O. Reg. 76/12: GENERAL

filed May 7, 2012 under Health Insurance Act, R.S.O. 1990, c. H.6

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ontario regulation 76/12

made under the

Health Insurance Act

Made: May 2, 2012
Filed: May 7, 2012
Published on e-Laws: May 8, 2012
Printed in The Ontario Gazette: May 26, 2012

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

(General)

1. (1) The definition of “schedule of benefits” in subsection 1 (1) of Regulation 552 of the Revised Regulations of Ontario, 1990 is amended by adding the following paragraph:

20. Amendments dated April 1, 2012;

(2) The definition of “schedule of benefits” in subsection 1 (1) of the Regulation is amended by adding the following paragraph:

21. Amendments dated April 1, 2013;

(3) The definition of “schedule of benefits” in subsection 1 (1) of the Regulation is amended by adding the following paragraph:

22. Amendments dated April 1, 2014;

(4) The definition of “schedule of benefits” in subsection 1 (1) of the Regulation is amended by adding the following paragraph:

23. Amendments dated April 1, 2015;

2. Clause (e) of the definition of “schedule of dental benefits” in subsection 16 (8) of the Regulation is revoked and the following substituted:

(e) 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, 2006)”, but does not include the “[Commentary…]” portions of the document, if the service is performed on or after April 1, 2006 but before October 1, 2012,

(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. (1) The heading preceding section 27 of the Regulation is revoked and the following substituted:

Interpretation

(2) Subsections 27 (1) and (2) of the Regulation are revoked and the following substituted:

(1) For the purposes of section 28.0.2,

(a) a preferred provider arrangement is a written agreement between the Minister and the operator of a hospital or health facility outside Ontario but within Canada for the delivery of specified insured services to insured persons; and

(b) a reference to the preferred provider is a reference to the operator.

(3) Section 27 of the Regulation is amended by adding the following subsection:

(5) In sections 28 to 29,

“in-patient services” means the hospital or health facility component of services,

(a) that are provided by a hospital to a hospital in-patient, or

(b) that are provided by a health facility to a person who is admitted for an overnight stay in the health facility;

4. Sections 28 and 28.0.1 of the Regulation are revoked and the following substituted:

28. (1) Out-patient services rendered outside Ontario but within Canada are prescribed as insured services if they are rendered in a hospital and,

(a) they are medically necessary;

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

(d) the hospital that supplied the service is licensed or approved as a hospital by the governmental hospital licensing authority in whose jurisdiction the hospital is situated;

(e) the service, if performed in Ontario, is one to which the insured person would be entitled without charge pursuant to section 8; and

(f) the services are rendered for the purpose of treating an illness, disease, condition or injury that,

(i) is acute and unexpected,

(ii) arose outside Ontario, 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;

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

(3) An insured person may be reimbursed by the Plan for an amount paid for insured services prescribed by subsection (1) on presentation to the General Manager of an account, including a detailed receipt, from the hospital for payment made by the person to the hospital, or the General Manager may cause reimbursement to be made directly to the hospital.

(4) The amount to be reimbursed under subsection (3) is the amount payable in accordance with the applicable interprovincial reciprocal billing agreement entered into by the Minister under clause 2 (2) (b) of the Act.

(5) Despite anything in this section, this section does not apply to a service that is a therapeutic laboratory service or a diagnostic laboratory test, unless the therapeutic laboratory service or diagnostic laboratory test is necessary for the purpose of rendering a service that is insured under this section and that is not a therapeutic laboratory service or diagnostic laboratory test.

28.0.1 (1) In-patient services rendered outside Ontario but within Canada are prescribed as insured services if they are rendered in a hospital and,

(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;

(d) the hospital that supplied the service is approved by the General Manager for the purpose of the Plan;

(e) the hospital that supplied the service is licensed or approved as a hospital by the governmental hospital licensing authority in whose jurisdiction the hospital is situated;

(f) the service, if performed in Ontario, is one to which the insured person would be entitled without charge pursuant to section 7;

(g) the services received, including accommodation, do not constitute, in the opinion of the General Manager, the domiciliary type of care provided in a long-term care home, an infirmary or other institution of a similar character; and

(h) the services are rendered for the purpose of treating an illness, disease, condition or injury that,

(i) is acute and unexpected,

(ii) arose outside Ontario, and

(iii) requires immediate treatment.

(2) 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.

28.0.2 (1) In this section,

“emergency circumstances” means medical circumstances in which an insured person faces immediate risk of,

(a) death, or

(b) medically significant irreversible tissue damage;

“emergency patient referral service” means a person, agency or organization operating in Ontario that,

(a) is approved by the General Manager, and

(b) provides information to physicians, hospitals or health facilities about health services available in emergency circumstances;

“exempt resident” means,

(a) a resident to whom subsection 1.5 (3) applies,

(b) a resident who is considered to meet the physical presence requirement by virtue of any of sections 1.6 to 1.14,

(d) a child who is considered to have the same physical location as a person mentioned in clause (a), (b) or (c) by virtue of the application of subsection 1.5 (2);

“health facility” means a facility that is licensed by the government in whose jurisdiction the facility is situated and with whose operator the Minister has entered into a preferred provider arrangement;

“hospital” means a hospital that is approved by the General Manager for the purpose of the Plan;

“North West resident” means a resident whose address, for the purpose of determining their primary place of residence, is located within the geographic area of the Local Health Integration Network (North West Ontario) as defined in the Local Health System Integration Act, 2006;

“urgent circumstances” means emergency circumstances in which it would be impossible or so impractical as to be impossible for a hospital or health facility in which services are rendered to give notice to the General Manager before the services are rendered.

(2) In-patient services that are rendered outside Ontario but within Canada to insured persons who are exempt residents are prescribed as insured services if,

(a) the service is generally accepted by the medical profession in the jurisdiction where the service is rendered as appropriate for a person in the same medical circumstances as the insured person;

(b) the service is medically necessary;

(c) the service, if performed in Ontario, is one to which the insured person would be entitled without charge pursuant to section 7; and

(d) in Ontario, the insured person would ordinarily have been admitted to a public hospital as an in-patient in order to receive the service.

(3) In-patient services that are rendered outside Ontario but within Canada to insured persons who are not exempt residents are prescribed as insured services if,

(a) the service is generally accepted by the medical profession in Ontario as appropriate for a person in the same medical circumstances as the insured person;

(b) the service is medically necessary;

(i) the identical or equivalent service is not performed in Ontario, or

(ii) the identical or equivalent service is performed in Ontario but it is necessary that the insured person travel out of Ontario to avoid a delay that would result in death or medically significant irreversible tissue damage;

(d) the service, if performed in Ontario, is one to which the insured person would be entitled without charge pursuant to section 7; and

(e) in Ontario, the insured person would ordinarily have been admitted to a public hospital as an in-patient in order to receive the service.

(4) Services that are rendered to insured persons outside Ontario but within Canada as out-patient services at a hospital or health facility are prescribed as insured services if,

(a) the service is generally accepted by the medical profession in the jurisdiction where the service is rendered as appropriate for a person in the same medical circumstances as the insured person;

(b) the service is medically necessary; and

(c) the service, if performed in Ontario, is one to which the insured person would be entitled without charge pursuant to section 8.

(5) Despite anything else in this section, where a service rendered outside Ontario but within Canada at a hospital or health facility consists primarily of the administration of a drug, the service, including the provision of the drug to be administered, is only an insured service if,

(a) all of the other applicable conditions under this section are satisfied; and

(b) there is a recommendation from the executive officer appointed under the Ontario Drug Benefit Act for payment for the drug for a person in the same medical circumstances as the insured person.

(6) A service that is rendered to an insured person outside Ontario but within Canada at a hospital or a health facility is prescribed as an insured service if,

(a) the service is generally accepted by the medical profession in the jurisdiction where the service is rendered as appropriate for a person in the same medical circumstances as the insured person;

(b) the service is medically necessary; and

(c) the service is rendered in urgent circumstances in order to treat medical complications resulting or arising from services,

(i) that are insured services under subsection (3);

(ii) that are rendered in circumstances that are not emergency circumstances, and

(iii) for which written approval of payment was granted before the services are rendered, in accordance with subparagraph 1 i of subsection (8).

(7) This section does not apply to a service that is a therapeutic laboratory service or a diagnostic laboratory test, unless the therapeutic laboratory service or diagnostic laboratory test is necessary for the purpose of rendering a service that is insured under this section and that is not a therapeutic laboratory service or diagnostic laboratory test.

(8) A service is not an insured service under subsection (2) or (3), or under subsection (4) if the service described in subsection (4) consists primarily of the administration of a drug, including the provision of the drug to be administered, unless the following conditions are satisfied:

1. For services rendered in circumstances that are not emergency circumstances,

i. written approval of payment of the amount for the services is granted by the General Manager before the services are rendered, and

ii. the services are rendered within the time limit set out in the written approval.

2. For services rendered in emergency circumstances, written approval of payment of the amount for the services is granted by the General Manager, either before or after the services are rendered.

(9) For the purposes of subsection (3), a service is performed in Ontario if the service can be legally obtained by an insured person in Ontario and includes,

(a) services that are prescribed as insured services, other than under this section;

(b) services that are publicly funded, in whole or in part;

(c) services that are for sale anywhere in Ontario to a person in the same medical circumstances as the insured person; and

(d) services that a person in the same medical circumstances as the insured person is eligible to receive in Ontario under or through any program or policy, including a program or policy permitting special or extraordinary access to the services.

(10) An amount is payable for insured services prescribed by subsection (2) if the following conditions are met:

1. An application for approval of payment is submitted to the General Manager on behalf of the insured person by a physician who practises medicine in the jurisdiction where the service is rendered.

2. The application mentioned in paragraph 1 includes written confirmation that the conditions set out in clauses (2) (a) and (b) are satisfied.

3. If the service is provided in association with a physician service that is not listed in the schedule of benefits, there is written confirmation from a physician who is a specialist, as defined in the schedule of benefits, in the type of service for which approval of payment is sought, that the service is generally accepted as appropriate by the medical community in Ontario.

(11) An amount is payable for insured services prescribed by subsection (3) if the following conditions are met:

1. An application for approval of payment is submitted to the General Manager on behalf of the insured person,

i. by a physician who practises medicine in Ontario, or

ii. by an emergency patient referral service, but only in emergency circumstances.

2. The application mentioned in paragraph 1 includes written confirmation that the conditions set out in clauses (3) (a) and (b) and one of the conditions set out in clause (3) (c) are satisfied, from,

i. a physician who is a specialist, as defined in the schedule of benefits, in the type of service for which approval of payment is sought,

ii. a general practitioner, if the type of service for which approval of payment is sought is within the general practitioner’s scope of practice, or

iii. in emergency circumstances, a physician who practises medicine in Ontario or an emergency patient referral service.

(12) For the purposes of subclause (3) (c) (i), if there is a physician in Ontario who has provided written confirmation that he or she is available to provide the service that is the subject of an application under subsection (11) and the service is within the physician’s scope of practice, the service is deemed to be identical or equivalent to the service that is the subject of the application.

(13) For the purposes of subclause (3) (c) (ii), a “delay” does not include a delay in receiving services referred to in clause (9) (c).

(14) An insured person may be reimbursed by the Plan for an amount paid for insured services prescribed by subsection (4) on presentation to the General Manager of an account, including a detailed receipt, from the hospital or health facility that performed the service for payment made by the person to the hospital or health facility, or the General Manager may cause reimbursement to be made directly to the hospital or health facility.

(15) An amount is payable for insured services prescribed by subsection (6) if the following conditions are met:

1. An application for approval of payment is submitted to the General Manager by or on behalf of the insured person.

2. The application includes written confirmation from the hospital or health facility in which the service is rendered that, in the opinion of the hospital or health facility,

i. the service is rendered in urgent circumstances in order to treat medical complications resulting or arising from services that are insured services under subsection (3), and

ii. the service is medically necessary.

(16) Despite anything in this section, this section does not apply to a service that is a therapeutic laboratory service or a diagnostic laboratory test, unless the therapeutic laboratory service or diagnostic laboratory test is necessary for the purpose of rendering a service that is insured under this section and that is not a therapeutic laboratory service or diagnostic laboratory test.

(17) The amount payable for insured services prescribed by this section,

(a) in the case of a health facility, is the amount provided for in the preferred provider arrangement; and

(b) in the case of a hospital, is the amount payable in accordance with the applicable interprovincial reciprocal billing agreement entered into by the Minister under clause 2 (2) (b) of the Act, unless the Minister has entered into a preferred provider arrangement with the hospital, in which case the amount payable is the amount provided for in the preferred provider arrangement.

(18) Where an insured person is receiving insured in-patient services at a hospital or a health facility outside Ontario but within Canada on April 1, 2014, section 28 or 28.0.1 of this Regulation, as the case may be, as they existed immediately before that date, continue to apply for the duration of the time that the insured person is receiving in-patient services for the same condition at the same hospital or health facility.

28.0.3 (1) A therapeutic laboratory service or diagnostic laboratory test that is performed outside Ontario but within Canada for an insured person is prescribed as an insured service if,

(a) in the case of a service or test to which clause (3) (a) applies, that kind of service or test is generally accepted in Ontario as appropriate for a person in the same circumstances as the insured person; or

(b) in the case of a service or test to which clause (3) (b) applies, 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.

(2) Despite subsection (1), a service or test is not prescribed as an insured service if,

(a) the service or test is experimental or the service or test is performed for research purposes; or

(b) if the service or test does not constitute a test as defined in section 5 of the Laboratory and Specimen Collection Centre Licensing Act.

(3) An amount is payable for an insured service prescribed by subsection (1) if,

(a) the service is provided to an insured person who is an exempt resident; or

(b) the service is provided to an insured person who is not an exempt resident and an application for approval of payment is submitted to the General Manager on behalf of the insured person by a physician who practises medicine in Ontario and,

(i) the application includes written confirmation from the physician that, in his or her opinion, the conditions in clause (1) (b) are satisfied, and

(ii) written approval of payment of the amount for the service is granted by the General Manager before the service is rendered and the service is rendered within the time limit set out in the written approval.

(4) Where an insured service prescribed by subsection (1) is a genetic service or test, an amount is not payable for the insured service unless there is a recommendation from the Ontario Health Quality Council for payment for the service or test for a person in the same medical circumstances as the insured person and,

(a) in the case of an insured person who is an exempt resident, an application for approval of payment is submitted to the General Manager on behalf of the insured person by a physician who practices medicine in the jurisdiction where the service is rendered and the application includes written confirmation from a physician who has the designation of a Fellow with the Canadian College of Medical Geneticists that, in his or her opinion, the conditions in clause (1) (a) are satisfied; or

(b) in the case of an insured person who is not an exempt resident, the application under clause (3) (b) includes written confirmation from an Ontario physician who has the designation of a Fellow with the Canadian College of Medical Geneticists that, in his or her opinion, the conditions in clause (1) (b) are satisfied.

(5) The amount payable by the Plan for a service or test prescribed by subsection (1) is the amount determined by the General Manager.

(6) An insured person may be reimbursed by the Plan for an amount paid for insured services prescribed by subsection (1) on presentation to the General Manager of an account, including a detailed receipt, from the laboratory that performed the service for payment made by the person to the laboratory, or the General Manager may cause reimbursement to be made directly to the laboratory.

(7) In this section,

“exempt resident” has the same meaning as in section 28.0.2.

28.0.4 In the case of any service prescribed under sections 28 to 29, the General Manager may require information and records to be provided in order to assess and verify the claim for payment, and where such information and records are not provided to the satisfaction of the General Manager, the amount payable for the insured service is nil.

5. (1) Clause 28.2 (1) (b) of the Regulation is revoked and the following substituted:

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

(2) Clause 28.2 (1) (d) of the Regulation is amended by striking out “in connection with” in the portion before subclause (i) and substituting “for the purpose of treating”.

(3) Subsection 28.2 (4) of the Regulation is revoked and the following substituted:

(4) The amounts in the Table 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.

6. Clause 28.3 (1) (d) of the Regulation is amended by striking out “in connection with” in the portion before subclause (i) and substituting “for the purpose of treating”.

7. (1) Clauses 28.4 (2) (d) and (e) of the Regulation are revoked and the following substituted:

(d) in the case of a hospital service or a service rendered in a health facility, the service, if performed in Ontario, is one to which the insured person would be entitled without charge pursuant to section 7 in the case of an in-patient service or section 8 in the case of an out-patient service; and

(e) in the case of a service performed for an insured person who is admitted as an in-patient at a hospital or for an overnight stay at a health facility in Ontario, the insured person would ordinarily have been admitted to a public hospital as an in-patient.

(2) Subsection 28.4 (9) of the Regulation is revoked and the following substituted:

(9) Subject to subsection (4), this section, as it read immediately before April 1, 2014, continues to apply to applications for approval of payment for services in circumstances that are not emergency circumstances,

(a) if the applications were mailed, faxed or otherwise delivered to the General Manager before that date; or

(b) if the applications are in respect of the continuation or extension of the same service for which approval was granted before that date, as long as,

(i) the service is for the same insured person,

(ii) the service is for the same medical condition, and

(iii) the insured person has been outside of Canada receiving the service at a hospital or health facility on a continuous basis without having returned to Ontario since before April 1, 2014.

8. Subsection 28.5 (4.1) of the Regulation is revoked and the following substituted:

(4.1) Where an insured service prescribed by subsection (1) is a genetic service or test, an amount is not payable for the insured service unless,

(a) there is a recommendation from the Ontario Health Quality Council for payment for the service or test for a person in the same medical circumstances as the insured person; and

(b) in addition to the written confirmation required under paragraph 2 of subsection (4), there is written confirmation from an Ontario physician who has the designation of a Fellow with the Canadian College of Medical Geneticists that, in his or her opinion, the conditions in subsection (1) are satisfied.

(4.2) This section, as it read immediately before April 1, 2013, continues to apply to applications for approval of payment for services if the applications were mailed, faxed or otherwise delivered to the General Manager before that date.

9. (1) Section 29 of the Regulation is amended by adding the following subsection:

(0.2) Despite subsection (0.1), if a physician service is rendered outside Ontario but within Canada to an insured person who is receiving in-patient services, the physician service is not an insured service unless it is rendered in association with an insured service rendered by the hospital or health facility where the insured person is receiving the in-patient services.

(2) Subsection 29 (1) of the Regulation is revoked and the following substituted:

(1) The amount payable by the Plan for an insured service rendered by a physician outside Ontario to an insured person is as follows:

1. If payment for the service is provided for in a preferred provider arrangement, the amount payable is the amount provided for in the preferred provider arrangement.

2. In all other cases, the amount payable is the lesser of the following:

i. The amount actually billed by the physician.

ii. The amount payable for the service in the schedule of benefits.

(3) Subsection 29 (10.2) of the Regulation is revoked.

10. Sections 31 and 32 of the Regulation are revoked.

11. Subsection 38.4 (1) of the Regulation is amended by adding the following paragraph:

8.1 If the service is a diagnostic procedure listed under the “Magnetic Resonance Imaging” or “Diagnostic and Therapeutic Procedures” in the schedule of benefits, that is listed with both a professional and technical component, the Ontario Health Insurance Plan identification number of the referring physician.

Commencement

12. (1) Subject to subsections (2) to (6), this Regulation comes into force on the day it is filed.

(2) Subsection 1 (1) and section 11 are deemed to have come into force on April 1, 2012.

(3) Section 2 comes into force on October 1, 2012.

(4) Subsection 1 (2) and section 8 come into force on April 1, 2013.

(5) Subsection 1 (3) and sections 3, 4, 5, 6, 7, 9 and 10 come into force on April 1, 2014.

(6) Subsection 1 (4) comes into force on April 1, 2015.

CORRECTION

An incorrect version of this Regulation was published on May 7, 2012. The correct version was published on May 8, 2012. This correction notice was posted on May 8, 2012.

O. Reg. 76/12: GENERAL

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