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O. Reg. 129/05: GENERAL

filed March 23, 2005 under Health Insurance Act, R.S.O. 1990, c. H.6

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ontario regulation 129/05

made under the

Health Insurance Act

Made: March 23, 2005
Filed: March 23, 2005
Printed in The Ontario Gazette: April 9, 2005

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

(General)

1. Subsection 1 (1) of Regulation 552 of the Revised Regulations of Ontario, 1990 is amended by adding the following definition:

“physiotherapist” means a member of the College of Physiotherapists of Ontario;

2. (1) Subsections 21 (1), (2), (2.1), (2.2), (3), (4), (4.0.1), (4.0.2), (4.1) and (4.2) of the Regulation are revoked and the following substituted:

(1) In this section,

“designated physiotherapist” means a physiotherapist who is employed by a designated physiotherapy clinic or who renders physiotherapy services on behalf of the operator of a designated physiotherapy clinic under a written agreement with the operator;

“designated physiotherapy clinic” means a physiotherapy clinic prescribed as a health facility for the purposes of the Act under subsection 35 (10);

“insured physiotherapy service” means a physiotherapy service rendered by a designated physiotherapist that is an insured service under this section.

(2) For the purposes of paragraph 1 of subsection 11.2 (1) of the Act, physiotherapy services are prescribed as insured services for the purposes of the Act if,

(a) the physiotherapy services,

(i) are ordered by a physician,

(ii) are rendered to an insured person who is younger than 20 years of age or 65 years of age or older, and

(iii) are rendered at a designated physiotherapy clinic by a designated physiotherapist;

(b) the physiotherapy services,

(i) are ordered by a physician on the medical staff of a hospital,

(ii) are provided to an insured person following his or her discharge as an inpatient of that hospital,

(iii) are directly connected to the condition, illness or injury for which the insured person was admitted to the hospital, and

(iv) are rendered at a designated physiotherapy clinic by a designated physiotherapist; or

(c) the physiotherapy services,

(i) are ordered by a physician,

(ii) are provided to an insured person in his or her home by a designated physiotherapist, and

(iii) are required to be rendered in the insured person’s home because of the insured person’s condition, illness or injury.

(3) The amount payable by the Plan for insured physiotherapy services rendered to an insured person by a designated physiotherapist is determined as follows:

1. The amount payable for the first insured physiotherapy service rendered to an insured person is,

i. $24.40 if the first insured physiotherapy service is rendered to the insured person in his or her home in circumstances in which clause (2) (c) applies, or

ii. $12.20 in any other case.

2. The amount payable for subsequent insured physiotherapy services rendered to an insured person is $12.20, whether the insured services are rendered in the insured person’s home or at a designated physiotherapy clinic.

3. The amount payable by the Plan under paragraph 1 or 2 in respect of an insured person is the maximum amount payable by the Plan for all insured physiotherapy services rendered to the insured person on the same day.

4. The amount payable by the Plan in respect of an insured person for a fiscal year shall not exceed the maximum amount payable,

i. for 100 days in the case of an insured person referred to in clause (2) (a) or (c), or

ii. for 50 days in the case of an insured person referred to in clause (2) (b).

5. For the purposes of subparagraph 1 i, the first insured physiotherapy service provided on or after April 1, 2005 to an insured person is not the first insured physiotherapy service rendered to the insured person if the insured person ever received any physiotherapy service before April 1, 2005 that was an insured service.

(2) Subsection 21 (5) of the Regulation is amended by striking out the portion before clause (a) and substituting the following:

(5) Payment for physiotherapy services that were rendered before April 1, 2005 and were  insured services may only be made,

. . . . .

(3) Section 21 of the Regulation is amended by adding the following subsections:

(6) A payment for insured physiotherapy services rendered by a designated physiotherapist on or after April 1, 2005 may only be made if the following conditions are satisfied:

1. The operator of the designated physiotherapy clinic has submitted to the Plan an account for the insured physiotherapy services in such form as the General Manager may require and containing the appropriate fee code, the service location indicator, the indicator identifying the physician who ordered the insured physiotherapy services and such other information as this Regulation or the General Manager may require.

2. The payment is to the operator of the designated physiotherapy clinic who submitted the account.

3. The operator receiving the payment accepts it as payment in full for the insured physiotherapy services.

4. No person other than the operator charges or accepts any payment or benefit for rendering the insured physiotherapy services, other than salary, wages or other remuneration payable by the operator.

(7) For the purposes of paragraph 7 of subsection 18 (2) of the Act, the following are prescribed as circumstances in which the General Manager may refuse to pay an account submitted by an operator of a designated physiotherapy clinic for insured physiotherapy services rendered to an insured person after April 1, 2005 or may pay a reduced amount:

1. If the operator or clinic fails to prepare and maintain written records in accordance with subsection (8) relating to the insured physiotherapy services to which the account relates.

2. If the operator or clinic has failed to prepare and maintain written records in accordance with subsection (8) relating to all previous physiotherapy services rendered to the same insured person by the designated physiotherapy clinic.

(8) For the purposes of subsection (7), written records relating to physiotherapy services provided to an insured person must include,

(a) the name of the insured person to whom physiotherapy services were rendered;

(b) the dates when the physiotherapy services were rendered and the location or locations at which the services were rendered on each of those dates;

(c) a detailed description of the services rendered on each date and at each location; and

(d) the name or names of the person or persons who actually rendered each service referred to in clause (c) on each date and at each location and the number of each of their licences or certificates of registration issued by the College of Physiotherapists of Ontario.

3. The Regulation is amended by adding the following section:

21.1 (1) For the purposes of paragraph 3 of subsection 11.2 (1) of the Act, physiotherapy services are prescribed as insured services for the purposes of the Act if,

(a) the physiotherapy services,

(i) are ordered by a physician,

(ii) are rendered to an insured person who resides in a long-term care facility by a physiotherapist who has entered into a written agreement with the Minister to provide physiotherapy services to insured persons who reside in long-term care facilities on a basis other than fee for service, and

(iii) are required to be rendered in the insured person’s long-term care facility because of the insured person’s condition, illness or injury; or

(b) the physiotherapy services,

(i) are ordered by a physician,

(ii) are provided to an insured person who is 65 years of age or older at a place in which health, cultural, recreational or social services are ordinarily provided to persons 65 years of age or older, and

(iii) are rendered by a physiotherapist who has entered into a written agreement with the Minister to provide physiotherapy services to insured persons at a place described in subclause (ii) on a basis other than fee for service.

(2) In this section,

“long-term care facility” means a facility that is a long-term care facility for the purposes of section 59 of the Long-Term Care Act, 1994.

4. Subsection 35 (10) of the Regulation is revoked and the following substituted:

(10) Every physiotherapy clinic listed in the document published by the Ministry of Health and Long-Term Care titled “Schedule of Designated Physiotherapy Clinics”, dated April 1, 2005, is prescribed as a health facility for the purposes of the Act.

5. (1) Subparagraph 1 ii of subsection 38.4 (1) of the Regulation is revoked and the following substituted:

ii. the physiotherapy clinic listed in the document published by the Ministry of Health and Long-Term Care titled “Schedule of Designated Physiotherapy Clinics”, dated April 1, 2005, that rendered the service, or

(2) Subparagraph 14 iv of subsection 38.4 (1) of the Regulation is revoked and the following substituted:

iv. by the Plan if,

A. 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 or by an osteopath, or

B. the service is an insured physiotherapy service for the purposes of section 21.

(3) Subparagraph 14 iv of subsection 38.4 (1) of the Regulation, as remade by section 6 of Ontario Regulation 352/04, is revoked and the following substituted:

iv. by the Plan if,

A. the service was rendered by a podiatrist who is a member of the College of Chiropodists of Ontario or by an osteopath, or

B. the service is an insured physiotherapy service for the purposes of section 21.

6. Schedule 5 to the Regulation is revoked.

7. (1) Subject to subsection (2), this Regulation comes into force on April 1, 2005.

(2) Subsection 5 (3) comes into force on June 1, 2005.