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O. Reg. 519/17: GENERAL

filed December 15, 2017 under Health Insurance Act, R.S.O. 1990, c. H.6

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ontario regulation 519/17

made under the

Health Insurance Act

Made: December 13, 2017
Filed: December 15, 2017
Published on e-Laws: December 15, 2017
Printed in The Ontario Gazette: December 30, 2017

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

(GENERAL)

1. The definition of “schedule of laboratory benefits” in subsection 1 (1) of Regulation 552 of the Revised Regulations of Ontario, 1990 is revoked and the following substituted:

“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 November 7, 2017 (effective as of April 1, 2017), and which is available on a website of the Government of Ontario;

2. (1) Clause 22 (1) (a) of the Regulation is amended by adding “and in a manner” after “form”.

(2) Clause 22 (1) (b) of the Regulation is revoked and the following substituted:

(b) the test is performed in a laboratory that,

(i) is not part of a hospital unless in performing the test the laboratory is providing a community laboratory service under section 22 of the Public Hospitals Act, and

(ii) is licensed under the Laboratory and Specimen Collection Centre Licensing Act to perform the test for which payment is claimed.

(3) Clause 22 (2) (c) of the Regulation is revoked and the following substituted:

(c) if the services are performed in a laboratory that,

(i) is not part of a hospital unless in performing the services the laboratory is providing community laboratory services under section 22 of the Public Hospitals Act, and

(ii) is licensed under the Laboratory and Specimen Collection Centre Licensing Act to perform the services for which payment is claimed.

(4) Subsection 22 (4) of the Regulation is revoked and the following substituted:

(4) Subject to subsection (5), the basic fee payable by the Plan for an insured service rendered by a medical laboratory on or after April 1, 2017 is the applicable fee set out opposite the service in the schedule of laboratory benefits.

(5) Subsection 22 (5) of the Regulation is revoked and the following substituted:

(5) The basic fee payable by the Plan for an insured service rendered by a medical laboratory that is a party to a written agreement with the Minister under clause 2 (2) (a) of the Act is nil.

(6) Subsections 22 (6) and (8) of the Regulation are revoked.

(7) Paragraph 2 of subsection 22 (10) of the Regulation is revoked and the following substituted:

2. The medical laboratory must, at the time the service was rendered, be a party to either,

i. a written agreement with the Minister entered into under clause 2 (2) (a) of the Act, or

ii. a written verification agreement with the General Manager.

(8) Paragraph 2 of subsection 22 (10) of the Regulation, as remade by subsection (7), is revoked and the following substituted:

2. The medical laboratory must, at the time the service was rendered, be a party to a written agreement with the Minister entered into under clause 2 (2) (a) of the Act.

(9) Subsection 22 (11) of the Regulation is revoked.

3. (1) Sections 22.1 and 22.2 of the Regulation are revoked and the following substituted:

22.1 (1) In this section,

“applicable cap” is the amount determined under subsection (4);

“fiscal year” means the 12-month period beginning on April 1, 2017;

“market share” means, with respect to a medical laboratory, the percentage of claims approved by the General Manager for the medical laboratory of all claims approved by the General Manager for all medical laboratories with respect to insured services from October 1, 2015 to March 31, 2017.

(2) For the purposes of subsections 17.1 (6) and 17.2 (4) of the Act, with respect to a medical laboratory,

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

(b) the prescribed period is the fiscal year; and

(c) the prescribed amount is the laboratory’s applicable cap for the fiscal year.

(3) If the total amount payable under subsection 22 (4) by the Plan to a medical laboratory with respect to insured services provided by it during the fiscal year equals or exceeds the laboratory’s applicable cap, the fee payable for each subsequent insured service it performs during the fiscal year is decreased to nil.

(4) The applicable cap for a medical laboratory shall be determined by multiplying,

(a) the provincial cap for the fiscal year of $580,000,000; and

(b) the medical laboratory’s market share, subject to subsection (5).

(5) If the market share of a single medical laboratory is greater than 70 per cent, the percentage to be used for the purpose of clause (4) (b) shall be,

(a) 70 per cent, in the case of the medical laboratory that has a market share of greater than 70 per cent; and

(b) in the case of all other medical laboratories, the number, expressed as a percentage, determined by,

(i) multiplying the laboratory’s market share by 30 per cent, and

(ii) dividing the product obtained under subclause (i) by the sum of the market shares of all the medical laboratories, other than the laboratory described in clause (a).

(6) This section does not apply with respect to hospital laboratories.

22.2 For greater certainty, the amounts to be paid by the Plan to medical laboratories, other than hospital laboratories, with respect to insured services provided by those laboratories from April 1, 2012 to March 31, 2017, shall be determined in accordance with sections 22.1 to 22.11 as they read immediately before April 1, 2017.

(2) Section 22.1 of the Regulation, as remade by subsection (1), is revoked.

4. Sections 22.3 to 22.11 of the Regulation are revoked.

Commencement

5. (1) Subject to subsections (2) to (5), this Regulation comes into force on the day it is filed.

(2) Section 1, subsections 2 (4) and (6), subsection 3 (1) and section 4 are deemed to have come into force on April 1, 2017.

(3) Subsections 2 (5) and (7) are deemed to have come into force on June 1, 2017.

(4) Subsections 2 (8) and (9) and 3 (2) come into force on the later of April 1, 2018 and the day this Regulation is filed.

(5) Subsections 2 (2) and (3) come into force on the later of the day section 13 of Schedule 3 to the Protecting Patients Act, 2017 comes into force and the day this Regulation is filed.