O. Reg. 178/21: GENERAL

 

ontario regulation 178/21

made under the

Health Insurance Act

Made: March 11, 2021
Filed: March 11, 2021
Published on e-Laws: March 12, 2021
Printed in The Ontario Gazette: March 27, 2021

Amending Reg. 552 of R.R.O. 1990

(GENERAL)

1. The definition of “oral and maxillofacial surgeon” in subsection 1 (1) of Regulation 552 of the Revised Regulations of Ontario, 1990 is amended by striking out “or” after clause (a), by adding “or” after clause (b) and by adding the following clause:

(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);

2. Clauses (f) and (g) of the definition of “schedule of dental benefits” in section 16 (8) of the Regulation are revoked and the following substituted:

(f)  the document published by the Ministry of Health and Long-Term Care titled “Schedule of Benefits — Dental Services under the Health Insurance Act (April 1, 2012)”, but does not include the “[Commentary…]” portions of the document, if the service is performed on or after October 1, 2012.

3. Paragraph 2 of subsection 20 (1) of the Regulation is amended by striking out “but within Canada” at the end.

4. Clause 27 (4) (a) of the Regulation is amended by striking out “but within Canada”.

5. The Regulation is amended by adding the following sections:

28.1 Licensed facilities outside Canada where medical or surgical services are rendered are prescribed as health facilities for the purposes of the Act.

28.2 (1) Out-patient services described in subsection (3) and rendered outside Canada are prescribed as insured services if,

(a)  they are medically necessary;

(b)  they are rendered by persons other than physicians, dental surgeons, optometrists, osteopaths 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 for the purpose of treating an illness, disease, condition or injury that,

(i)  is acute and unexpected,

(ii)  arose outside Canada, and

(iii)  requires immediate treatment.

(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.

(3) The following are the amounts payable by the Plan for insured services prescribed in subsection (1):

1.  $50 for services that include Magnetic Resonance Imaging (one scan) prescribed by a physician.

2.  $50 for services that include cancer chemotherapy prescribed by a physician.

3.  $50 for services that support a surgical procedure that is ordinarily rendered in an operating room and ordinarily requires the services of an anaesthetist.

4.  $50 for services that include a Computerized Axial Tomography scan prescribed by a physician.

5.  $50 for services that include either lithotripsy or Magnetic Resonance Imaging (more than one scan), prescribed by a physician.

6.  $50 for services not otherwise described in this section that are rendered,

i.  in a hospital, or

ii.  in a health facility, if the services 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 “#”.

(4) The amounts set out in subsection (3) are daily amounts that cover all the out-patient services rendered during the day by persons other than physicians, dental surgeons, optometrists, osteopaths or podiatrists.

(5) If a day’s services are described by more than one paragraph in subsection (3), the highest amount listed in those paragraphs is the amount payable for the services.

(6) 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.

(7) 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.

(8) Subsection (7) does not apply if no amount would be payable under the Act and this Regulation if the services were rendered in Ontario.

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 for the purpose of treating an illness, disease, condition or injury that,

(i)  is acute and unexpected,

(ii)  arose outside Canada, and

(iii)  requires immediate treatment.

(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.

(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 long-term care home, the services are not prescribed as insured services.

(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.

(5) The higher level of care for the purposes of subsection (4) 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.

(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.

6. (1) Subsection 28.6 (1) of the Regulation is amended by striking out “section 28.4” in the portion before clause (a) and substituting “section 28.3 or 28.4”.

(2) Subsection 28.6 (2) of the Regulation is amended by striking out “section 28.4” in the portion before clause (a) and substituting “section 28.2 or 28.4”.

(3) Subsection 28.6 (3) of the Regulation is amended by striking out “section 28.4” in the portion before clause (a) and substituting “section 28.2, 28.3 or 28.4”.

7. (1) Subsection 29 (1) of the Regulation is amended by striking out “but within Canada”.

(2) Subsection 29 (2) of the Regulation is amended by striking out “but within Canada” in the portion before paragraph 1.

(3) Subsection 29 (3) of the Regulation is amended by striking out “but within Canada” in the portion before paragraph 1.

(4) Section 29 of the Regulation is amended by adding the following subsections:

(4) 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.

(5) In the case of insured services rendered outside Canada that are covered by a preferred provider arrangement, if the insured person receives services performed by an identical or equivalent procedure from a physician or practitioner who is not a preferred provider, the amount payable is nil.

Commencement

8. This Regulation is deemed to have come into force on January 1, 2020.