divided by 91.2

 

 

Person with three dependants — maximum aggregate estimated incomes $5,449.00

Aggregate estimated incomes less $3,157.00, divided by 3

Aggregate estimated incomes less $3,157.00, divided by 91.2

 

 

Person with four or more dependants — maximum aggregate estimated incomes $5,738.00

Aggregate estimated incomes less $3,446.00, divided by 3

Aggregate estimated incomes less $3,446.00, divided by 91.2

 

 

Person not referred to elsewhere in this item

$764.02

$25.12

4.

On or after the 1st day of August, 1991, but before the 1st day of November, 1991.

Person with no dependants — maximum estimated income $891.88

Estimated income less $112.00

Estimated income less $112.00, divided by 30.4

 

 

Person with one dependant — maximum aggregate estimated incomes $4,976.00

Aggregate estimated incomes less $2,636.00, divided by 3

Aggregate estimated incomes less $2,636.00, divided by 91.2

 

 

Person with two dependants — maximum aggregate estimated incomes $5,354.00

Aggregate estimated incomes less $3,014.00, divided by 3

Aggregate estimated incomes less $3,014.00, divided by 91.2

 

 

Person with three dependants — maximum aggregate estimated incomes $5,696.00

Aggregate estimated incomes less $3,356.00, divided by 3

Aggregate estimated incomes less $3,356.00, divided by 91.2

 

 

Person with four or more dependants — maximum aggregate estimated incomes $6,003.00

Aggregate estimated incomes less $3,663.00, divided by 3

Aggregate estimated incomes less $3,663.00, divided by 91.2

 

 

Person not referred to elsewhere in this item

$779.88

$25.64

5.

On or after the 1st day of November, 1991, but before the 1st day of February, 1992.

Person with no dependants — maximum estimated income $899.97

Estimated income less $112.00

Estimated income less $112.00, divided by 30.4

 

 

Person with one dependant — maximum aggregate estimated incomes $5,000.00

Aggregate estimated incomes less $2,636.00, divided by 3

Aggregate estimated incomes less $2,636.00, divided by 91.2

 

 

Person with two dependants — maximum aggregate estimated incomes $5,378.00

Aggregate estimated incomes less $3,014.00, divided by 3

Aggregate estimated incomes less $3,014.00, divided by 91.2

 

 

Person with three dependants — maximum aggregate estimated incomes $5,720.00

Aggregate estimated incomes less $3,356.00, divided by 3

Aggregate estimated incomes less $3,356.00, divided by 91.2

 

 

Person with four or more dependants — maximum aggregate estimated incomes $6,027.00

Aggregate estimated incomes less $3,663.00, divided by 3

Aggregate estimated incomes less $3,663.00, divided by 91.2

 

 

Person not referred to elsewhere in this item

$787.97

$25.91

6.

On or after the 1st day of February, 1992, but before the 1st day of May, 1992.

Person with no dependants — maximum estimated income $901.61

Estimated income less $112.00

Estimated income less $112.00, divided by 30.4

 

 

Person with one dependant — maximum aggregate estimated incomes $5,005.00

Aggregate estimated incomes less $2,636.00, divided by 3

Aggregate estimated incomes less $2,636.00, divided by 91.2

 

 

Person with two dependants — maximum aggregate estimated incomes $5,383.00

Aggregate estimated incomes less $3,014.00, divided by 3

Aggregate estimated incomes less $3,014.00, divided by 91.2

 

 

Person with three dependants — maximum aggregate estimated incomes $5,725.00

Aggregate estimated incomes less $3,356.00, divided by 3

Aggregate estimated incomes less $3,356.00, divided by 91.2

 

 

Person with four or more dependants — maximum aggregate estimated incomes $6,032.00

Aggregate estimated incomes less $3,663.00, divided by 3

Aggregate estimated incomes less $3,663.00, divided by 91.2

 

 

Person not referred to elsewhere in this item

$789.61

$25.96

7.

On or after the 1st day of May, 1992, but before the 1st day of August, 1992.

Person with no dependants — maximum estimated income $902.42

Estimated income less $112.00

Estimated income less $112.00, divided by 30.4

 

 

Person with one dependant — maximum aggregate estimated incomes $5,007.00

Aggregate estimated incomes less $2,636.00, divided by 3

Aggregate estimated incomes less $2,636.00, divided by 91.2

 

 

Person with two dependants — maximum aggregate estimated incomes $5,385.00

Aggregate estimated incomes less $3,014.00, divided by 3

Aggregate estimated incomes less $3,014.00, divided by 91.2

 

 

Person with three dependants — maximum aggregate estimated incomes $5,727.00

Aggregate estimated incomes less $3,356.00, divided by 3

Aggregate estimated incomes less $3,356.00, divided by 91.2

 

 

Person with four or more dependants — maximum aggregate estimated incomes $6,034.00

Aggregate estimated incomes less $3,663.00, divided by 3

Aggregate estimated incomes less $3,663.00, divided by 91.2

 

 

Person not referred to elsewhere in this item

$790.42

$25.99

8.

On or after the 1st day of August, 1992, but before the 1st day of November, 1992.

Person with no dependants — maximum estimated income $906.51

Estimated income less $112.00

Estimated income less $112.00, divided by 30.4

 

 

Person with one dependant — maximum aggregate estimated incomes $5,064.00

Aggregate estimated incomes less $2,680.00, divided by 3

Aggregate estimated incomes less $2,680.00, divided by 91.2

 

 

Person with two dependants — maximum aggregate estimated incomes $5,448.00

Aggregate estimated incomes less $3,064.00, divided by 3

Aggregate estimated incomes less $3,064.00, divided by 91.2

 

 

Person with three dependants — maximum aggregate estimated incomes $5,796.00

Aggregate estimated incomes less $3,412.00, divided by 3

Aggregate estimated incomes less $3,412.00, divided by 91.2

 

 

Person with four or more dependants — maximum aggregate estimated incomes $6,108.00

Aggregate estimated incomes less $3,724.00, divided by 3

Aggregate estimated incomes less $3,724.00, divided by 91.2

 

 

Person not referred to elsewhere in this item

$794.51

$26.12

9.

On or after the 1st day of November, 1992, but before the 1st day of February, 1993.

Person with no dependants — maximum estimated income $910.63

Estimated income less $112.00

Estimated income less $112.00, divided by 30.4

 

 

Person with one dependant — maximum aggregate estimated incomes $5,076.00

Aggregate estimated incomes less $2,680.00, divided by 3

Aggregate estimated incomes less $2,680.00, divided by 91.2

 

 

Person with two dependants — maximum aggregate estimated incomes $5,460.00

Aggregate estimated incomes less $3,064.00, divided by 3

Aggregate estimated incomes less $3,064.00, divided by 91.2

 

 

Person with three dependants — maximum aggregate estimated incomes $5,808.00

Aggregate estimated incomes less $3,412.00, divided by 3

Aggregate estimated incomes less $3,412.00, divided by 91.2

 

 

Person with four or more dependants — maximum aggregate estimated incomes $6,120.00

Aggregate estimated incomes less $3,724.00, divided by 3

Aggregate estimated incomes less $3,724.00, divided by 91.2

 

 

Person not referred to elsewhere in this item.

$798.63

$26.26

10.

On or after the 1st day of February, 1993, but before the 1st day of May, 1993

Person with no dependants — maximum estimated income $912.29

Estimated income less $112.00

Estimated income less $112.00, divided by 30.4

 

 

Person with one dependant — maximum aggregate estimated incomes $5,081.00

Aggregate estimated incomes less $2,680.00, divided by 3

Aggregate estimated incomes less $2,680.00, divided by 91.2

 

 

Person with two dependants — maximum aggregate estimated incomes $5,465.00

Aggregate estimated incomes less $3,064.00, divided by 3

Aggregate estimated incomes less $3,064.00, divided by 91.2

 

 

Person with three dependants — maximum aggregate estimated incomes $5,813.00

Aggregate estimated incomes less $3,412.00, divided by 3

Aggregate estimated incomes less $3,412.00, divided by 91.2

 

 

Person with four or more dependants — maximum aggregate estimated incomes $6,125.00

Aggregate estimated incomes less $3,724.00, divided by 3

Aggregate estimated incomes less $3,724.00, divided by 91.2

 

 

Person not referred to elsewhere in this item

$800.29

$26.31

11.

On or after May 1, 1993, but before August 1, 1993

Person with no dependants — maximum estimated income $918.09

Estimated income less $112.00

Estimated income less $112.00, divided by 30.4

 

 

Person with one dependant — maximum aggregate estimated incomes $5,098.00

Aggregate estimated incomes less $2,680.00, divided by 3

Aggregate estimated incomes less $2,680.00, divided by 91.2

 

 

Person with two dependants — maximum aggregate estimated incomes $5,482.00

Aggregate estimated incomes less $3,064.00, divided by 3

Aggregate estimated incomes less $3,064.00, divided by 91.2

 

 

Person with three dependants — maximum aggregate estimated incomes $5,830.00

Aggregate estimated incomes less $3,412.00, divided by 3

Aggregate estimated incomes less $3,412.00, divided by 91.2

 

 

Person with four or more dependants — maximum aggregate estimated incomes $6,142.00

Aggregate estimated incomes less $3,724.00, divided by 3

Aggregate estimated incomes less $3,724.00, divided by 91.2

 

 

Person not referred to elsewhere in this item

$806.09

$26.50

12.

On or after August 1, 1993, but before November 1, 1993

Person with no dependants — maximum estimated income $922.27

Estimated income less $112.00

Estimated income less $112.00, divided by 30.4

 

 

Person with one dependant — maximum aggregate estimated incomes $5,159.00

Aggregate estimated incomes less $2,728.00, divided by 3

Aggregate estimated incomes less $2,728.00, divided by 91.2

 

 

Person with two dependants — maximum aggregate estimated incomes $5,550.00

Aggregate estimated incomes less $3,119.00, divided by 3

Aggregate estimated incomes less $3,119.00, divided by 91.2

 

 

Person with three dependants — maximum aggregate estimated incomes $5,904.00

Aggregate estimated incomes less $3,474.00, divided by 3

Aggregate estimated incomes less $3,474.00, divided by 91.2

 

 

Person with four or more dependants — maximum aggregate estimated incomes $6,222.00

Aggregate estimated incomes less $3,791.00, divided by 3

Aggregate estimated incomes less $3,791.00, divided by 91.2

 

 

Person not referred to elsewhere in this item

$810.27

$26.64

13.

On or after November 1, 1993 but before February 1, 1994

Person with no dependants — maximum estimated income $924.79

Estimated income less $112.00

Estimated income less $112.00, divided by 30.4

 

 

Person with one dependant — maximum aggregate estimated incomes $5,167.00

Aggregate estimated incomes less $2,728.00, divided by 3

Aggregate estimated incomes less $2,728.00, divided by 91.2

 

 

Person with two dependants — maximum aggregate estimated incomes $5,558.00

Aggregate estimated incomes less $3,119.00, divided by 3

Aggregate estimated incomes less $3,119.00, divided by 91.2

 

 

Person with three dependants — maximum aggregate estimated incomes $5,913.00

Aggregate estimated incomes less $3,474.00, divided by 3

Aggregate estimated incomes less $3,474.00, divided by 91.2

 

 

Person with four or more dependants — maximum aggregate estimated incomes $6,230.00

Aggregate estimated incomes less $3,791.00, divided by 3

Aggregate estimated incomes less $3,791.00, divided by 91.2

 

 

Person not referred to elsewhere in this item

$812.79

$26.72

14.

On or after February 1, 1994, but before May 1, 1994

Person with no dependants — maximum estimated income $927.31

Estimated income less $112.00

Estimated income less $112.00, divided by 30.4

 

 

Person with one dependant — maximum aggregate estimated incomes $5,174.00

Aggregate estimated incomes less $2,728.00, divided by 3

Aggregate estimated incomes less $2,728.00, divided by 91.2

 

 

Person with two dependants — maximum aggregate estimated incomes $5,565.00

Aggregate estimated incomes less $3,119.00, divided by 3

Aggregate estimated incomes less $3,119.00, divided by 91.2

 

 

Person with three dependants — maximum aggregate estimated incomes $5,920.00

Aggregate estimated incomes less $3,474.00, divided by 3

Aggregate estimated incomes less $3,474.00, divided by 91.2

 

 

Person with four or more dependants — maximum aggregate estimated incomes $6,237.00

Aggregate estimated incomes less $3,791.00, divided by 3

Aggregate estimated incomes less $3,791.00, divided by 91.2

 

 

Person not referred to elsewhere in this item

$815.31

$26.80

15.

On or after May 1, 1994 but before August 1, 1994

Person with no dependants — maximum estimated income $931.53

Estimated income less $112.00

Estimated income less $112.00, divided by 30.4

 

 

Person with one dependant — maximum aggregate estimated incomes $5,187.00

Aggregate estimated incomes less $2,728.00, divided by 3

Aggregate estimated incomes less $2,728.00, divided by 91.2

 

 

Person with two dependants — maximum aggregate estimated incomes $5,578.00

Aggregate estimated incomes less $3,119.00, divided by 3

Aggregate estimated incomes less $3,119.00, divided by 91.2

 

 

Person with three dependants — maximum aggregate estimated incomes $5,933.00

Aggregate estimated incomes less $3,474.00, divided by 3

Aggregate estimated incomes less $3,474.00, divided by 91.2

 

 

Person with four or more dependants — maximum aggregate estimated incomes $6,250.00

Aggregate estimated incomes less $3,791.00, divided by 3

Aggregate estimated incomes less $3,791.00, divided by 91.2

 

 

Person not referred to elsewhere in this item

$819.53

$26.94

16.

On or after August 1, 1994 but before January 1, 1997

Person with no dependants — maximum estimated income $931.53

Estimated income less $112.00

Estimated income less $112.00, divided by 30.4

 

 

Person with one dependant — maximum aggregate estimated incomes $5,193.00

Aggregate estimated incomes less $2,734.00, divided by 3

Aggregate estimated incomes less $2,734.00, divided by 91.2

 

 

Person with two dependants — maximum aggregate estimated incomes $5,585.00

Aggregate estimated incomes less $3,126.00, divided by 3

Aggregate estimated incomes less $3,126.00, divided by 91.2

 

 

Person with three dependants — maximum aggregate estimated incomes $5,941.00

Aggregate estimated incomes less $3,482.00, divided by 3

Aggregate estimated incomes less $3,482.00, divided by 91.2

 

 

Person with four or more dependants — maximum aggregate estimated incomes $6,259.00

Aggregate estimated incomes less $3,800.00, divided by 3

Aggregate estimated incomes less $3,800.00, divided by 91.2

 

 

Person not referred to elsewhere in this item

$819.53

$26.94

17.

On or after January 1, 1997 but before July 1, 1997

Person with no dependants — maximum estimated income $1,337.62

Estimated income less $112.00

Estimated income less $112.00, divided by 30.4

 

 

Person with one dependant — maximum aggregate estimated incomes $6,518.00

Aggregate estimated incomes less $2,841.00, divided by 3

Aggregate estimated incomes less $2,841.00, divided by 91.2

 

 

Person with two dependants — maximum aggregate estimated incomes $6,925.00

Aggregate estimated incomes less $3,248.00, divided by 3

Aggregate estimated incomes less $3,248.00, divided by 91.2

 

 

Person with three dependants — maximum aggregate estimated incomes $7,295.00

Aggregate estimated incomes less $3,618.00, divided by 3

Aggregate estimated incomes less $3,618.00, divided by 91.2

 

 

Person with four or more dependants — maximum aggregate estimated incomes $7,626.00

Aggregate estimated incomes less $3,949.00, divided by 3

Aggregate estimated incomes less $3,949.00, divided by 91.2

 

 

Person not referred to elsewhere in this item

$1,225.62

$40.29

18.

On or after July 1, 1997 but before July 1, 1998

Person with no dependants — maximum estimated income $1,364.04

Estimated income less $112.00

Estimated income less $112.00, divided by 30.4

 

 

Person with one dependant — maximum aggregate estimated incomes $6,659.00

Aggregate estimated incomes less $2,902.00, divided by 3

Aggregate estimated incomes less $2,902.00, divided by 91.2

 

 

Person with two dependants — maximum aggregate estimated incomes $7,075.00

Aggregate estimated incomes less $3,318.00, divided by 3

Aggregate estimated incomes less $3,318.00, divided by 91.2

 

 

Person with three dependants — maximum aggregate estimated incomes $7,453.00

Aggregate estimated incomes less $3,696.00, divided by 3

Aggregate estimated incomes less $3,696.00, divided by 91.2

 

 

Person with four or more dependants — maximum aggregate estimated incomes $7,791.00

Aggregate estimated incomes less $4,034.00, divided by 3

Aggregate estimated incomes less $4,034.00, divided by 91.2

 

 

Person not referred to elsewhere in this item

$1,252.04

$41.16

19.

On or after July 1, 1998 but before August 1, 1999

Person with no dependants — maximum estimated income $1,376.01

Estimated income less $112.00

Estimated income less $112.00, divided by 30.4

 

 

Person with one dependant — maximum aggregate estimated incomes $6,722.00

Aggregate estimated incomes less $2,929.00, divided by 3

Aggregate estimated incomes less $2,929.00, divided by 91.2

 

 

Person with two dependants — maximum aggregate estimated incomes $7,142.00

Aggregate estimated incomes less $3,349.00, divided by 3

Aggregate estimated incomes less $3,349.00, divided by 91.2

 

 

Person with three dependants — maximum aggregate estimated incomes $7,524.00

Aggregate estimated incomes less $3,731.00, divided by 3

Aggregate estimated incomes less $3,731.00, divided by 91.2

 

 

Person with four or more dependants — maximum aggregate estimated incomes $7,865.00

Aggregate estimated incomes less $4,072.00, divided by 3

Aggregate estimated incomes less $4,072.00, divided by 91.2

 

 

Person not referred to elsewhere in this item

$1,264.01

$41.56

20.

On or after August 1, 1999 but before July 1, 2000

Person with no dependants — maximum estimated income $1,389.95

Estimated income less $112.00

Estimated income less $112.00, divided by 30.4

 

 

Person with one dependant — maximum aggregate estimated incomes $6,741.00

Aggregate estimated incomes less $2,948.00, divided by 3

Aggregate estimated incomes less $2,948.00, divided by 91.2

 

 

Person with two dependants — maximum aggregate estimated incomes $7,164.00

Aggregate estimated incomes less $3,371.00, divided by 3

Aggregate estimated incomes less $3,371.00, divided by 91.2

 

 

Person with three dependants — maximum aggregate estimated incomes $7,548.00

Aggregate estimated incomes less $3,755.00, divided by 3

Aggregate estimated incomes less $3,755.00, divided by 91.2

 

 

Person with four or more dependants — maximum aggregate estimated incomes $7,891.00

Aggregate estimated incomes less $4,098.00, divided by 3

Aggregate estimated incomes less $4,098.00, divided by 91.2

 

 

Person not referred to elsewhere in this item

$1,277.95

$42.01

21.

On or after July 1, 2000 but before July 1, 2001

Person with no dependants — maximum estimated income $1,420.89

Estimated income less $112.00

Estimated income less $112.00, divided by 30.4

 

 

Person with one dependant — maximum aggregate estimated incomes $6,943.00

Aggregate estimated incomes less $3,016.00, divided by 3

Aggregate estimated incomes less $3,016.00, divided by 91.2

 

 

Person with two dependants — maximum aggregate estimated incomes $7,375.00

Aggregate estimated incomes less $3,448.00, divided by 3

Aggregate estimated incomes less $3,448.00, divided by 91.2

 

 

Person with three dependants — maximum aggregate estimated incomes $7,768.00

Aggregate estimated incomes less $3,841.00, divided by 3

Aggregate estimated incomes less $3,841.00, divided by 91.2

 

 

Person with four or more dependants — maximum aggregate estimated incomes $8,119.00

Aggregate estimated incomes less $4,192.00, divided by 3

Aggregate estimated incomes less $4,192.00, divided by 91.2

 

 

Person not referred to elsewhere in this item

$1,308.89

$43.03

22.

On or after July 1, 2001 but before September 1, 2002

Person with no dependants — maximum estimated income $1,465.73

Estimated income less $112.00

Estimated income less $112.00, divided by 30.4

 

 

Person with one dependant — maximum aggregate estimated incomes $7,173.00

Aggregate estimated incomes less $3,111.00, divided by 3

Aggregate estimated incomes less $3,111.00, divided by 91.2

 

 

Person with two dependants — maximum aggregate estimated incomes $7,618.00

Aggregate estimated incomes less $3,556.00, divided by 3

Aggregate estimated incomes less $3,556.00, divided by 91.2

 

 

Person with three dependants — maximum aggregate estimated incomes $8,024.00

Aggregate estimated incomes less $3,962.00, divided by 3

Aggregate estimated incomes less $3,962.00, divided by 91.2

 

 

Person with four or more dependants — maximum aggregate estimated incomes $8,386.00

Aggregate estimated incomes less $4,324.00, divided by 3

Aggregate estimated incomes less $4,324.00, divided by 91.2

 

 

Person not referred to elsewhere in this item

$1,353.73

$44.51

23.

On or after September 1, 2002 but before July 1, 2003

Person with no dependants — maximum estimated income $1,496.74

Estimated income less $112.00

Estimated income less $112.00, divided by 30.4167

 

 

Person with one dependant — maximum aggregate estimated incomes $7,492.00

Aggregate estimated incomes less $3,155.00, divided by 3

Aggregate estimated incomes less $3,155.00, divided by 91.2

 

 

Person with two dependants — maximum aggregate estimated incomes $7,944.00

Aggregate estimated incomes less $3,607.00, divided by 3

Aggregate estimated incomes less $3,607.00, divided by 91.2

 

 

Person with three dependants — maximum aggregate estimated incomes $8,355.00

Aggregate estimated incomes less $4,018.00, divided by 3

Aggregate estimated incomes less $4,018.00, divided by 91.2

 

 

Person with four or more dependants — maximum aggregate estimated incomes $8,723.007

Aggregate estimated incomes less $4,386.00, divided by 3

Aggregate estimated incomes less $4,386.00, divided by 91.2

 

 

Person not referred to elsewhere in this item

$1,445.71

$47.53

24.

On or after July 1, 2003

Person with no dependants — maximum estimated income $1,532.15

Estimated income less $112.00

Estimated income less $112.00, divided by 30.4167

 

 

 

Person with one dependant — maximum aggregate estimated incomes $7,717.00

Aggregate estimated incomes less $3,273.00, divided by 3

Aggregate estimated incomes less $3,273.00, divided by 91.2

 

 

 

Person with two dependants — maximum aggregate estimated incomes $8,186.00

Aggregate estimated incomes less $3,742.00, divided by 3

Aggregate estimated incomes less $3,742.00, divided by 91.2

 

 

 

Person with three dependants — maximum aggregate estimated incomes $8,612.00

Aggregate estimated incomes less $4,168.00, divided by 3

Aggregate estimated incomes less $4,168.00, divided by 91.2

 

 

 

Person with four or more dependants — maximum aggregate estimated incomes $8,994.00

Aggregate estimated incomes less $4,550.00, divided by 3

Aggregate estimated incomes less $4,550.00, divided by 91.2

 

 

 

Person not referred to elsewhere in this item

$1,480.99

$48.69

 

R.R.O. 1990, Reg. 552, Table 2; O. Reg. 9/91, s. 2; O. Reg. 161/91, s. 2; O. Reg. 435/91, s. 3; O. Reg. 656/91, s. 2; O. Reg. 36/92, s. 2; O. Reg. 215/92, s. 2; O. Reg. 408/92, s. 3; O. Reg. 655/92, s. 2; O. Reg. 33/93, s. 2; O. Reg. 203/93, s. 2; O. Reg. 430/93, s. 1; O. Reg.736/93, s. 1; O. Reg. 19/94, s. 1; O. Reg. 302/94, s. 1; O. Reg. 502/94, s. 2; O. Reg. 496/96, s. 4; O. Reg. 197/97, ss. 2, 3; O. Reg. 236/98, s. 1; O. Reg. 368/99, s. 1; O. Reg. 300/00, s. 1; O. Reg. 183/01, s. 1; O. Reg. 234/02, s. 1; O. Reg. 221/03, s. 4.

Table 3 Revoked:  O. Reg. 375/93, s. 10.

TABLE 4

Item

Column 1

Column 2

Column 3

Column 4

1.

On or after April 1, 1991

On or after April 1, 1991

51.7

38.7

O. Reg. 2/98, s. 3.

TABLE 5

Item

Column 1

Column 2

Column 3

Column 4

Column 5

1.

On or after April 1, 1991

On or after April 1, 1991

51.7

38.7

25.8

O. Reg. 2/98, s. 4.

TABLE 6

Column 1

Column 2

From and including April 1, 1991 to and including March 31, 1992

From and including April 1, 1992

O. Reg. 322/93, s. 4.

Schedule 1

PART I

Active Treatment Hospitals

Item

Location

Name of Hospital

1.

Don Mills

One Medical Place

2.

Scarborough

Bellwood Health Services Inc.

3.

Thornhill

Shouldice Hospital Limited

4.

Toronto

Institute of Traumatic, Plastic and Restorative Surgery

PART II

Chronic Care Hospitals

Item

Location

Name of Hospital

1.

Lakefield

Lakefield Private Hospital

2.

London

Grace Villa Hospital

3.

Penetanguishene

Beechwood Private Hospital

4.

Perth

Wiseman’s Private Hospital

5.

Willowdale

St. Joseph’s Infirmary

6.

Woodstock

Woodstock Private Hospital

O. Reg. 306/01, s. 1.

Schedule 2
FEDERAL HOSPITALS

PART I

Active Treatment Hospitals:

Item

Location

Name of Hospital

1.

Attawapiskat

Nursing Station

2.

Big Trout Lake

Nursing Station

3.

Fort Albany (on the Island of St. Clair)

Nursing Station

4.

Fort Hope

Nursing Station

5.

Kashechewan

Nursing Station

6.

Lac Seul

Nursing Station

7.

Lansdowne House

Nursing Station

8.

Manitowaning

Manitowaning Hospital

9.

Moose Factory

Moose Factory General Hospital

10.

Moosonee

R.C.A.F. Hospital

11.

Ohsweken

Lady Willingdon Hospital

12.

Osnaburgh

Nursing Station

13.

Ottawa

National Defence Medical Centre

14.

Pikangikum

Nursing Station

15.

Round Lake

Nursing Station

16.

Sandy Lake

Nursing Station

17.

Sioux Lookout

Sioux Lookout Indian Hospital

18.

Winisk

Nursing Station

PART II

Chronic Care Hospitals:

Item

Location

Name of Hospital

1.

Ottawa

National Defence Medical Centre (Chronic Unit)

R.R.O. 1990, Reg. 552, Sched. 2.

Schedule 3 Revoked:  O. Reg. 375/93, s. 11.

Schedule 4
HOSPITALS FOR PSYCHIATRIC ILLNESSES AND FOR ALCOHOLISM AND DRUG ADDICTION

PART I

Public Hospitals for Psychiatric Illnesses:

Item

Location

Name of Hospital

1.

Toronto

Addiction and Mental Health Services Corporation-Clarke Institute Site

2.

Toronto

Addiction and Mental Health Services Corporation-Queen Street Mental Health Centre Site

PART II

Public Hospitals for Alcoholism and Drug Addiction:

Item

Location

Name of Hospital

1.

Toronto

Addiction and Mental Health Services Corporation-Donwood Site

2.

Toronto

Addiction and Mental Health Services Corporation-Addiction Research Foundation Site

O. Reg. 111/98, s. 2.

Schedule 5
APPROVED PHYSIOTHERAPY FACILITIES

PART I

Physiotherapy Facilities approved to provide Office and Home Treatment:

Item

Location

Name

1.

Aurora

Coxwell Physiotherapy Centre

2.

Barrie

Barrie Physiotherapy Clinic

3.

Belleville

Quinte Physiotherapy Clinic

4.

Bramalea

Evans Physiotherapy Clinic

5.

Brampton

North Brampton Physiotherapy

6.

Brantford

Greystone Physiotherapy Clinic

7.

Brantford

Scott Physiotherapy Clinic

8.

Brechin

Mr. B. MacIntyre

9.

Burlington

Brant 730 Physiotherapy

10.

Cambridge

The Harrington Physiotherapy Clinic

11.

Cornwall

Cornwall Physiotherapy Clinic

12.

Durham

Bluewater Physiotherapy Clinic

13.

Etobicoke

Four Seasons Physiotherapy

14.

Etobicoke

Kingsway Physiotherapy

15.

Etobicoke

Queensway Physiotherapy Centre

16.

Etobicoke

Six Points Physiotherapy

17.

Guelph

Stone Road Mall Physiotherapy

18.

Hamilton

First Place Physiotherapy

19.

Hamilton

Mountain Physiotherapy

20.

Hamilton

Park Physical Therapy

21.

Hamilton

Physiotherapy Services

22.

Revoked:  O. Reg. 142/97, s. 1 (1).

23.

Hamilton

68 Charlton Avenue West Ltd.

24.

Hamilton

Steel City Physiotherapy

25.

Hamilton

The Hamilton Physiotherapy Clinic

26.

Hamilton

Upper Ottawa Physiotherapy

27.

Hamilton

West End Physiotherapy Clinic

28.

Kingston

Blaser’s Physiotherapy Clinic

29.

Kitchener

Kitchener Physiotherapy Centre

30.

Lindsay

Lindsay Physiotherapy Services

31.

London

Mr. J. Salo

32.

London

The London Physical Therapy Clinic

33.

Midland

Mrs. M. Thomson

34.

North York

Canadian Physiotherapy Centre

35.

North York

Lawrence Curlew Physiotherapy

36.

North York

Kinesis Physical Therapy

37.

North York

Freda Naiman Physiotherapy

38.

North York

North East Physiotherapy Services

39.

North York

North Toronto Physiotherapy Centre

40.

North York

Physiotherapy Associates

41.

North York

The Physiotherapy Centre

42.

North York

Willowdale Physiotherapy Clinic

43.

Oakville

Oakville Physiotherapy Centre

44.

Oshawa

Central Park Physiotherapy Centre

45.

Oshawa

Mr. G. F. Monckton

46.

Oshawa

Oshawa Clinic

47.

Ottawa

Mrs. A. G. Arnold

48.

Ottawa

Cleave Physiotherapy

49.

Ottawa

The Sports Therapy Clinic

50.

Ottawa

Regional Physiotherapy Clinic

51.

Ottawa

The Ottawa and District Physiotherapy Clinic

52.

Pembroke

Pembroke Physiotherapy Clinic

53.

Sarnia

Lambton County Physiotherapy Services

54.

Sarnia

Sam Shuqair Physiotherapy

55.

Sault Ste. Marie

Sault Physiotherapy Centre

56.

Sault Ste. Marie

Sault Ste. Marie & District Group Health Association

57.

Scarborough

Central Scarborough Physiotherapy Clinic

58.

Scarborough

Scarborough-South Physiotherapy Centre

59.

Scarborough

Yee Hong Rehabilitation Centre

60.

Scarborough

Miss M. W. Seaver

61.

Simcoe

Elgin Ave. Physiotherapy

62.

Revoked:  O. Reg. 752/94, s. 1 (1).

63.

Stoney Creek

Queenston Physiotherapy

64.

Stouffville

Stouffville Physiotherapy Clinic

65.

Thorold

Thorold Medical Clinic

66.

Tillsonburg

Tillsonburg Physiotherapy Clinic

67.

Toronto

Albany Physiotherapy Clinic

68.

Toronto

Bloor Medical Clinic

69.

Toronto

Davisville Physiotherapy Centre

70.

Toronto

Eglinton-Bayview Physiotherapy

71.

Toronto

Mrs. M. Gacich

72.

Toronto

High Park Physiotherapy

73.

Toronto

Community Physiotherapy Clinic

74.

Toronto

Miss D. Madgett

75.

Toronto

Main & Gerrard Physiotherapy Clinic

76.

Toronto

Parkdale Physiotherapy Associates

77.

Toronto

Physical Therapy Services

78.

Toronto

Physiotherapy Ki Li

79.

Toronto

Kings Professional Physiotherapy Clinic

80.

Toronto

Brenda L. Rusnak

81.

Toronto

St. Clair-Dufferin Medical Centre

82.

Toronto

Scarborough North Physiotherapy Clinic

83.

Toronto

St. George Physiotherapy Clinic

84.

Toronto

Shelton Physiotherapy Associates

84.0.1

Waterdown

King East Physiotherapy

84.1

Welland

Physiotherapy Rehabilitation Centre

85.

Weston

Weston Physiotherapy Centre

86.

Windsor

Joseph Berkeley Ltd.

87.

Windsor

Windsor Physiotherapy Services

88.

Windsor

Wardle’s Physiotherapy Clinic

89.

York

York Physiotherapy and Rehabilitation Centre

90.

York

Humber Physiotherapy Services

91.

York

Professional Physiotherapy Centre

PART II

Physiotherapy Facilities approved to provide Home Treatment only:

Item

Location

Name

1.

Ajax

Mrs. E. Boyes

2.

Bala

Mrs. J. Goltz

3.

Cherrywood

Pemberton-Piggott Physiotherapy

4.

Coldwater

Mrs. Jessie LeGard

5.

Emo

Mrs. Elinor James

6.

Etobicoke

Mrs. D. A. Bertolin

7.

Etobicoke

Mrs. M. J. Howell

8.

Fort Frances

Mrs. G. E. Polenske

9.

Georgetown

Mrs. J. Davis

10.

Guelph

Mr. J. Flavell

11.

Kingston

Mrs. H. Kiwala

12.

Lakefield

Mrs. Ann Harris

13.

London

Mrs. C. Kimmins

14.

Maple

Mr. D. Creighton

15.

Mississauga

Mrs. M. Clarkson

16.

North York

Mrs. H. Blythe

17.

North York

Mrs. D. Daniel

18.

North York

Mrs. E. A. Fricker

19.

North York

Mrs. H. Hargraft

20.

North York

Mrs. G. Reeves

21.

Ottawa

Mobile Physiotherapy

22.

Scarborough

Mrs. M. Marsh

23.

Stratford

Mr. W. Naumenko

24.

Thedford

Mrs. B. Sercombe

25.

Toronto

Mrs. M. Kerr

26.

Toronto

Miss M. Leslie

27.

Toronto

Mrs. V. H. Richardson

28.

Toronto

Mrs. Hanna Scheutze

29.

Wallaceburg

Mrs. H. Metcalfe

R.R.O. 1990, Reg. 552, Sched. 5; O. Reg. 64/91, s. 1; O. Reg. 104/91, s. 1; O. Reg. 209/91, s. 1; O. Reg. 668/92, s. 1; O. Reg. 255/94, s. 1; O. Reg. 752/94, s. 1; O. Reg. 543/95, s. 1; O. Reg. 142/97, s. 1; O. Reg. 567/98, s. 1; O. Reg. 108/99, s. 1; O. Reg. 490/99, s. 1; O. Reg. 314/02, s. 1.

Schedule 6
REHABILITATION AND CRIPPLED CHILDREN’S CENTRES

PART I

Centres providing Occupational Therapy:

Item

Location

Name of Centre

1.

Brantford

Lansdowne Children’s Centre

2.

Hamilton

Hamilton District Society for Crippled Children

3.

Kitchener

Kitchener-Waterloo Rotary Children’s Centre

4.

London

Thames Valley Children’s Centre

5.

Mississauga

Credit Valley Treatment Centre for Children

6.

Oshawa

Simcoe Hall Children’s Centre

7.

Ottawa

The Ottawa Crippled Children’s Treatment Centre

8.

Peterborough

Five Counties Children’s Centre

9.

St. Catharines

Niagara Peninsula Crippled Children’s Treatment Centre

10.

St. Catharines

Niagara Peninsula Rehabilitation Centre

11.

Sarnia

Sarnia and District Children’s Treatment Centre

12.

Sudbury

Laurentian Hospital Children’s Treatment Centre

13.

Thunder Bay

George Jeffrey Children’s Treatment Centre

14.

Toronto

Ontario Crippled Children’s Centre

15.

Toronto

Toronto Rehabilitation Centre

16.

Windsor

The Children’s Rehabilitation Centre of Essex County

PART II

Centres providing Physiotherapy:

Item

Location

Name of Centre

1.

Brantford

Lansdowne Children’s Centre

2.

Chatham

Kent County Children’s Treatment Centre

3.

Hamilton

Hamilton District Society for Crippled Children

4.

Kitchener

Kitchener-Waterloo Rotary Children’s Centre

5.

London

Thames Valley Children’s Centre

6.

Mississauga

Credit Valley Treatment Centre for Children

7.

Oshawa

Simcoe Hall Children’s Centre

8.

Ottawa

The Ottawa Crippled Children’s Treatment Centre

9.

Peterborough

Five Counties Children’s Centre

10.

St. Catharines

Niagara Peninsula Crippled Children’s Treatment Centre

11.

St. Catharines

Niagara Peninsula Rehabilitation Centre

12.

Sarnia

Sarnia and District Children’s Treatment Centre

13.

Sault Ste. Marie

Sault Ste. Marie Children’s Rehabilitation Centre

14.

Sudbury

Laurentian Hospital Children’s Treatment Centre

15.

Thunder Bay

George Jeffrey Children’s Treatment Centre

16.

Toronto

The Canadian Arthritis and Rheumatism Society

17.

Toronto

Ontario Crippled Children’s Centre

18.

Toronto

Toronto Rehabilitation Centre

19.

Windsor

The Children’s Rehabilitation Centre of Essex County

PART III

Centres providing Speech Therapy:

Item

Location

Name of Centre

1.

Brantford

Lansdowne Children’s Centre

2.

Chatham

Kent County Children’s Treatment Centre

3.

Hamilton

Hamilton District Society for Crippled Children

4.

Kitchener

Kitchener-Waterloo Rotary Children’s Centre

5.

London

Thames Valley Children’s Centre

6.

Mississauga

Credit Valley Treatment Centre for Children

7.

Oshawa

Simcoe Hall Children’s Centre

8.

Ottawa

The Ottawa Crippled Children’s Treatment Centre

9.

Peterborough

Five Counties Children’s Centre

10.

St. Catharines

Niagara Peninsula Crippled Children’s Treatment Centre

11.

St. Catharines

Niagara Peninsula Rehabilitation Centre

12.

Sarnia

Sarnia and District Children’s Treatment Centre

13.

Sault Ste. Marie

Sault Ste. Marie Children’s Rehabilitation Centre

14.

Sudbury

Laurentian Hospital Children’s Treatment Centre

15.

Thunder Bay

George Jeffrey Children’s Treatment Centre

16.

Toronto

Ontario Crippled Children’s Centre

17.

Toronto

Toronto Rehabilitation Centre

18.

Windsor

The Children’s Rehabilitation Centre of Essex County

19.

Windsor

Remedial Speech Association of Essex

R.R.O. 1990, Reg. 552, Sched. 6.

Schedule 7
AMBULANCE SERVICE OPERATORS

PART I

Hospital Ambulance Services:

Item

Location

Name of Operator

1.

Ajax

Ajax and Pickering General Hospital

2.

Alexandria

Glengarry Memorial Hospital

3.

Alliston

The Stevenson Memorial Hospital

4.

Almonte

Almonte General Hospital

5.

Arnprior

Arnprior and District Memorial Hospital

6.

Atikokan

Atikokan General Hospital

7.

Barrie

Royal Victoria Hospital of Barrie

8.

Barry’s Bay

St. Francis Memorial Hospital

9.

Blind River

St. Joseph’s General Hospital

10.

Bowmanville

Memorial Hospital

11.

Brockville

Brockville General Hospital

12.

Burk’s Falls

Red Cross Outpost Hospital

13.

Cambridge

Cambridge Memorial Hospital

14.

Campbellford

Campbellford Memorial Hospital

15.

Chapleau

Lady Minto Hospital

16.

Cochenour

Margaret Cochenour Hospital

17.

Cochrane

Lady Minto Hospital at Cochrane

18.

Dryden

Dryden District General Hospital

19.

Dunnville

Haldimand War Memorial Hospital

20.

Durham

Durham Memorial Hospital

21.

Elliot Lake

St. Joseph’s General Hospital

22.

Englehart

Englehart and District Hospital

23.

Espanola

Espanola General Hospital

24.

Fergus

Groves Memorial Community Hospital

25.

Forest

Forest District Ambulance Service

26.

Fort Frances

La Verendrye Hospital

27.

Goderich

Alexandra Marine and General Hospital

28.

Hagersville

West Haldimand General Hospital

29.

Hanover

Hanover Memorial Hospital

30.

Hearst

Notre-Dame Hospital

31.

Hornepayne

Hornepayne Community Hospital

32.

Huntsville

Huntsville District Memorial Hospital

33.

Iroquois Falls

Anson General Hospital

34.

Kapuskasing

Sensenbrenner Hospital

35.

Kemptville

Kemptville District Hospital

36.

Kenora

Lake of the Woods District Hospital

37.

Kincardine

Kincardine General Hospital

38.

Kingston

Hotel Dieu Hospital

39.

Kirkland Lake

Kirkland and District Hospital

40.

Kitchener

Kitchener-Waterloo Hospital

41.

Listowel

The Listowel Memorial Hospital

42.

Little Current

Manitoulin Health Centre

43.

Manitouwadge

Manitouwadge General Hospital

44.

Marathon

Wilson Memorial General Hospital

45.

Markdale

Centre Grey General Hospital

46.

Matheson

Bingham Memorial Hospital

47.

Mattawa

Mattawa General Hospital

48.

Meaford

Meaford General Hospital

49.

Newmarket

York County Hospital

50.

Nipigon

Nipigon District Memorial Hospital

51.

North Bay

North Bay Civic Hospital

52.

Orangeville

Dufferin Area Hospital

53.

Owen Sound

The Owen Sound General and Marine Hospital

54.

Paris

The Willett Hospital

55.

Parry Sound

The Parry Sound General Hospital

56.

Pembroke

General Hospital

57.

Perth

The Great War Memorial Hospital of Perth District

58.

Peterborough

The Peterborough Civic Hospital

59.

Rainy River

Red Cross Outpost Hospital

60.

Richard’s Landing

Red Cross Outpost Hospital

61.

St. Catharines

Hotel Dieu Hospital

62.

St. Marys

St. Marys Memorial Hospital

63.

St. Thomas

St. Thomas-Elgin General Hospital

64.

Sarnia

Sarnia General Hospital

65.

Sault Ste. Marie

Plummer Memorial Public Hospital

66.

Shelburne

Shelburne District Hospital

67.

Sioux Lookout

Sioux Lookout General Hospital

68.

Smooth Rock Falls

Smooth Rock Falls Hospital

69.

Stratford

Stratford General Hospital

70.

Sturgeon Falls

St. Jean de Brébeuf Hospital

71.

Sudbury

Sudbury General Hospital

72.

Thessalon

Red Cross Outpost Hospital

73.

Thunder Bay

McKellar General Hospital

74.

Thunder Bay

St. Joseph’s General Hospital

75.

Tillsonburg

Tillsonburg District Memorial Hospital

76.

Uxbridge

The Cottage Hospital (Uxbridge)

77.

Walkerton

County of Bruce General Hospital

78.

Wawa

The Lady Dunn General Hospital

79.

Wiarton

Bruce Peninsula and District Memorial Hospital

80.

Wingham

Wingham and District Hospital

PART II

Municipal Ambulance Services:

Item

Location

Name of Operator

1.

Ancaster

Township of Ancaster Volunteer Ambulance Service

2.

Beardmore

Improvement District of Beardmore

3.

Brantford

City of Brantford Fire Department

4.

Ear Falls

Ear Falls Ambulance Service

5.

Haliburton

Municipality of Dysart et al

6.

Ignace

Township of Ignace

7.

Lindsay

Lindsay Fire Department and Ambulance Service

8.

Minden

Minden Ambulance Service

9.

Noelville

Noelville Ambulance Service

10.

Sioux Narrows

Sioux Narrows Ambulance Service

11.

Temagami

Improvement District of Temagami

12.

Timmins

Timmins Dispatch Centre

13.

Toronto

Municipality of Metropolitan Toronto, Department of Emergency Services

14.

Virginiatown

Township of McGarry Ambulance Service

15.

Wasaga Beach

Wasaga Beach Ambulance Service

16.

White River

Improvement District of White River

PART III

Private Ambulance Operators:

Item

Location

Name of Operator

1.

Agincourt

Ogden Ambulance Service

2.

Alfred

Lamarre & Son Ambulance Service

3.

Bancroft

Hattin’s Ambulance Service

4.

Beaverton

Beaverton Ambulance Service

5.

Belleville

City Ambulance (of Quinte) Ltd.

6.

Belleville

LaSalle Ambulance Service

7.

Bobcaygeon

Bobcaygeon Ambulance Service

8.

Bracebridge

Muskoka Ambulance Service

9.

Bradford

Lewis Ambulance Service

10.

Brigden

Steadman’s Ambulance Service

11.

Burlington

District of Halton and Mississauga Ambulance Service

12.

Carleton Place

Allan R. Barker Ambulance Service

13.

Casselman

Casselman Ambulance Service

14.

Chatham

Arbour’s Chatham Ambulance Service Limited

15.

Cobourg

Cobourg Ambulance Service

16.

Colborne

Rutherford’s Ambulance Service

17.

Collingwood

McKechnie Ambulance Service

18.

Dashwood

Hoffman’s Ambulance Service

19.

Delhi

D.L. Murphy Ambulance Service

20.

Drayton

N. Wellington Ambulance Service

21.

Fenelon Falls

Fenelon Ambulance Service

22.

Finch

Brownlee Ambulance Service

23.

Fisherville

Yeates Ambulance Service

24.

Gananoque

Gananoque Ambulance Service

25.

Geraldton

Fawcett Ambulance Service

26.

Glencoe

J.B. Gough & Son Ambulance Service

27.

Grimsby

West Lincoln Ambulance Service

28.

Guelph

Royal City Ambulance Service

29.

Haileybury

Buffam Ambulance Service

30.

Hamilton

Fleetview Services Limited

31.

Hamilton

Superior Ambulance Limited

32.

Harrow

Gerald A. Smith & Sons Ambulance Service

33.

Hawkesbury

Noel Ambulance Service Limited

34.

Hawkesbury

Quenneville Ambulance Service

35.

Langton

Verhoeve Ambulance Service

36.

Leamington

Sunparlour Ambulance Service

37.

London

Thames Valley Ambulance Limited

38.

Lucan

Lucan Ambulance Service

39.

MacTier

Jordan’s Ambulance Service

40.

Madoc

City Ambulance Service (of Quinte) Limited

41.

Midland

Midland District Ambulance Service

42.

Mississauga

Fleuty Ambulance Service

43.

Morrisburg

Seaway Valley Ambulance Service Limited

44.

Mount Forest

Hiller Ambulance Service

45.

Napanee

City Ambulance Service of Quinte Limited

46.

Palmerston

Henderson Ambulance Service

47.

Parham

Parham District Ambulance Service

48.

Parkhill

Parkhill Ambulance Service

49.

Petawawa

Upper Ottawa Valley Ambulance

50.

Petrolia

Jay’s Ambulance Service

51.

Picton

Bond’s Ambulance Service

52.

Port Colborne

Port Colborne Ambulance Service

53.

Port Elgin

Saugeen District Ambulance Service

54.

Port Perry

Brignall’s Ambulance Service

55.

Port Rowan

Port Rowan Ambulance Service

56.

Rodney

Padfield Ambulance Service

57.

Schreiber

King’s Ambulance Service

58.

Seaforth

R.S. Box Ambulance Service

59.

Simcoe

Green’s Ambulance Service

60.

Smithville

Book’s Ambulance Service

61.

Stratford

Stratford Ambulance Service

62.

Strathroy

Denning Brothers Ambulance Service

63.

Streetsville

Lee Ambulance Service

64.

Sutton

Taylor’s Ambulance Service

65.

Tecumseh

Suburban Ambulance Service

66.

Thedford

Gilpin Ambulance Service

67.

Tilbury

Tilbury District Ambulance Service

68.

Timmins

Porcupine Area Ambulance Service

69.

Toronto

Hallowell Ambulance Service

70.

Toronto

Kane Ambulance Service

71.

Toronto

Metro Ambulance Service

72.

Toronto

Watson Ambulance Service

73.

Trenton

Rushnell’s Ambulance Service

74.

Wallaceburg

Arbour’s Chatham Ambulance Service Limited

75.

Waterdown

Patton Ambulance Service

76.

Welland

Greater Welland Ambulance Service

77.

Whitby

W.C. Town Ambulance Service

78.

Woodstock

Woodstock Ambulance Limited

79.

Zurich

Westlake Ambulance Service

PART IV

Volunteer Ambulance Operators:

Item

Location

Name of Operator

1.

Amherstburg

Amherstburg, Anderdon & Malden District First Aid Squad

2.

Bolton

Bolton & District Ambulance Association (Volunteer)

3.

Dubreuilville

Dubreuilville Volunteer Ambulance Service

4.

Georgetown

Georgetown Volunteer Ambulance Service

5.

Gore Bay

Gore Bay Volunteer Ambulance Group

6.

Hastings

Hastings Ambulance Service

7.

Nestor Falls

Nestor Falls Volunteer Ambulance Service

8.

Niagara-on-the-Lake

Niagara Volunteer Ambulance Service

9.

Nobleton

Nobleton Firefighters & Ambulance Association

10.

Powassan

Powassan & District Ambulance Service

11.

Rockland

Rockland Ambulance Service

12.

Seeley’s Bay

Seeley’s Bay Emergency Ambulance

R.R.O. 1990, Reg. 552, Sched. 7.

Schedule 8
PUBLIC HEALTH LABORATORIES APPROVED AS RELATED HEALTH FACILITIES

Item

Location

Ontario Ministry of Health Public Health Laboratories

1.

Hamilton

Hamilton Psychiatric Hospital

Fennell Avenue West

Mailing Address: P.O. Box 2100

L8N 3R5

2.

Kingston

Government Building

181 Barrie Street

Mailing Address: Box 240

K7L 4V8

3.

London

Fifth Floor

London Psychiatric Hospital

Off Highbury Avenue

Mailing Address: Box 5704,

Postal Terminal ‘A’

N6A 4L6

4.

Orillia

Highway 11B

Mailing Address: Box 600

L3V 6K5

5.

Ottawa

346 Moodie Drive

R.R. 2

Bells Corners

Mailing Address: Box 6301

K2A 1S8

6.

Palmerston

Midwestern Reg. Children’s Centre

Mailing Address: P.O. Box 700

N0G 2P0

7.

Peterborough

1341 Dobbin Avenue

Mailing Address: P.O. Box 265

K9J 6Y8

8.

Sault Ste. Marie

Albert and Brock Streets

Mailing Address: P.O. Box 220

P6A 5L6

9.

Sudbury

1300 Paris Crescent

Mailing Address: 1300 Paris Crescent

P3E 3A3

10.

Thunder Bay

336 South Syndicate Avenue Mailing Address: P.O. Box 1100, Station ‘F’, P7C 4X9

11.

Timmins

67 Wilson Avenue

Mailing Address: 67 Wilson Avenue

P4N 2S5

Toronto

12.

Toronto

Central Laboratories

Resources Road

Islington and Highway 401

Etobicoke

Mailing Address: Box 9000,

Terminal ‘A’, M5W 1R5

13.

Windsor

3400 Huron Church Rd.

Mailing Address: P.O. Box 1616

N9A 6S2

R.R.O. 1990, Reg. 552, Sched. 8.

Schedule 9 Revoked:  O. Reg. 253/00, s. 6.

Schedule 10 Revoked:  O. Reg. 253/00, s. 6.

Schedule 11 Revoked:  O. Reg. 201/99, s. 6.

schedule 12

1.

Abstainers Insurance Company

2.

Advocate General Insurance Company of Canada

3.

Aetna Casualty Company of Canada

4.

The Aetna Casualty and Surety Company

5.

Aetna Insurance Company

6.

Algoma Mutual Fire Insurance Company

7.

Allianz Insurance Company

8.

Allstate Insurance Company of Canada

9.

Alpina Insurance Company Limited

10.

The American Insurance Company

11.

American Mutual Liability Insurance Company

12.

Anglo Canada General Insurance Company

13.

The Ayr Farmers’ Mutual Fire Insurance Company

14.

Baltica-Skandinavia Insurance Company of Canada

15.

The Bay City General Insurance Company

16.

Bay of Quinte Agricultural Mutual Fire Insurance Company

17.

Bertie and Clinton Mutual Fire Insurance Company

18.

Blanchard Mutual Fire Insurance Company

19.

Brant Mutual Fire Insurance Company

20.

The Canada Accident and Fire Assurance Company

21.

The Canadian Commerce Insurance Company

22.

Canadian General Insurance Company

23.

Canadian Home Assurance Company

24.

The Canadian Indemnity Company

25.

The Canadian Provincial Insurance Company

26.

The Canadian Surety Company

27.

Canadian Universal Insurance Company Limited

28.

The Casualty Company of Canada

29.

Cayuga Mutual Fire Insurance Company

30.

Centennial Insurance Company

31.

The Century Insurance Company of Canada

32.

Chateau Insurance Company

33.

The Citadel General Assurance Company

34.

Coachman Insurance Company

35.

Commercial Union Assurance Company of Canada

36.

Constitution Insurance Company of Canada

37.

The Continental Insurance Company

38.

The Continental Insurance Company of Canada

39.

The Contingency Insurance Company Limited

40.

Co-Operative Fire and Casualty Company

41.

Co-Operators Insurance Association

42.

Cornhill Insurance Company Limited

43.

Coronation Insurance Company Limited

44.

Culross Mutual Fire Insurance Company

45.

Cumis General Insurance Company

46.

Cumis Insurance Society, Inc.

47.

Dominion Insurance Corporation

48.

The Dominion of Canada General Insurance Company

49.

Dufferin Mutual Fire Insurance Company

50.

Dumfries Mutual Fire Insurance Company

51.

Dunwich Farmers’ Mutual Fire Insurance Company

52.

East Williams Mutual Fire Insurance Company

53.

Eaton Bay Insurance Company

54.

Economical Mutual Insurance Company

55.

Elma Mutual Fire Insurance Company

56.

Employers Insurance of Wasau a Mutual Company

57.

Erie Mutual Fire Insurance Company

58.

Farmers’ Mutual Fire Insurance Company (Lindsay)

59.

Federal Insurance Company

60.

Federated Mutual Insurance Company

61.

Federation Insurance Company of Canada

62.

Fidelity Insurance Company of Canada

63.

Fireman’s Fund Insurance Company

64.

Fireman’s Fund Insurance Company of Canada

65.

First National Insurance Company of America

66.

Formosa Mutual Fire Insurance Company

67.

The General Accident Assurance Company of Canada

68.

General Insurance Company of America

69.

General Security Insurance Company of Canada

70.

Gerling Global General Insurance Company

71.

Germania Farmers’ Mutual Fire Insurance Company

72.

Gibraltar General Insurance Company

73.

Gold Circle Insurance Company

74.

Gore Mutual Insurance Company

75.

The Grenville Patron Mutual Fire Insurance Company

76.

Grey & Bruce Mutual Fire Insurance Company

77.

Guarantee Company of North America

78.

Guardian Insurance Company of Canada

79.

The Halifax Insurance Company

80.

Halwell Mutual Fire Insurance Company

81.

The Hartford Fire Insurance Company

82.

Hay Township Farmers’ Mutual Fire Insurance Company

83.

Herald Insurance Company

84.

Highlands Insurance Company

85.

The Home Insurance Company

86.

Howard Mutual Fire Insurance Company

87.

Howick Farmers’ Mutual Fire Insurance Company

88.

INA Insurance Company of Canada

89.

Insurance Company of North America

90.

The Insurance Corporation of Ireland Limited

91.

Jevco Insurance Company

92.

Lambton Mutual Fire Insurance Company

93.

The Lanark County Farmers’ Mutual Fire Insurance Company

94.

La Paix General Insurance Company of Canada

95.

La Paix Compagnie D’Assurances Generales Du Canada

96.

Liberty Mutual Fire Insurance Company

97.

The London Assurance

98.

London-Canada Insurance Company

99.

London Township Mutual Fire Insurance Company

100.

Lumbermen’s Mutual Casualty Company

101.

Maplex General Insurance Company

102.

Markel Insurance Company of Canada

103.

McGillivray Mutual Fire Insurance Company

104.

McKillop Mutual Fire Insurance Company

105.

The Mississquoi and Rouville Insurance Company

106.

National Employers Mutual General Insurance Association Limited

107.

Niagara Fire Insurance Company

108.

Non-Marine Underwriters, Members of (Lloyd’s) London, England

109.

Norfolk Mutual Fire Insurance Company

110.

North Blenheim Farmers’ Mutual Fire Insurance Company

111.

North Kent Mutual Fire Insurance Company

112.

Northern Frontier General Insurance Company

113.

The Nova Scotia General Insurance Company

114.

The Omaha Indemnity Company

115.

Ontario Motorist Insurance Company

116.

Ontario Mutual General Insurance Company

117.

Otter Dorchester Mutual Insurance Company

118.

Oxford Mutual Fire Insurance Company

119.

Pafco Insurance Company, Limited

120.

The Peel and Maryborough Mutual Fire Insurance Company

121.

The Personal Insurance Company of Canada

122.

Perth Insurance Company

123.

Phoenix Assurance Company of Canada

124.

Pilot Insurance Company

125.

Pitts Insurance Company

126.

The Portage la Prairie Mutual Insurance Company

127.

Premier Insurance Company

128.

Prescott Mutual Fire Insurance

129.

La Prevoyance Compagnie D’Assurances

130.

The Provident Assurance Company

131.

The Prudential Assurance Company Limited (of England)

132.

Quebec Assurance Company

133.

Reliance Insurance Company

134.

Royal General Insurance Company of Canada

135.

Royal Insurance Company of Canada

136.

Safeco Insurance Company of America

137.

Scottish & York Insurance Company Limited

138.

St. Paul Fire and Marine Insurance Company

139.

Security Casualty Company

140.

Security Mutual Casualty Company

141.

Sentry Insurance A Mutual Company

142.

Simcoe & Erie General Insurance Company

143.

South Easthope Farmers’ Mutual Fire Insurance Company

144.

The Sovereign General Insurance Company

145.

The Stanstead & Sherbrooke Insurance Company

146.

State Farm Mutual Automobile Insurance Company

147.

Sun Alliance Insurance Company

148.

The Tokio Marine and Fire Insurance Company Limited

149.

Toronto General Insurance Company

150.

Townsend Farmers’ Mutual Fire Insurance Company

151.

Traders General Insurance Company

152.

Trafalgar Insurance Company Limited

153.

Transit Insurance Company

154.

Transport Insurance Company

155.

Travelers Indemnity Company

156.

Travelers Indemnity Company of Canada

157.

The United Provinces Insurance Company

158.

United States Fidelity and Guaranty Company

159.

United States Fire Insurance Company

160.

The Unity Fire and General Insurance Company

161.

Victoria Insurance Company of Canada

162.

Wabisa Mutual Fire Insurance Company

163.

Waterloo Mutual Insurance Company

164.

The Wawanesa Mutual Insurance Company

165.

West Elgin Mutual Fire Insurance Company

166.

West Wawanosh Mutual Fire Insurance Company

167.

The Western Assurance Company

168.

Westminister Mutual Fire Insurance Company

169.

The Yarmouth Mutual Fire Insurance Company

170.

York Fire & Casualty Insurance Company

171.

Zurich Insurance Company

R.R.O. 1990, Reg. 552, Sched. 12.

Schedule 13 Revoked:  O. Reg. 86/03, s. 3.

Schedule 14 Revoked:  O. Reg. 86/03, s. 3.

Schedule 15 Revoked:  O. Reg. 86/03, s. 3.

Schedule 16
Schedule of Benefits for out of province services nuclear medicine — in vivo

Nuclear Medicine — In Vivo

 

 

 

Code

Cardiovascular System

 

J802/J602

Venography — peripheral and superior vena cava

91.70

J804/J604

First transit without blood pool images

15.30

J867/J667

First transit with blood pool images

54.60

J806/J606

Cardioangiography — first pass for shunt detection, cardiac output and transit studies

90.60

J807/J607

Myocardial perfusion scintigraphy — immediate post stress, resting

207.30

J808/J608

— delayed

76.40

J810/J610

Myocardial scintigraphy — acute infarction, injury

84.00

J811/J611

Myocardial wall motion studies

90.60

J812/J612

— repeat same day (maximum of three repeats)

45.80

J813/J613

Myocardial wall motion studies with ejection fraction

128.80

J814/J614

— repeat same day (maximum of three repeats)

45.80

J815/J615

Detection of venous thrombosis using radioiodinated fibrinogen up to ten days

125.50

 

 

Endocrine System

 

J816/J616

Adrenal scintigraphy with idocholesterol

367.75

J868/J668

— with idocholesterol and dexamethasone suppression

431.05

J869/J669

— with MIBG

529.05

J817/J617

Thyroid uptake

27.30

J870/J670

— repeat

14.20

J818/J618

Thyroid scintigraphy with Tc99m or I-131

61.10

J871/J671

— with I-123

98.20

J820/J620

Parathyroid scintigraphy — dual isotope technique with T1201 and Tc99m Iodine

224.80

J872/J672

Metastatic survey with I-131

229.10

 

 

Gastrointestinal System

 

J821/J621

Schilling test — single isotope

42.60

J823/J623

— dual isotope

45.80

J824/J624

Malabsorption test with C14 substrate

54.60

J873/J673

— with whole body counting

131.00

J825/J625

Gastrointestinal protein loss

78.50

J874/J674

Gastrointestinal blood loss — Cr51

58.90

J826/J626

Calcium absorption — Ca45

58.90

J875/J675

Calcium47 absorption/excretion

241.15

J827/J627

Esophageal motility studies — one or more

114.60

J829/J629

Gastrointestinal transit

98.20

J876/J676

Gastrointestinal reflux

54.60

J877/J677

Gastroestophageal aspiration

38.20

J830/J630

Abdominal scintigraphy for gastrointestinal bleed — Tc99m sulphur colloid or Tc04

82.90

J878/J678

— labeled RBCs

136.40

J879/J679

— Le Veen shunt patency

63.25

J831/J631

Biliary scintigraphy

109.10

J832/J632

Liver/spleen scintigraphy

76.30

J833/J633

Salivary gland scintigraphy

91.65

 

 

Genitourinary System

 

J834/J634

Dynamic renal imaging

91.65

J835/J635

Computer assessed renal function (includes first transit)

125.50

J880/J680

— repeat after pharmacological intervention

43.00

J836/J636

Static renal scintigraphy

30.50

J837/J637

ERPF by blood sample method

38.20

J838/J638

GFR by blood sample method

38.20

J839/J639

Cystography for vesicoureteric reflux

114.80

J840/J640

Testicular and scrotal scintigraphy (includes first transit)

78.50

 

 

Hematopoietic System

 

J841/J641

Plasma volume

41.45

J843/J643

Red cell volume

45.80

J847/J647

Ferrokinetics — clearance, turnover, and utilization

381.90

J848/J648

Red cell, white cell or platelet survival

98.20

J849/J649

Red cell, survival with serial surface counts

141.90

J881/J681

Bone marrow scintigraphy — whole body

109.10

J882/J682

— single site

80.80

J883/J683

In-111 leukocyte scintigraphy — whole body

347.00

J884/J684

— single site

305.60

 

 

Musculoskeletal System

 

J850/J650

Bone scintigraphy — general survey

98.80

J851/J651

— single site

80.80

J852/J652

Gallium scintigraphy — general survey

169.20

J853/J653

— single site

117.85

J854/J654

Bone mineral density by single photon method

29.50

J855/J655

Total body calcium — neutron activation

185.50

J888/J688

Bone mineral content by dual photon absorptiometry — single site

111.90

J856/J656

— two or more sites

146.40

 

 

Nervous System

 

J857/J657

CSF circulation — with Tc99m or I-131 HSA

114.60

J885/J685

— with In-111

294.60

J886/J686

— via shunt puncture

85.05

J858/J658

Brain scintigraphy

86.20

 

 

Respiratory System

 

J859/J659

Perfusion long scintigraphy

81.80

J887/J687

Ventilation lung scintigraphy

102.60

J860/J660

Perfusion and ventilation scintigraphy — same day

163.70

 

 

Miscellaneous

 

J861/J661

Radionuclide lymphangiogram

106.90

J862/J662

Ocular tumour localization

72.00

J864/J664

Tear duct scintigraphy

92.80

J865/J665

Total body counting

179.00

J866/J666

Tomography (SPECT)

41.45

 

 

diagnostic radiology

 

 

Head and Neck

 

X001

Skull — four views

30.65

X009

— five or more views

38.20

X003

Sella turcica (when skull not examined)

15.30

X004

Facial bones — minimum of three views

22.20

X005

Nose — minimum of two views

15.30

X006

Mandible — minimum of three views (uni or bilateral)

22.20

X012

— four or more views

30.65

X007

Temporomandibular joints — minimum of four views including open and closed mouth views

22.20

X008

Sinuses — minimum of three views

22.20

X010

Mastoids — bilateral — minimum of six views

29.40

X011

Internal auditory meati (when skull not examined)

22.20

X016

Eye, for foreign body

15.20

X017

Eye, for localization, additional

15.60

X018

Optic foramina

17.20

X019

Salivary gland region

14.10

X020

Neck for soft tissues — minimum of two views

14.10

 

 

Spine and Pelvis

 

X025

Cervical spine — two or three views

26.50

X202

— four or five views

34.20

X203

— six or more views

41.40

X027

Thoracic spine — two views

24.30

X204

— three or more

31.90

X028

Lumbar or lumbrosacral spine — two or three views

26.50

X205

— four or five views

34.20

X206

— six or more views

41.50

X032

Entire spine — (scoliosis series) minimum of four views

54.95

X033

— Orthoroentgenogram (3 foot film) — single view

22.20

X031

— two or more views

30.60

X034

Sacrum and/or coccyx — two views

25.60

X207

— three or more views

31.90

X035

Sacro-iliac joints — two or three views

22.20

X208

— four or more views

29.70

X036

Pelvis and/or hip(s) — one view

15.30

X037

— two views (e.g. A.P. and frog view, both hips; or A.P. both hips plus lateral one hip)

28.50

X038

— three or more views (e.g. pelvis and sacro-iliac joints, or A.P. both hips plus lateral each hip)

32.70

 

 

Upper Extremities

 

X045

Clavicle — two views

15.30

X209

— three or more views

23.50

X046

Acromioclavicular joints (bilateral) with or without weighted distraction — two views

22.20

X210

— three or more views

30.40

X047

Sternoclavicular joints — (bilateral) — two or three views

18.30

X211

— four or more views

26.40

X048

Shoulder — two views

18.30

X212

— three or more views

26.40

X049

Scapula — two views

18.30

X213

— three or more views

26.40

X050

Humerus — including one joint — two views

15.30

X214

— three or more views

23.50

X051

Elbow — two views

15.30

X215

— three or four views

23.50

X216

— five or more views

31.60

X052

Forearm — including one joint — two views

15.30

X217

— three or more views

23.50

X053

Wrist — two or three views

15.30

X218

— four or more views

23.50

X054

Hand — two or three views

15.30

X219

— four or more views

23.50

X055

Wrist and hand — two or three views

22.20

X220 

— four or more views

28.35

X056

Finger or thumb — two views

11.80

X221

— three or more views

15.30

 

 

Lower Extremities

 

X060

Hip — (unilateral) — two or more views

24.30

X063

Femur, including one joint — two views

15.30

X223

— three or more views

23.50

X065

Knee (including patella) — two views

15.30

X224

— three or four views

23.50

X225

— five or more views

31.60

X066

Tibia and fibula (including one joint) — two views

15.30

X226

— three or more views

23.50

X067

Ankle — two or three views

15.30

X227

— four or more views

23.50

X068

Calcaneus — two views

15.30

X228

— three or more views

23.50

X069

Foot — two or three views

15.30

X229

— four or more views

23.50

X072

Toe — two views

11.80

X230

— three or more views

15.30

X064

Leg length studies (orthoroentgenogram)

22.20

 

 

Skeletal Surveys

 

X057

Skeletal survey for bone age — single film

15.30

X058

— two or more films or views

22.40

X080

Other survey studies — e.g., rheumatoid, metabolic or metastic — basic

7.60

X081

— plus per film or view

7.60

 

 

Chest

 

X090

Single film

15.30

X091

Two views

22.50

X092

Three or more views

28.90

X039

Ribs — two or more views

18.30

X040

Sternum — two or more views

18.30

X096

Thoracic inlet — two or more views

15.30

 

 

Abdomen

 

X100

Single view

15.30

X101

Two or more views

23.40

 

 

G.I. Tract

 

X105

Palatopharyngeal analysis (cine or videotape)

30.20

X106

Pharynx and oesophagus (cine or videotape)

30.20

X107

Oesophagus — when X103, X104, X108 or X109 not billed

27.40

X108

Oesophagus, stomach and duodenum — including survey film if taken

47.50

X104

Oesophagus, stomach and duodenum — double contrast, including survey film if taken

49.40

X103

Oesophagus, stomach and duodenum — double contrast, including survey film if taken, and small bowel

62.50

X109

Oesophagus, stomach and small bowel

60.55

X110

Hypotonic duodenogram

40.40

X111

Small bowel only — when only examination performed during patient’s visit

27.40

X112

Colon — barium enema (including survey film, if taken)

49.50

X113

Colon — air contrast, primary or secondary, including survey films, if taken

62.60

X114

Gallbladder (one or multiple day examinations)

30.65

X120

Gallbladder (one or multiple day examinations with preliminary plain film

40.80

X116

T-tube cholangiogram

22.20

X117

Operative cholangiogram

22.20

X118

Intravenous cholangiogram

50.70

X123

Operative pancreatogram or E.R.C.P.

22.20

 

 

G.U. Tract

 

X129

Retrograde pyelogram, unilateral or bilateral

22.20

X130

Intravenous pyelogram including preliminary film

50.80

X137

Cystogram (catheter)

24.40

X135

Cystourethrogram, stress or voiding (catheter)

28.30

X131

Cystourethrogram (non-catheter)

5.95

X191

Intestinal conduit examination or nephrostogram

22.20

X138

Percutaneous antegrade pyelogram

22.20

X139

Percutaneous nephrostogram

22.20

X134

Urethrogram (retrograde)

18.30

X136

Vasogram

18.30

 

 

Obstetrics and Gynaecology

 

X143

Survey film

15.30

X144

Pelvimetry

22.20

X147

Hysterosalpingogram

30.60

X148

Intra-uterine foetal transfusion — radiological control

40.40

 

 

Fluoroscopy — by physician with or without spot films

 

X195

Chest

9.50

X196

Skeleton

9.50

X197

Abdomen

9.50

X189

Fluoroscopic control of clinical procedures done by another physician per 1/4 hour

7.50

 

 

Special Examinations

 

X155

Abdominal or pelvic pneumogram

41.00

 

Angiography

 

 

— by catheterization

 

 

abdominal, thoracic, cervical, or cranial

 

 

— using single films

 

X179

non-selective

30.60

X180

selective (per vessel to max. of 4)

40.40

 

— using film changer, cine or multiformat camera

 

X181

non-selective

61.15

X182

selective (per vessel to a max. of 4)

81.40

X140

selective (5 or more vessels)

325.60

X160

Carotid angiogram — direct puncture

 

 

— unilateral

50.15

X161

— bilateral

80.60

X174

Peripheral angiogram — unilateral

30.60

X175

— bilateral

40.40

X198

Splenoportogram

60.60

X199

Translumbar aortogram

60.60

X132

Vertebral angiogram — direct puncture or retrograde brachial injection — unilateral

50.15

X133

— bilateral

82.00

X156

Arthrogram, tenogram, or bursogram

26.90

X200

— with fluoroscopy and complete positioning throughout by physician

37.70

X157

Bone density (mineral content) measurement

34.30

X158

Bronchogram — unilateral

30.10

X159

— bilateral

39.90

X162

Cerebral stereotaxis

61.15

X122

Cholangiogram, percutaneous transhepatic

30.30

 

 

Miscellaneous Examinations

 

X151

Cordotomy, percutaneous

50.15

X163

Dacrocystogram

30.60

X164

Discogram(s) — one or more levels

30.10

X167

Fistula or sinus

22.20

X169

Laminogram, planigram, tomogram

41.00

X170

Laryngogram

30.10

X171

Lymphangiogram

50.70

X192

Mammary ductography

22.20

X184

Mammogram — dedicated equipment — unilateral

25.40

X185

— bilateral

37.80

X186

— using xeroradiography — unilateral

31.45

X187

— bilateral

48.30

X150

Mechanical evaluation of knee

26.20

X193

Microradioscopy of the hands

15.05

X173

Myelogram (spine and/or posterior fossa)

35.90

X190

Pantomography

18.30

X154

Penis

16.40

X176

Sialogram

30.60

X177

Skin thickness measurement

16.10

X183

Ventriculogram

50.15

X166

Examination using portable machine, add to first examination only

64.80

 

Note: X166 may only be claimed one per day regardless of the number of people x‑rayed in the same residence

 

 

 

diagnostic ultrasound

 

 

Head and Neck

 

J122

Brain — complete, B-mode

46.10

 

Echography — ophthalmic (excluding vascular study)

 

J102

Quantitative, A-mode

21.80

J103

B-scan immersion

42.90

J107

B-scan contact

21.70

J108

Biometry (Axial length — A-mode)

22.20

J105

Face and/or neck (excluding vascular study)

46.20

J106

Paranasal sinuses, A-mode

6.35

 

 

Heart — echocardiography (see listings in
Diagnostic and Therapeutic Procedures)

 

 

 

Thorax

 

J125

Chest masses, pleural effusion — A & B-mode

47.60

 

 

Abdomen and Retroperitoneum

 

J135

Abdominal scan, complete

47.60

J128

Abdominal scan, limited study (e.g. gallbladder only, aorta only or follow-up study)

31.40

 

 

Pelvis

 

J159

Pregnancy, complete

47.60

J162

Pelvic, complete

47.60

J163

Pelvis or pregnancy, limited study (e.g. foetal age determination, placental localization, I.U.C.D. localization)

31.40

J138

Intracavity ultrasound (e.g. transrectal, transvaginal)

47.60

 

 

Vascular System

 

J190

Extra-cranial vessel assessment (bilateral carotid and/or subclavian and/or vertebral arteries) — Doppler scan or B scan

41.70

J191

— frequency analysis

41.70

J192

— frequency analysis with Doppler scan

52.40

J201

— Duplex scan i.e. simultaneous real time, B mode imaging and spectral analysis

64.60

J193

Peripheral artery and/or vein evaluation — Doppler scan or B scan, unilateral

21.60

J194

— frequency analysis, unilateral

14.40

J195

— frequency analysis with Doppler scan, unilateral

27.10

J202

— Duplex scan i.e. simultaneous real time, B-mode imaging and spectral analysis, unilateral

32.40

J198

Venous assessment (bilateral — includes assessment of femoral, popliteal and posterior or tibial veins with appropriate functional manoeuvres and permanent record)

7.20

J205

Doppler evaluation of organ transplantation — arterial and/or venous

21.60

 

 

Vascular laboratory fees

 

J200

Ankle pressure measurements with segmental pressure recordings and/or pulse volume recordings and/or Doppler recordings

19.90

J196

Ankle pressure measurements with exercise and/or quantitative measurements added to the above

7.80

J197

Penile pressure recordings — two or more pressures

6.75

J203

Transcutaneous tissue oxygen tension measurements

23.50

J204

— when done in addition to Doppler studies

12.90

 

 

Miscellaneous

 

J180

Echography for placement of radiation therapy fields, scan B-mode

34.30

J182

Extremities — per limb (excluding vascular study)

23.10

J127

Breast — scan B-mode (per breast)

23.10

J183

Scrotal — scan

46.20

J149

Ultrasonic guidance of biopsy, aspiration, amniocentesis or drainage procedures (one physician only)

46.20

 

pulmonary function studies

 

J311

Functional residual capacity by gas dilution method

16.00

J307

Functional residual capacity by body plethysmography

17.30

J305

Lung compliance (pressure volume curve of the lung from TLC to FRC)

51.30

J306

Airways resistance by plethysmography or estimated using esophageal catheter

15.90

J340

Maximum inspiratory and expiratory pressures

2.70

J309

Carbon monoxide diffusing capacity by steady state at rest

10.60

J310

Carbon monoxide diffusing capacity by single breath method

21.20

J308

Carbon dioxide ventilatory response

19.70

J328

Oxygen ventilatory response (physician must be present)

19.70

J315

Stage I: Graded exercise to maximum tolerance (exercise must include continuous heart rate, oximetry and ventilation at rest and at each workload)

61.70

E450

J315 plus J301 or J304 before and/or after exercise, add

13.10

E451

J315 plus 12 lead E.C.G. done at rest, used for monitoring during the exercise and followed for at least 5 minutes post exercise, add

17.90

J316

Stage II: Repeated steady state graded exercise (must include heart rate, ventilation, VO2, VCO2, BP, ECG, end tidal and mixed venous CO2 at rest, 3 levels of exercise and recovery

88.95

J317

Stage III: J316 plus arterial blood gases, pH and bicarbonate or lactate

171.50

J330

Assessment of exercise induced asthma (workload sufficient to achieve heart rate 85% of predicted maximum; performance of J301 or J304 before exercise and 5-10 minutes post exercise)

32.90

J319

Blood gas analysis: pH, PO2, PCO2, bicarbonate and base excess

11.10

J318

Arterialized venous blood sample collection (e.g. ear lobe)

3.70

J320

A-a oxygen gradient requiring measurement of RQ by sampling mixed expired gas and using alveolar air equation

27.20

J331

Estimate of shunt (Qs/Qt) breathing pure oxygen

27.20

J313

Mixed venous PCO2, by the rebreathing method

11.10

J323

O2 saturation by oximetry at rest, with or without O2

4.20

J332

Oxygen saturation by oximetry at rest and exercise, or during sleep with or without O2

17.40

J334

J332 with at least two levels of supplemental O2

30.25

J322

Standard O2 consumption and CO2 production

5.20

J333

Non-specific bronchial provocative test (histamine, methylcholine, thermal challenge)

47.65

J335

Antigen challenge test

51.20

J341

Trans diaphragmatic pressure measurement

51.30

R.R.O. 1990, Reg. 552, Sched. 16.

Schedule 17
MEDICATIONS FOR THE TREATMENT OF CYSTIC FIBROSIS

I.

Oral Anti-infectives

 

amoxicillin

 

amoxicillin/clavulanic acid

 

cefaclor

 

cefuroxime axetil

 

cephalexin

 

chloramphenicol

 

ciprofloxacin

 

clindamycin

 

cloxacillin capsules

 

erythromycin

 

erythromycin/sulfisoxazole

 

flucloxacillin oral liquid

 

itraconazole

 

metronidazole

 

nystatin suspension

 

ofloxacin

 

pivampicillin

 

tetracycline

 

trimethoprim/sulfamethoxazole

 

vancomycin

II.

Inhaled/Intravenous Anti-infectives

 

amikacin

 

ceftazidime

 

chloramphenicol

 

clindamycin

 

cloxacillin

 

colistimethate

 

gentamicin

 

imipenem

 

netilmycin

 

piperacillin

 

polymyxin b sulphate

 

ticarcillin

 

tobramycin

III.

Other Anti-infectives

 

nystatin topical

 

nystatin vaginal

IV.

Chest Therapy

 

amiloride

 

beclomethasone

 

budesonide

 

cromoglycate sodium

 

fenoterol

 

ipratropium

 

n-acetylcysteine

 

prednisone

 

salbutamol

 

terbutaline

 

theophylline

V.

Pancreatic Enzymes

VI.

Gastrointestinal Therapy

 

cimetidine

 

cisapride

 

domperidone

 

gastric lavage solution

 

lactulose

 

mineral oil

 

omeprazole

 

ranitidine

 

sucralfate

 

ursodiol

VII.

Vitamins

 

vitamin A

 

vitamin D

 

vitamin E

 

vitamin K

 

vitamin B12 injection

 

fluoride

VIII.

Nutrition Products

 

Alimentum

 

Biocare

 

Boost

 

Caloreen

 

Compleat Modified

 

Ensure

 

Ensure Plus

 

Isocal

 

Isosource

 

Magnacal

 

MCT Oil

 

Meritene

 

Mighty Shakes

 

Mineral Mix

 

Nutren

 

Pediasure

 

Peptamen

 

Polycose

 

Pregestimil

 

Pulmocare

 

Resource

 

Resource Plus

 

Scandishakes

 

Sustacal

 

Vital HN

IX.

Others

 

beclomethasone nasal spray/aqueous nasal spray

 

budesonide aqueous nasal spray

 

ibuprofen tablets

 

naproxen oral suspension

 

insulin

 

chlorpropamide

 

glyburide

 

metformin

 

tolbutamide

 

digoxin

 

furosemide

 

hydrochlorothiazide/spironolactone

 

sodium chloride 0.9% ampoules

 

sterile water ampoules

O. Reg. 175/95, s. 2.

Schedule 18
MEDICATIONS FOR THE TREATMENT OF THALASSEMIA

 

amoxicillin

 

ascorbic acid (vitamin C)

 

deferoxamine

 

folic acid

 

hydrocortisone injection

 

penicillin

 

sterile water for injection

 

trimethoprim/sulfamethoxazole

O. Reg. 175/95, s. 2.

Schedules 19-21 Revoked:  O. Reg. 370/00, s. 4.

Note:  Despite its revocation, Schedule 21, as it read immediately before January 1, 2000, continues to apply with respect to payments for services rendered before January 1, 2000.  See:  O. Reg. 370/00, s. 5 (2).

Schedule 22
LABORATORY TESTS AUTHORIZED BY REGISTERED NURSE IN THE EXTENDED CLASS

(Subclause 22(1)(a)(ii))

 

Bacteriology

1.

L622

Chlamydia — culture isolation or non-cultural assays

2.

L625

Cultures — cervical, vaginal, including GC culture, Gram smear, yeast identification (e.g. Germ tube)

3.

L627

Cultures — GC culture and smear

4.

L628

Cultures — other swabs or pus-culture and smear (includes screening)

5.

L629

Cultures — sputum-culture and smear

6.

L630

Cultures — stool culture, including the necessary agglutinations and culture for campylobacter

7.

L631

Cultures — tuberculosis, including ZN or fluorescent smear

8.

L634

Cultures — urine calibrated volume to include plate, turbidimetric or photometric techniques

9.

L640

Cultures — throat swab, for streptococcus screen only

10.

L641

Cultures — urine, screening, actual culture without identification

11.

L643

Smear only, Gram or Papanicolaou stain, as sole procedure

12.

L653

Wet preparation (for fungus, trichomonas, parasites)

13.

L636

Streptococcus grouping, Lancefield or equivalent with extractions

14.

L638

Streptococcus grouping, coagglutination method

15.

L656

Penicillinase production

16.

L637

Virus Isolation

Mycology

17.

L626

Cultures — fungus, including KOH preparation and smear

18.

L652

Smear only, special stain, e.g. ZN, inclusions, spores, diphtheria

Parasitology

19.

L650

Parasites and ova (faeces concentration)

20.

L654

Parasites and ova, smear only, special stain(s)

21.

L651

Pinworm (Scotch tape prep)

Cytology

22.

L710

Direct smears — oral, larynx, nipple discharge, vulvar

23.

L713

Cervicovaginal specimen (including all types of cellular abnormality, assessment of flora and/or cytohormonal evaluation)

24.

L733

Cervicovaginal specimen (including all types of cellular abnormality, assessment of flora and/or cytohormonal evaluation) using the monolayer cell methodology.

25.

L716

Sputum per specimen for general and/or specified assessment (e.g. cellular abnormality, asbestos bodies, lipid, hemosiderin, etc.)

26.

L718

Seminal fluid examination (complete)

27.

L719

Smear for spermatozoa only (post-operative)

Biochemistry

28.

L005

Albumin, quantitative

29.

L018

Amylase

30.

L030

Bilirubin, total

31.

L031

Bilirubin, conjugated

32.

L040

Carbamazepine, quantitative (Tegretol)

33.

L045

Calcium

34.

L053

Chloride

35.

L055

Cholesterol, total

36.

L067

Creatinine

37.

L078

Drugs of abuse screen, urine

38.

L085

Electrophoresis, serum — including total protein

39.

L107

Gamma glutamyl transpeptidase

40.

L111

Glucose, quantitative (not by dipstick)

41.

L093

Glycosylated hemoglobin — HgbA1

42.

L117

High density lipoprotein cholesterol

43.

L139

Iron, Total — with iron binding capacity and percent saturation

44.

L148

Lead

45.

L157

Lithium

46.

L181

Occult blood

47.

L191

Phosphatase, alkaline

48.

L194

Phosphorus (inorganic phosphate)

49.

L204

Potassium

50.

L208

Protein, total

51.

L215

Quinidine

52.

L221

Salicylate, quantitative

53.

L222

SGOT (AST)

54.

L223

SGPT (ALT)

55.

L226

Sodium

56.

L073

Target drug testing, urine, qualitative or quantitative

57.

L243

Triglycerides

58.

L252

Uric acid (urate)

59.

L253

Urinalysis, routine chemical (any of S.G., pH, protein, sugar, hemoglobin, ketones, urobilinogen, bilirubin, leukocyte esterase, nitrate)

60.

L254

Urinalysis microscopic examination of centrifuged specimen

61.

L257

Valproic acid (valproate)

Immunoassays

62.

L306

Digoxin

63.

L309

Folate, in red cells, to include hematocrit and if requested, serum folate.

64.

L310

Estradiol

65.

L311

Estriol

66.

L315

FSH (pituitary gonadotrophins)

67.

L318

HCG (human chorionic gonadotrophins)

68.

L319

Hepatitis associated antigen or antibody immunoassay (e.g. hepatitis B surface antigen or antibody, hepatitis B core antibody, hepatitis A antibody)

69.

L321

Aminophylline (theophylline)

70.

L324

Diphenylhydantoin (phenytoin), quantitative (dilantin)

71.

L329

Ferritin

72.

L330

Parathyroid hormone

73.

L332

Prolactin

74.

L341

TSH (thyroid stimulating hormone)

75.

L345

Vitamin B12

76.

L691

Alphafetoprotein

77.

L605

1,25-dihydroxy Vitamin D

78.

L606

25- hydroxy Vitamin D

Immunology

79.

L500

Screen for miscellaneous agglutination reactions

80.

L544

Fluorescent Antibody Tests (Immunofluorescent Studies), Tests for serum antibodies to tissue and cell components — antinuclear

81.

L655

Pregnancy test

82.

L667

Non-cultural direct bacterial antibody or antigen assays by fluorescence, agglutination or ELISA techniques

83.

L668

Heterophile antibodies — screen (slide or single tube) — with or without absorption

84.

L679

Virus antibodies — hemagglutination inhibition or ELISA techniques

85.

L683

Non-cultural indirect antibody or antigen assays by fluorescence, agglutination or ELISA technique

Hematology

86.

L393

Complete Blood Count (any method)

87.

L377

Bleeding time — Ivy method

88.

L395

Eosinophil count

89.

L398

Reticulocyte count

90.

L419

Hemoglobin electrophoresis or chromatography to include Hb A2 fraction

91.

L445

Prothrombin time

92.

L452

Sickle cell preparation

93.

L462

Partial thromboplastin time

Immunohematology

94.

L481

Antibody Titre per antibody, per specimen

95.

L482

Antibody screening

96.

L490

Blood Group — ABO and RhD

97.

L493

Blood Group — ABO and Rh Phenotype

O. Reg. 61/02, s. 1.

Schedule 23
OPTOMETRY SERVICES

Item

Fee Code

Insured Service

Fee Payable

1.

V402

Oculo-visual minor assessment

$19.25

2.

V404

Periodic oculo-visual assessment of a person 19 years of age or younger

39.15

3.

V405

Periodic oculo-visual assessment of a person older than 19 years of age and younger than 65

39.15

4.

V406

Periodic oculo-visual assessment of a person 65 years of age or older

39.15

5.

V407

Additional periodic oculo-visual assessment of a person older than 19 years of age and younger than 65

39.15

O. Reg. 145/98, s. 2.

Form 1 Revoked:  O. Reg. 375/93, s. 12.

Form 2 Revoked:  O. Reg. 44/98, s. 8.