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

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Health Insurance Act

R.S.O. 1990, CHAPTER H.6

Consolidation Period:  From December 10, 2019 to the e-Laws currency date.

Last amendment: 2019, c. 15, Sched. 15, s. 1-35.

Legislative History: R.S.O. 1990, c. H.6, s. 18.0.5 (2); 1992, c. 32, s. 15; 1993, c. 10, s. 53; 1993, c. 2, s. 12; 1993, c. 32, s. 2; 1994, c. 17, s. 68-74; 1996, c. 1, Sched. H, s. 1-35; 1996, c. 21, s. 51; 1997, c. 16, s. 7; 1998, c. 18, Sched. G, s. 54; 1999, c. 10, s. 1, 2; 2000, c. 26, Sched. H, s. 1; 2000, c. 42, Sched., s. 17-19; 2001, c. 8, s. 32, 33; 2002, c. 18, Sched. I, s. 8; 2004, c. 3, Sched. A, s. 85; 2004, c. 5, s. 36-43; 2004, c. 13, s. 1; 2006, c. 19, Sched. C, s. 1 (1); 2006, c. 19, Sched. L, s. 3, 11; 2006, c. 21, Sched. F, s. 136 (1); 2006, c. 35, Sched. C, s. 53; 2007, c. 8, s. 209; 2007, c. 10, Sched. C; 2007, c. 10, Sched. G, s. 1-34 (See 2015, c. 20, Sched. 15, s. 19 and Table of Public Statute Provisions Repealed Under Section 10.1 of the Legislation Act, 2006); 2007, c. 10, Sched. P, s. 16; 2007, c. 16, Sched. B; 2009, c. 26, s. 11 (See 2015, c. 20, Sched. 15, s. 20 and 2019, c. 15, Sched. 15, s. 38); 2009, c. 33, Sched. 6, s. 61; 2009, c. 33, Sched. 18, s. 11, 17 (2); 2015, c. 18, s. 1; 2015, c. 20, Sched. 15, s. 1-14; CTS 23 OC 07 - 1; CTS 23 OC 07 - 2; 2016, c. 30, s. 38 (See 2019, c. 5, Sched. 3, s. 28); 2017, c. 11, Sched. 3, s. 11; 2017, c. 25, Sched. 9, s. 97 (See 2019, c. 15, Sched. 15, s. 39); 2017, c. 34, Sched. 46, s. 17; 2019, c. 15, Sched. 15, s. 1-35.

CONTENTS

1.

Definitions

Administration

2.

Administration of Plan by Minister

3.

Ontario-Canada agreement

4.

General Manager

4.1

Collection of personal information

Joint Committee

5.

Transitional

Medical Eligibility Committee

7.

Transitional

Report to Assembly

9.

Report to Assembly

Ontario Health Insurance Plan

10.

Ontario Health Insurance Plan continued

11.

Right to insurance

11.1

Health card

11.2

Insured services

12.

Entitlement to insured services

13.

Choice of physician or practitioner

14.

Other insurance prohibited

15.

Billing – physicians

15.1

Billing – practitioners

15.2

Transitional

15.3

Billing number — health facilities

16.

Billing numbers

16.1

Direction to make payments to entity

16.2

Billing numbers

17.

Accounts for insured services

17.1

Fees payable for insured services

17.2

Fees payable, health facilities

17.3

Information

17.4

Record-keeping

17.5

Refusal to pay if not required form, etc.

18.

Payment of accounts

18.0.1

Reimbursement, non-entitled person

18.0.2

Debt

18.0.3

Transitional

18.0.4

Settlement

18.0.6

Settlement

18.0.7

Transitional

18.2

Recovery from requesting physician

18.2.1

Practitioners and health facilities

18.3

Interest

19.2

Refusal of claims, entitlement

20.

Hearing by Appeal Board

21.

Powers of Appeal Board

22.

Parties

23.

Evidence

24.

Appeal to Divisional Court

26.

Service of notice

27.

Proposed revision of O.M.A. schedule of fees

27.1

Contributions to the Plan

27.2

Payments, etc., to the Plan

28.

Payment by contribution to annual expenditures

29.

Disclosure authorized

Subrogation

30.

Subrogation

31.

Subrogated claim included in action

32.

Motor Vehicle Accident Claims Fund

33.

Judge to divide award

34.

Release not to bind Plan

35.

Insurer to pay Ontario

36.

Future insured services

Direct Recovery

36.0.1

Direct cause of action

Third Party Services

36.1

Third party service

36.2

Third party liable

36.3

Amounts owing by third parties

36.4

Service provider to reimburse insured person

General

38.

Information confidential

38.1

Filing with court

39.

Limitation of liability

39.1

Limitations on remedies

39.2

No Crown liability

39.3

Amendments apply despite agreements

39.4

Publication

40.3

Suspension of payments

41.

Appointment of reviewers

42.

Copy constitutes evidence

42.1

Order to enter

42.2

Obstruction offence

42.3

Production order

42.4

Not compellable witness

42.5

Protection of information

42.6

Certain documents

43.

Offence, payment without entitlement

43.1

Mandatory reporting

44.

General penalty, individual

45.

Regulations

45.1

No appeal

Mental Illness

46.

Mental illness

Schedule 1

Physician payment review process

 

Definitions

1 In this Act,

“Appeal Board” means the Health Services Appeal and Review Board under the Ministry of Health and Long-Term Care Appeal and Review Boards Act, 1998; (“Commission d’appel”)

“billing number” means the unique identifying number issued by the General Manager to a physician, practitioner or health facility that has been granted a billing number by the General Manager under section 16.2; (“numéro de facturation”)

Note: On a day to be named by proclamation of the Lieutenant Governor, section 1 of the Act is amended by adding the following definition: (See: 2017, c. 25, Sched. 9, s. 97 (1))

“community health facility” means a community health facility within the meaning of the Oversight of Health Facilities and Devices Act, 2017; (“établissement de santé communautaire”)

“Deputy Minister” means the Deputy Minister of Health and Long-Term Care; (“sous-ministre”)

“future cost of insured services” means the estimated total cost of the future insured services made necessary as the result of an injury that will probably be required by a patient after the date of settlement or, where there is no settlement, the first day of trial; (“coût futur des services assurés”)

“General Manager” means the General Manager appointed under section 4; (“directeur général”)

Note: On a day to be named by proclamation of the Lieutenant Governor, section 1 is amended by adding the following definition:

“general requisition number” means the unique identifying number issued by the General Manager to a practitioner or health facility to identify that a service rendered by another practitioner or health facility or by a physician, hospital or independent health facility was requested by the practitioner or health facility; (“numéro de demande général”)

See: 2009, c. 26, ss. 11 (1), 27 (2).

Note: On a day to be named by proclamation of the Lieutenant Governor, the definition of “general requisition number” in section 1 of the Act is amended by striking out “independent health facility” and substituting “community health facility”. (See: 2017, c. 25, Sched. 9, s. 97 (2))

“health card” means a document in a prescribed form issued by the General Manager; (“carte Santé”)

“health facility” means an ambulance service, a medical laboratory and any other facility prescribed by the regulations as a health facility for the purposes of this Act; (“établissement de santé”)

Note: On a day to be named by proclamation of the Lieutenant Governor, section 1 is amended by adding the following definition:

“independent health facility” means an independent health facility within the meaning of the Independent Health Facilities Act; (“établissement de santé autonome”)

See: 2009, c. 26, ss. 11 (1), 27 (2).

Note: On a day to be named by proclamation of the Lieutenant Governor, the definition of “independent health facility” in section 1 of the Act is repealed. (See: 2017, c. 25, Sched. 9, s. 97 (3))

“insured person” means a person who is entitled to insured services under this Act and the regulations; (“assuré”)

“insured services” means services that are determined under section 11.2 to be insured services; (“services assurés”)

“justice” has the same meaning as in the Provincial Offences Act; (“juge”)

“Minister” means the Minister of Health and Long-Term Care; (“ministre”)

“Ministry” means the Ministry of Health and Long-Term Care; (“ministère”)

“past cost of insured services” means the total cost of the insured services made necessary as the result of an injury and provided to a patient up to and including the date of settlement or, where there is no settlement, the first day of trial; (“coût antérieur des services assurés”)

“personal information” means personal information as defined in the Freedom of Information and Protection of Privacy Act and includes personal health information as defined in the Personal Health Information Protection Act, 2004; (“renseignements personnels”)

“physician” means a legally qualified medical practitioner lawfully entitled to practise medicine in the place where medical services are rendered by the physician; (“médecin”)

“Plan” means the Ontario Health Insurance Plan referred to in section 10; (“Régime”)

“practitioner” means a person other than a physician who is lawfully entitled to render insured services in the place where they are rendered; (“praticien”)

“prescribed” means prescribed by the regulations; (“prescrit”)

“provincial offences officer” has the same meaning as in the Provincial Offences Act; (“agent des infractions provinciales”)

“regulations” means the regulations made under this Act; (“règlements”)

“resident” means a resident as defined in the regulations and the verb “reside” has a corresponding meaning; (“résident”)

“reviewer” means a reviewer provided for under section 41; (“examinateur”)

“schedule of benefits” means the schedule of benefits as defined by the regulations. (“liste des prestations”)  R.S.O. 1990, c. H.6, s. 1; 1993, c. 2, s. 12; 1993, c. 32, s. 2 (1); 1994, c. 17, s. 68; 1996, c. 1, Sched. H, s. 1 (2) - 1/05/1996; 1998, c. 18, Sched. G, s. 54 (1); 2006, c. 19, Sched. L, s. 11 (2, 4); 2007, c. 10, Sched. G, s. 1; 2009, c. 33, Sched. 18, ss. 11 (1), 17 (2); 2019, c. 15, Sched. 15, s. 1.

Section Amendments with date in force (d/m/y)

1993, c. 2, s. 12 - 01/07/1993; 1993, c. 32, s. 2 (1) - 14/12/1993; 1994, c. 17, s. 68 - 01/04/1994; 1996, c. 1, Sched. H, s. 1 (1) - no effect; 1996, c. 1, Sched. H, s. 1 (2) - 01/05/1996; 1998, c. 18, Sched. G, s. 54 (1) - 01/02/1999

2006, c. 19, Sched. L, s. 11 (2, 4) - 22/06/2006

2007, c. 10, Sched. G, s. 1 (1, 2) - 04/09/2007; 2007, c. 10, Sched. G, s. 1 (3) - 01/09/2009

2009, c. 26, s. 11 (1) - not in force; 2009, c. 33, Sched. 18, ss. 11 (1), 17 (2) - 15/12/2009

2017, c. 25, Sched. 9, s. 97 (1-3) - not in force

2019, c. 15, Sched. 15, s. 1 (1, 2) - 10/12/2019

Administration

Administration of Plan by Minister

2 (1) The Minister is responsible in respect of the administration and operation of the Plan and is the public authority for Ontario for the purposes of the Canada Health Act.  R.S.O. 1990, c. H.6, s. 2 (1).

Duties of Minister

(2) The Minister may,

(a) enter into arrangements for the payment of remuneration to physicians, practitioners and health facilities rendering insured services to insured persons on a basis other than fee for service;

(b) enter into agreements with persons, organizations and government agencies outside Ontario for the provision of insured services to insured persons.

(c), (d), (e) Repealed:  2009, c. 33, Sched. 18, s. 11 (2).

R.S.O. 1990, c. H.6, s. 2 (2); 2009, c. 33, Sched. 18, s. 11 (2); 2017, c. 11, Sched. 3, s. 11.

Collection of personal information

(3) The Minister may collect, directly or indirectly,

(a) personal information that relates to the eligibility of a person to become or to continue to be an insured person; or

(b) the prescribed personal information, which may include a photograph and signature, that relates to the form or content of the health card.  1994, c. 17, s. 69.

Agreements concerning personal information

(4) The Minister may enter into agreements to collect, use or disclose the personal information referred to in clause (3) (a) and to collect and use the personal information referred to in clause (3) (b).  1994, c. 17, s. 69.

Agreements concerning payment information

(4.1) The Minister may enter into agreements to collect, use and disclose,

(a) personal information concerning insured services provided by physicians, practitioners or health facilities; and

(b) such other personal information as may be prescribed.  1996, c. 1, Sched. H, s. 2 (1).

Limitation

(5) An agreement shall provide that personal information collected or disclosed under the agreement will be used only,

(a) to verify the accuracy of information held or exchanged by a party to the agreement;

(b) to administer or enforce a law administered by a party to the agreement; or

(c) for such other purposes as may be prescribed.  1994, c. 17, s. 69; 1996, c. 1, Sched. H, s. 2 (2).

Confidentiality

(6) An agreement shall provide that personal information collected, used or disclosed under it is confidential and shall establish mechanisms for maintaining the confidentiality of the information.  1996, c. 1, Sched. H, s. 2 (3).

Deemed terms

(7) The Lieutenant Governor in Council may make regulations providing for provisions that shall be deemed to be included in arrangements made under clause (2) (a) that require reporting of physician payments to individual physicians from remuneration provided under such arrangements, and which shall be deemed to be included in arrangements entered into before the regulations were made and before this subsection came into force. 2019, c. 15, Sched. 15, s. 2.

(8) Repealed: 2015, c. 20, Sched. 15, s. 1.

Section Amendments with date in force (d/m/y)

1994, c. 17, s. 69 - 23/06/1994; 1996, c. 1, Sched. H, s. 2 (1-3) - 01/05/1996

2007, c. 10, Sched. C, s. 1 - 04/06/2007

2009, c. 33, Sched. 18, s. 11 (2) - 15/12/2009

2015, c. 20, Sched. 15, s. 1 - 29/10/2015

2016, c. 30, s. 38 - no effect - see 2019, c. 5, Sched. 3, s. 28 - 18/04/2019

2017, c. 11, Sched. 3, s. 11 - 30/05/2017

2019, c. 15, Sched. 15, s. 2 - 10/12/2019

Ontario-Canada agreement

3 (1) The Government of Ontario, represented by the Minister of Finance, may enter into and amend from time to time an agreement with the Government of Canada under which Canada will contribute to the cost of that part of the Plan related to the provision of any insured services in or by hospitals and health facilities in accordance with such terms and conditions as the agreement provides.  R.S.O. 1990, c. H.6, s. 3 (1); 2006, c. 19, Sched. L, s. 11 (5).

Idem

(2) The Government of Ontario, represented by the Minister, may enter into and amend from time to time an agreement with the Government of Canada under which Canada will contribute to the cost of that part of the Plan related to insured services other than insured services provided in or by a hospital or health facility, in accordance with such terms and conditions as the agreement provides.  R.S.O. 1990, c. H.6, s. 3 (2).

Section Amendments with date in force (d/m/y)

2006, c. 19, Sched. L, s. 11 (5) - 22/06/2006

General Manager

4 (1) A General Manager for the Plan shall be appointed by the Lieutenant Governor in Council.  R.S.O. 1990, c. H.6, s. 4 (1).

Duties

(2) Subject to this Act and the regulations, it is the function of the General Manager and he or she has the power,

(a) to administer the Plan as the chief executive officer of the Plan;

(b) to carry out registrations in the Plan, including the determination of eligibility and the verification of eligibility;

(c) to make payments by the Plan for insured services, including the determination of eligibility and amounts;

(d) to establish and maintain branch offices for the administration of the Plan;

(e) to conduct actions and negotiate settlements on behalf of the Plan under the subrogation of the Plan under this Act to the rights of insured persons;

(f) to require any information required or permitted to be provided to the General Manager under this Act or the regulations to be provided in such form as he or she specifies;

(g) to perform such other function and discharge such other duties as are assigned to the General Manager by this Act and the regulations or by the Minister.  R.S.O. 1990, c. H.6, s. 4 (2); 2006, c. 19, Sched. L, s. 3 (1).

Section Amendments with date in force (d/m/y)

2006, c. 19, Sched. L, s. 3 (1) - 22/06/2006

Collection of personal information

4.1 (1) The Minister and the General Manager may directly or indirectly collect personal information, subject to such conditions as may be prescribed, for purposes related to the administration of this Act, the Commitment to the Future of Medicare Act, 2004 or the Independent Health Facilities Act or for such other purposes as may be prescribed.  1996, c. 1, Sched. H, s. 3; 2006, c. 19, Sched. L, s. 3 (2).

Note: On a day to be named by proclamation of the Lieutenant Governor, subsection 4.1 (1) of the Act is amended by striking out “Independent Health Facilities Act” and substituting “Oversight of Health Facilities and Devices Act, 2017”. (See: 2017, c. 25, Sched. 9, s. 97 (4))

Use of personal information

(2) The Minister and the General Manager may use personal information, subject to such conditions as may be prescribed, for purposes related to the administration of this Act, the Commitment to the Future of Medicare Act, 2004 or the Independent Health Facilities Act or for such other purposes as may be prescribed.  1996, c. 1, Sched. H, s. 3; 2006, c. 19, Sched. L, s. 3 (3).

Note: On a day to be named by proclamation of the Lieutenant Governor, subsection 4.1 (2) of the Act is amended by striking out “Independent Health Facilities Act” and substituting “Oversight of Health Facilities and Devices Act, 2017”. (See: 2017, c. 25, Sched. 9, s. 97 (4))

Disclosure

(3) The Minister and the General Manager shall disclose personal information, subject to such conditions as may be prescribed, if the disclosure is necessary for purposes related to the administration of this Act, the Commitment to the Future of Medicare Act, 2004 or the Independent Health Facilities Act or for such other purposes as may be prescribed, but shall not disclose the information if, in the opinion of the Minister or the General Manager, as the case may be, the disclosure is not necessary for those purposes. 2019, c. 15, Sched. 15, s. 3 (1).

Note: On a day to be named by proclamation of the Lieutenant Governor, subsection 4.1 (3) of the Act is amended by striking out “Independent Health Facilities Act” and substituting “Oversight of Health Facilities and Devices Act, 2017”. (See: 2019, c. 15, Sched. 15, s. 3 (2))

Same

(3.1) Where the Minister or General Manager is of the opinion that it is advisable to do so, the Minister or General Manager shall disclose personal information to a College within the meaning of the Regulated Health Professions Act, 1991 for the purpose of the administration of that Act or an Act named in Schedule 1 to that Act. 2019, c. 15, Sched. 15, s. 3 (1).

Obligation

(4) Before disclosing personal information obtained under the Act or under an agreement, the person who obtained it shall delete from it all names and identifying numbers, symbols or other particulars assigned to individuals unless,

(a) disclosure of the names or other identifying information is necessary for the purposes described in subsection 2 (5), or in subsection (3) or (3.1) of this section; or

(b) disclosure of the names or other identifying information is otherwise authorized under the Freedom of Information and Protection of Privacy Act or the Personal Health Information Protection Act, 2004.  1996, c. 1, Sched. H, s. 3; 2004, c. 3, Sched. A, s. 85 (1); 2019, c. 15, Sched. 15, s. 3 (3).

Section Amendments with date in force (d/m/y)

1996, c. 1, Sched. H, s. 3 - 01/05/1996

2004, c. 3, Sched. A, s. 85 (1) - 01/11/2004

2006, c. 19, Sched. L, s. 3 (2-4) - 22/06/2006

2017, c. 25, Sched. 9, s. 97 (4) - not in force

2019, c. 15, Sched. 15, s. 3 (1, 3) - 10/12/2019; 2019, c. 15, Sched. 15, s. 3 (2) - not in force

Joint Committee

Transitional

5 The Physician Payment Review Board, as it existed immediately before the coming into force of subsection 5 (1) of Schedule 15 to the Plan to Build Ontario Together Act, 2019, continues to exist to the extent necessary to conclude any matters where a review panel had been constituted and a hearing was in progress before that section came into force. 2019, c. 15, Sched. 15, s. 4 (1).

Note: On a day to be named by proclamation of the Lieutenant Governor, section 5 of the Act is repealed. (See: 2019, c. 15, Sched. 15, s. 4 (2))

Section Amendments with date in force (d/m/y)

1993, c. 32, s. 2 (2) - 14/12/1993; 1996, c. 1, Sched. H, s. 4 (1, 2) - 01/05/1996

2000, c. 26, Sched. H, s. 1 (1-3) - 06/12/2000

2007, c. 10, Sched. G, s. 2 (1) - 04/09/2007

2009, c. 33, Sched. 18, s. 11 (3-5) - 15/12/2009

2019, c. 15, Sched. 15, s. 4 (1) - 10/12/2019; 2019, c. 15, Sched. 15, s. 4 (2) - not in force

5.1 Repealed: 2019, c. 15, Sched. 15, s. 4 (1).

Section Amendments with date in force (d/m/y)

2007, c. 10, Sched. G, s. 2 (1, 4) - 04/09/2007

2017, c. 34, Sched. 46, s. 17 - 01/01/2018

2019, c. 15, Sched. 15, s. 4 (1) - 10/12/2019

5.2, 5.3 Repealed: 2019, c. 15, Sched. 15, s. 4 (1).

Section Amendments with date in force (d/m/y)

2007, c. 10, Sched. G, s. 2 (1) - 04/09/2007

2019, c. 15, Sched. 15, s. 4 (1) - 10/12/2019

5.4 Repealed: 2019, c. 15, Sched. 15, s. 4 (1).

Section Amendments with date in force (d/m/y)

2007, c. 10, Sched. G, s. 3- 01/05/2009

2009, c. 33, Sched. 18, s. 11 (6) - 15/12/2009

2019, c. 15, Sched. 15, s. 4 (1) - 10/12/2019

6 Repealed: 2015, c. 20, Sched. 15, s. 2.

Section Amendments with date in force (d/m/y)

1993, c. 32, s. 2 (3) - 14/12/1993; 1996, c. 1, Sched. H, s. 5 (1, 2) - 01/05/1996; 1998, c. 18, Sched. G, s. 54 (2, 3) - 01/02/1999

2006, c. 35, Sched. C, s. 53 -28/08/2007

2009, c. 26, s. 11 (2) - no effect; 2009, c. 33, Sched. 18, s. 11 (1, 7) - 15/12/2009

2015, c. 20, Sched. 15, s. 2 - 29/10/2015

Medical Eligibility Committee

Transitional

7 The Medical Eligibility Committee, as it existed immediately before the coming into force of subsection 6 (1) of Schedule 15 to the Plan to Build Ontario Together Act, 2019, continues to exist to the extent necessary to conclude any matter that was referred to it but with respect to which it had not made a recommendation before that section came into force. 2019, c. 15, Sched. 15, s. 5 (1).

Note: On a day to be named by proclamation of the Lieutenant Governor, section 7 of the Act is repealed. (See: 2019, c. 15, Sched. 15, s. 5 (2))

Section Amendments with date in force (d/m/y)

1996, c. 1, Sched. H, s. 6 - 01/05/1996

2019, c. 15, Sched. 15, s. 5 (1) - 10/12/2019; 2019, c. 15, Sched. 15, s. 5 (2) - not in force

Report to Assembly

8 Repealed:  1998, c. 18, Sched. G, s. 54 (4).

Section Amendments with date in force (d/m/y)

1998, c. 18, Sched. G, s. 54 (4) - 01/02/1999

Report to Assembly

9 The Minister shall make a report annually to the Lieutenant Governor in Council upon the affairs of the Plan and the Minister shall lay the report before the Assembly if it is in session or, if not, at the next session.  R.S.O. 1990, c. H.6, s. 9.

Ontario Health Insurance Plan

Ontario Health Insurance Plan continued

10 The Ontario Health Insurance Plan is continued for the purpose of providing for insurance against the costs of insured services on a non-profit basis on uniform terms and conditions available to all residents of Ontario, in accordance with this Act, and providing other health benefits related thereto.  R.S.O. 1990, c. H.6, s. 10.

Right to insurance

11 (1) Every person who is a resident of Ontario is entitled to become an insured person upon application therefor to the General Manager in accordance with this Act and the regulations.  R.S.O. 1990, c. H.6, s. 11 (1).

Establishing entitlement

(2) It is the responsibility of every person to establish his or her entitlement to be, or to continue to be, an insured person.  1994, c. 17, s. 70.

Military families

(2.1) Where an application under subsection (1) is made with respect to a spouse or dependant of a member of the Canadian Forces, he or she is exempt from any waiting period that would otherwise apply.  2007, c. 16, Sched. B, s. 1.

Change in information

(3) It is the responsibility of every person who has been registered as an insured person to report to the General Manager, within 30 days of its occurrence, every change in the information that was reported to the General Manager for the purposes of establishing his or her entitlement to be or continue to be an insured person.  2007, c. 10, Sched. C, s. 2.

Section Amendments with date in force (d/m/y)

1994, c.17, s. 70 - 01/04/1994

2000, c. 26, Sched. H, s. 1 (4) - 06/12/2000

2007, c. 10, Sched. C, s. 2 - 04/06/2007; 2007, c. 16, Sched. B, s. 1 - 03/12/2007

Health card

11.1 (1) The General Manager shall issue a health card to each insured person. 2019, c. 15, Sched. 15, s. 6.

Non-transferable

(2) A health card is non-transferable. 2019, c. 15, Sched. 15, s. 6.

Must be presented

(3) An insured person shall present their health card upon the request of the hospital, physician, practitioner or health facility from which the person receives insured services. 2019, c. 15, Sched. 15, s. 6.

Form of card

(4) A health card shall be in the form approved by the Minister. 2019, c. 15, Sched. 15, s. 6.

Property of Minister

(5) A health card remains the property of the Minister at all times. 2019, c. 15, Sched. 15, s. 6.

Taking possession of card

(6) A prescribed person may take possession of a health card that is surrendered to the person voluntarily. 2019, c. 15, Sched. 15, s. 6.

Return to General Manager

(7) On taking possession of a health card under subsection (6), the person shall return it to the General Manager as soon as possible. 2019, c. 15, Sched. 15, s. 6.

Protection from liability

(8) No proceeding for taking possession of a health card shall be commenced against a person who does so in accordance with subsection (6). 2019, c. 15, Sched. 15, s. 6.

Fees

(9) The General Manager may charge a fee provided in the regulations for a replacement health card, subject to any terms or conditions provided for in the regulations. 2019, c. 15, Sched. 15, s. 6.

Section Amendments with date in force (d/m/y)

1993, c.32, s. 2 (4) - 14/12/1993

2019, c. 15, Sched. 15, s. 6 - 10/12/2019

Insured services

11.2 (1) The following services are insured services for the purposes of the Act:

1. Prescribed services of hospitals and health facilities rendered under such conditions and limitations as may be prescribed.

2. Prescribed medically necessary services rendered by physicians under such conditions and limitations as may be prescribed.

3. Prescribed health care services rendered by prescribed practitioners under such conditions and limitations as may be prescribed.  1996, c. 1, Sched. H, s. 8.

Efforts to change sexual orientation or gender identity

(1.1) Despite subsection (1) and subject to the regulations, if any, any services that seek to change the sexual orientation or gender identity of a person are not insured services. 2015, c. 18, s. 1.

Exception

(1.2) The services mentioned in subsection (1.1) do not include,

(a) services that provide acceptance, support or understanding of a person or the facilitation of a person’s coping, social support or identity exploration or development; and

(b) sex-reassignment surgery or any services related to sex-reassignment surgery. 2015, c. 18, s. 1.

Exceptions

(2) Despite subsection (1), services that a person is entitled to under the insurance plan established under the Workplace Safety and Insurance Act, 1997 or under the Homes for Special Care Act or under any Act of the Parliament of Canada except the Canada Health Act are not insured services.  1996, c. 1, Sched. H, s. 8; 1997, c. 16, s. 7.

Restrictions

(3) Such services as may be prescribed are insured services only if they are provided in or by designated hospitals or health facilities.

Same

(4) Such services as may be prescribed are insured services only if they are provided to insured persons in prescribed age groups.

Same

(5) Such services as may be prescribed are not insured services when they are provided to insured persons in prescribed age groups.  1996, c. 1, Sched. H, s. 8.

Regulations

(6) The Lieutenant Governor in Council may make regulations,

(a) clarifying the meaning of “services”, “sexual orientation”, “gender identity” or “seek to change” for the purposes of subsection (1.1);

(b) exempting services from the application of subsection (1.1). 2015, c. 18, s. 1.

Section Amendments with date in force (d/m/y)

1996, c. 1, Sched. H, s. 8 - 01/05/1996; 1997, c. 16, s. 7 - 1/01/1998

2015, c. 18, s. 1 - 04/06/2015

Entitlement to insured services

12 (1) Every insured person is entitled to payment to himself or herself or on his or her behalf for, or to be otherwise provided with, insured services in the amounts and subject to such conditions and co-payments, if any, as are prescribed.  R.S.O. 1990, c. H.6, s. 12.

(2), (3) Repealed:  2007, c. 10, Sched. G, s. 4.

Section Amendments with date in force (d/m/y)

1996, c. 1. Sched. H, s. 9 - no effect

2007, c. 10, Sched. G, s. 4 - 04/09/2007

Choice of physician or practitioner

13 This Act shall not be administered or construed to affect the right of an insured person to choose his or her own physician or practitioner, and does not impose any obligation upon any physician or practitioner to treat an insured person.  R.S.O. 1990, c. H.6, s. 13.

Other insurance prohibited

14 (1) Every contract of insurance, other than insurance provided under section 268 of the Insurance Act, for the payment of or reimbursement or indemnification for all or any part of the cost of any insured services other than,

(a) any part of the cost of hospital, ambulance and long-term care home services that is not paid by the Plan;

(b) compensation for loss of time from usual or normal activities because of disability requiring insured services;

(c) any part of the cost that is not paid by the Plan for such other services as may be prescribed when they are performed by such classes of persons or in such classes of facilities as may be prescribed,

performed in Ontario for any person eligible to become an insured person under this Act, is void and of no effect in so far as it makes provision for insuring against the costs payable by the Plan and no person shall enter into or renew such a contract.  R.S.O. 1990, c. H.6, s. 14 (1); 1996, c. 1, Sched. H, s. 10; 2007, c. 8, s. 209.

Resident not to benefit from prohibited insurance

(2) A resident shall not accept or receive any benefit under any contract of insurance prohibited under subsection (1) whereby the resident or his or her dependants may be provided with or reimbursed or indemnified for all or any part of the costs of, or costs directly related to the provision of any insured service.  R.S.O. 1990, c. H.6, s. 14 (2).

Exceptions

(3) Subsections (1) and (2) do not apply to a contract of insurance entered into by a resident whose principal employment is in the United States of America and who is entitled to enter into the contract by virtue of his or her employment.  R.S.O. 1990, c. H.6, s. 14 (3).

Idem

(4) Where payment is made to or on behalf of an insured person under a contract or agreement referred to in subsection (3) and such payment is less than would have been made under this Act and the regulations for the same insured services, the General Manager may pay to or on behalf of the insured person the difference between the amount paid under the contract or agreement and the amount established by the regulations for the insured services for which payment was made under the contract or agreement.  R.S.O. 1990, c. H.6, s. 14 (4).

Exception

(5) Subsections (1) and (2) do not apply during the period that a person who is a resident must wait to be registered as an insured person.  2000, c. 26, Sched. H, s. 1 (5); 2006, c. 19, Sched. L, s. 3 (5).

Section Amendments with date in force (d/m/y)

1996, c. 1, Sched. H, s. 10 - 01/05/1996;

2000, c. 26, Sched. H, s. 1 (5) - 06/12/2000

2006, c. 19, Sched. L, s. 3 (5) - 22/06/2006

2007, c. 8, s. 209 - 01/07/2010

Billing – physicians

15 (1) A physician shall submit all of his or her accounts for the performance of insured services rendered to an insured person directly to the Plan in accordance with and subject to the requirements of this Act and the regulations, unless an agreement under subsection 2 (2) provides otherwise.  2004, c. 5, s. 36.

Requirements where Plan billed

(2) Where a physician submits his or her accounts directly to the Plan under this section,

(a) payment shall be made,

(i) directly to the physician, or

(ii) as the physician directs in accordance with section 16.1; and

(b) the payment by the Plan for the insured services rendered to an insured person constitutes payment in full of the account.  2004, c. 5, s. 36.

Where s. 2 (2) applies

(3) Where an account is submitted to the Plan in accordance with subsection 2 (2) with respect to insured services rendered to an insured person, the payment by the Plan constitutes payment in full of the account.  2004, c. 5, s. 36.

Billing number

(4) A physician may only submit claims for payment to the Plan, or receive payments from the Plan pursuant to an arrangement under clause 2 (2) (a), and an insured person may only submit claims for payment to the Plan that have been presented by a physician, if the physician has been granted a billing number by the General Manager. 2019, c. 15, Sched. 15, s. 7.

Section Amendments with date in force (d/m/y)

2000, c. 42, Sched., s. 17 (1, 2) - 01/11/2001

2001, c. 8, s. 32 (1, 2) - 01/11/2001

2004, c. 5, s. 36 - 23/09/2004

2019, c. 15, Sched. 15, s. 7 - 10/12/2019

Billing – practitioners

15.1 (1) A designated practitioner shall submit all of his or her accounts for the performance of insured services directly to the Plan in accordance with and subject to the requirements of this Act and the regulations, unless an agreement under subsection 2 (2) provides otherwise.  2004, c. 5, s. 36.

Same – non-designated

(2) A non-designated practitioner shall submit directly to the Plan that part of his or her account for insured services rendered to an insured person that is payable by the Plan, unless an agreement under subsection 2 (2) provides otherwise.  2004, c. 5, s. 36.

Requirements where Plan billed

(3) Where a practitioner submits his or her accounts directly to the Plan under this section,

(a) payment shall be made,

(i) directly to the practitioner, or

(ii) as the practitioner directs in accordance with section 16.1;

(b) in the case of a designated practitioner, the payment by the Plan for the insured services performed constitutes payment in full of the account; and

(c) in the case of a non-designated practitioner, the payment by the Plan for that part of his or her account for an insured service rendered to an insured person that is payable by the Plan constitutes payment in full of that part of the account.  2004, c. 5, s. 36.

Where s. 2 (2) applies

(4) Where an account is submitted to the Plan in accordance with subsection 2 (2) with respect to insured services rendered to an insured person, the payment by the Plan constitutes payment in full of the account.  2004, c. 5, s. 36.

Billing number

(4.1) A practitioner may only submit claims for payment to the Plan, or receive payments from the Plan pursuant to an arrangement under clause 2 (2) (a), if the practitioner has been granted a billing number by the General Manager. 2019, c. 15, Sched. 15, s. 8.

Interpretation

(5) In this section,

“designated practitioner”, “non-designated practitioner” and “practitioner” have the same meanings as in Part II of the Commitment to the Future of Medicare Act, 2004.  2004, c. 5, s. 36.

Section Amendments with date in force (d/m/y)

2004, c. 5, s. 36 - 23/09/2004

2019, c. 15, Sched. 15, s. 8 - 10/12/2019

Transitional

15.2 (1) The following rules apply with respect to a physician or designated practitioner to whom subsection 11 (7) of the Commitment to the Future of Medicare Act, 2004 applies:

1. Sections 15 and 15.1 do not apply to him or her, other than subsection 15 (4).

2. Subsections 15 (5), 16 (5), 16.1 (2), 17 (2), 25 (2) to (9), and 27.2 (3) and (4), as applicable, as they existed immediately before their repeal by the Commitment to the Future of Medicare Act, 2004 continue to apply to the physician or designated practitioner, as the case may be, as if they had not been repealed, except in respect of any prescribed accounts or classes of accounts, and subject to any prescribed circumstances or conditions.

3. Where, under subsection 27.2 (3), the physician or designated practitioner is required to temporarily submit his or her accounts directly to the Plan, the submission of the accounts is not a deemed election for the purposes of subsection 11 (6) of the Commitment to the Future of Medicare Act, 2004, but subsection 10 (3) of that Act applies to him or her during the time that he or she is temporarily required to submit accounts directly to the Plan.

4. All other applicable provisions of this Act apply to the physician or designated practitioner.  2004, c. 5, s. 36; 2019, c. 15, Sched. 15, s. 9.

Same

(2) Where a designated practitioner to whom section 11 of the Commitment to the Future of Medicare Act, 2004 applies submits his or her accounts for the rendering of insured services to insured persons directly to the Plan, subsections 25 (2) to (9) of this Act, as they existed before their repeal, apply to him or her with respect to accounts submitted before he or she commenced submitting his or her accounts directly to the Plan.  2004, c. 5, s. 36; 2007, c. 10, Sched. G, s. 5 (1).

Same

(2.1) Despite paragraph 2 of subsection (1), subsections 25 (3), (4), (5), (6) and (8), as they existed immediately before their repeal by the Commitment to the Future of Medicare Act, 2004 cease to apply to physicians on the day that this subsection comes into force.  2007, c. 10, Sched. G, s. 5 (2).

Interpretation

(3) In this section,

“physician” and “designated practitioner” mean a physician or designated practitioner within the meaning of Part II of the Commitment to the Future of Medicare Act, 2004.  2004, c. 5, s. 36.

Section Amendments with date in force (d/m/y)

2004, c. 5, s. 36 - 23/09/2004

2007, c. 10, Sched. G, s. 5 (1, 2) - 04/09/2007

2019, c. 15, Sched. 15, s. 9 - 10/12/2019

Billing number — health facilities

15.3 A health facility may only submit claims for payment to the Plan, or receive payments from the Plan pursuant to an arrangement under clause 2 (2) (a), if the health facility has been granted a billing number by the General Manager. 2019, c. 15, Sched. 15, s. 10.

Section Amendments with date in force (d/m/y)

2019, c. 15, Sched. 15, s. 10 - 10/12/2019

Billing numbers

16 (1) An account or claim submitted in the name of a physician or practitioner in conjunction with the billing number issued to the physician or practitioner, and any payment made pursuant to the account or claim is deemed to have been,

(a) submitted personally by the physician or practitioner;

(b) paid to the physician or practitioner personally;

(c) received by the physician or practitioner personally; and

(d) made by and submitted with the consent and knowledge of the physician or practitioner.  2004, c. 5, s. 36.

Health facilities

(2) Subsection (1) applies with necessary modifications to health facilities.  2004, c. 5, s. 36.

Applies despite direction

(3) This section applies despite a direction given pursuant to section 16.1.  2004, c. 5, s. 36.

Exception

(4) This section does not apply to an account, claim or payment in the circumstances and on the conditions prescribed in the regulations.  2004, c. 5, s. 36.

(5) Repealed: 2019, c. 15, Sched. 15, s. 11.

Section Amendments with date in force (d/m/y)

2000, c. 42, Sched., s. 18 (1, 2) - 01/11/2001

2001, c. 8, s. 33 (1, 2) - 01/11/2001

2004, c. 5, s. 36 - 23/09/2004

2019, c. 15, Sched. 15, s. 11 - 10/12/2019

Direction to make payments to entity

16.1 (1) A physician or a practitioner may direct that payments for services performed by the physician or practitioner and to which the physician or practitioner is lawfully entitled may be directed to such person or entity as may be prescribed and in such circumstances and on such conditions as may be prescribed, including such requirements and other matters with respect to directions as may be prescribed.  2000, c. 42, Sched., s. 19.

(2) Repealed:  2004, c. 5, s. 37.

Person or entity not entitled

(3) The entitlement to payment for services performed by a physician or a practitioner is that of the physician or practitioner and not that of the person or entity to which the physician or practitioner has directed that such a payment be made.  2000, c. 42, Sched., s. 19.

Repayment to Plan

(4) Where payment is made by the Plan to a person or entity pursuant to subsection (1), any money owing to the Plan by the physician or the practitioner may be recovered from the physician or practitioner personally.  2000, c. 42, Sched., s. 19.

Interpretation

(5) A reference in this Act or the regulations to a payment to a physician or a practitioner where the reference relates to a payment for services performed by the physician or practitioner shall be deemed to include a payment made to a person or entity pursuant to a direction made under this section.  2000, c. 42, Sched., s. 19.

Keeping and inspection of records

(6) Section 37.1 applies with necessary modifications to a person or entity to which payment is made pursuant to a direction by a physician or practitioner. 2015, c. 20, Sched. 15, s. 3 (1).

Same

(7) Subsections 37 (5), (6) and (7) apply with necessary modifications to a person or entity to which payment is made pursuant to a direction by a physician in respect of the records required to be kept. 2015, c. 20, Sched. 15, s. 3 (2).

Section Amendments with date in force (d/m/y)

2000, c. 42, Sched., s. 19 - 01/11/2001

2004, c. 5, s. 37- 23/09/2004

2007, c. 10, Sched. G, s. 6 - 04/09/2007

2015, c. 20, Sched. 15, s. 3 (1, 2) - 29/10/2015

Billing numbers

16.2 Subject to an application process set out in the regulations, if any, the General Manager shall grant a billing number to a physician, practitioner or health facility. 2019, c. 15, Sched. 15, s. 12.

Section Amendments with date in force (d/m/y)

2019, c. 15, Sched. 15, s. 12 - 10/12/2019

Accounts for insured services

17 (1) Physicians, practitioners and health facilities shall prepare accounts for their insured services in such form as the General Manager may require. The accounts must meet the prescribed requirements.  1996, c. 1, Sched. H, s. 11.

(2) Repealed:  2004, c. 5, s. 38.

Time for submitting

(3) The physician, practitioner, health facility or, in the case of a patient who is billed directly, the patient must submit an account for an insured service to the General Manager within such time after the service is performed as may be prescribed. When submitted, the account must be in the required form and meet the prescribed requirements.  1996, c. 1, Sched. H, s. 11; 2000, c. 26, Sched. H, s. 1 (6).

Section Amendments with date in force (d/m/y)

1996, c. 1, Sched. H, s. 11 - 01/05/1996

2000, c. 26, Sched. H, s. 1 (6) - 24/01/2002

2004, c. 5, s. 38 - 23/09/2004

Fees payable for insured services

17.1 (1) Subject to section 18, a physician or practitioner who has been granted a billing number and who submits a claim for payment to the General Manager in accordance with this Act for insured services provided by the physician or practitioner shall be paid in accordance with this Act and the regulations. 2019, c. 15, Sched. 15, s. 13.

Same

(2) An insured person who submits a claim for payment to the General Manager in accordance with this Act for insured services provided by a physician or practitioner who has been granted a billing number shall be paid in accordance with this Act and the regulations. 2019, c. 15, Sched. 15, s. 13.

Amount

(3) The basic fee payable for an insured service is the amount set out in the regulations. The amount may differ for different classes of physician or practitioner.  1996, c. 1, Sched. H, s. 12.

Same

(4) The regulations may provide that the basic fee for an insured service is nil.  1996, c. 1, Sched. H, s. 12.

Adjustment of amount

(5) The basic fee payable for an insured service performed by a physician or practitioner may be increased or decreased as provided in the regulations based upon one or more of the following factors:

1. The professional specialization of the physician or practitioner.

2. The relevant professional experience of the physician or practitioner.

3. The frequency with which the physician or practitioner provides the insured service.

4. The geographic area in which the insured service is provided.

5. The setting in which the insured service is provided.

6. The period of time when the insured service is provided.

7. Such other factors as may be prescribed.  1996, c. 1, Sched. H, s. 12.

Threshold amount

(6) If the total amount payable for one or more prescribed insured services provided by a physician or practitioner during a prescribed period equals or exceeds a prescribed amount, the fee payable for an insured service may be increased or decreased in accordance with the regulations. The fee payable may be reduced to nil.  1996, c. 1, Sched. H, s. 12.

Same

(7) A change made under subsection (6) in the fee payable for an insured service is imposed in addition to any change made under subsection (5) in the basic fee payable.  1996, c. 1, Sched. H, s. 12.

(8) Repealed:  2007, c. 10, Sched. G, s. 7.

Section Amendments with date in force (d/m/y)

1996, c. 1, Sched. H, s. 12 - 01/05/1996

2007, c. 10, Sched. G, s. 7 - 04/09/2007

2019, c. 15, Sched. 15, s. 13 - 10/12/2019

Fees payable, health facilities

17.2 (1) Subject to sections 18 and 28, a health facility that has been granted a billing number and that submits a claim for payment to the General Manager in accordance with this Act for insured services performed by the facility shall be paid in accordance with this Act and the regulations. 2019, c. 15, Sched. 15, s. 14.

Same

(2) Subsections 17.1 (3) and (4) apply, with necessary modifications, with respect to the basic fee payable for an insured service. 1996, c. 1, Sched. H, s. 12.

Adjustment of amount

(3) The basic fee payable for an insured service performed by a health facility may be increased or decreased as provided in the regulations based upon such factors as may be prescribed. 1996, c. 1, Sched. H, s. 12.

Threshold amount

(4) Subsections 17.1 (6) and (7) apply, with necessary modifications, with respect to the fee payable to a health facility.  1996, c. 1, Sched. H, s. 12.

Section Amendments with date in force (d/m/y)

1996, c. 1, Sched. H, s. 12 - 01/05/1996

2019, c. 15, Sched. 15, s. 14 - 10/12/2019

Information

17.3 (1) Every physician, practitioner, health facility, hospital and independent health facility shall give the General Manager records or other information, including personal information, that the General Manager may require,

(a) for purposes related to the administration of this Act, the Commitment to the Future of Medicare Act, 2004 or the Independent Health Facilities Act; or

(b) for other prescribed purposes. 2019, c. 15, Sched. 15, s. 15 (1).

Note: On a day to be named by proclamation of the Lieutenant Governor, subsection 17.3 (1) of the Act is repealed and the following substituted: (See: 2019, c. 15, Sched. 15, s. 15 (2))

Information

(1) Every physician, practitioner, health facility, hospital and community health facility shall give the General Manager records or other information, including personal information, that the General Manager may require,

(a) for purposes related to the administration of this Act, the Commitment to the Future of Medicare Act, 2004 or the Oversight of Health Facilities and Devices Act, 2017; or

(b) for other prescribed purposes. 2019, c. 15, Sched. 15, s. 15 (2).

Same

(2) Such persons or organizations as may be prescribed shall give the General Manager such information, including personal information, as may be prescribed and such information as the General Manager may require for the purpose of administering this Act. 2019, c. 15, Sched. 15, s. 15 (1).

Form and time

(3) The records and other information shall be provided in the form, and within the time, specified by the General Manager. 2019, c. 15, Sched. 15, s. 15 (1).

Application

(4) This section applies despite anything in the Regulated Health Professions Act, 1991, an Act listed in Schedule 1 to the Regulated Health Professions Act, 1991, or any regulations made under those Acts. 2019, c. 15, Sched. 15, s. 15 (1).

Rules re providing records and information

(5) Where the General Manager requires a physician, practitioner or health facility that has been granted a billing number to provide records or other information, the following rules apply:

1. The physician, practitioner or facility shall submit copies of the requested records or other information and, where required by the General Manager, shall include a signed certificate of authenticity and a signed copy of an audit trail for electronic records.

2. If the General Manager is not satisfied with the copies of the requested records or other information, the General Manager may require the physician, practitioner or facility to produce the original documents to the General Manager, and the documents shall be returned to the physician, practitioner or facility in a timely manner after copies have been made.

3. Where a physician, practitioner or facility fails to produce the copies or originals of records or other information required under this section, the General Manager may, on notice to the physician, practitioner or facility, apply to a justice or a provincial judge for an order compelling production of the required records or other information and the justice or provincial judge may issue the order if they are satisfied that there are reasonable grounds for believing that the physician, practitioner or facility failed to produce the records or other information. 2019, c. 15, Sched. 15, s. 15 (1).

Electronic records

(6) Where records required to be kept by physicians for the purposes of this Act are in electronic form, they shall have the characteristics of electronic records set out in the regulations under the Medicine Act, 1991. 2019, c. 15, Sched. 15, s. 15 (1).

Certificate of authenticity

(7) A certificate of authenticity required under this section shall be in a form acceptable to the General Manager unless otherwise prescribed. 2019, c. 15, Sched. 15, s. 15 (1).

Section Amendments with date in force (d/m/y)

2019, c. 15, Sched. 15, s. 15 (1) - 10/12/2019; 2019, c. 15, Sched. 15, s. 15 (2) - not in force

Record-keeping

17.4 (1) For the purposes of this Act, every physician, practitioner and health facility shall maintain such records as may be necessary to establish whether they have provided an insured service to a person. 2019, c. 15, Sched. 15, s. 15 (1).

Same

(2) For the purposes of this Act, every physician, practitioner and health facility shall maintain such records as may be necessary to demonstrate that a service for which they prepare or submit a claim for payment is the service that they provided. 2019, c. 15, Sched. 15, s. 15 (1).

Same

(3) For the purposes of this Act, every physician and health facility shall maintain such records as may be necessary to establish whether a service they have provided is medically necessary. 2019, c. 15, Sched. 15, s. 15 (1).

Same

(4) For the purposes of this Act, every practitioner and health facility shall maintain such records as may be necessary to establish whether a service they have provided is therapeutically necessary. 2019, c. 15, Sched. 15, s. 15 (1).

Same

(5) The records described in subsections (1), (2), (3) and (4) must be prepared promptly when the service is provided. 2019, c. 15, Sched. 15, s. 15 (1).

Presumption

(6) In the absence of a record described in subsection (1), (3) or (4), it is presumed that an insured service was provided and that the basic fee payable is nil. 2019, c. 15, Sched. 15, s. 15 (1).

Different service provided

(7) In the absence of a record described in subsection (2), the insured service that was provided is presumed to be the insured service, if any, that the General Manager considers to be described in the records as having been provided and not the insured service for which the claim for payment was prepared or submitted. 2019, c. 15, Sched. 15, s. 15 (1).

Section Amendments with date in force (d/m/y)

2019, c. 15, Sched. 15, s. 15 (1) - 10/12/2019

Refusal to pay if not required form, etc.

17.5 The General Manager shall refuse to pay for an insured service if the claim for payment for the service is not prepared in the required form, does not meet the prescribed requirements or is not submitted to the General Manager within the prescribed time. However, the General Manager may pay for the service if, in the General Manager’s opinion, there are extenuating circumstances. 2019, c. 15, Sched. 15, s. 15 (1).

Section Amendments with date in force (d/m/y)

2019, c. 15, Sched. 15, s. 15 (1) - 10/12/2019

Payment of accounts

18 (1) The General Manager shall determine all issues relating to accounts for insured services in accordance with this Act and shall make the payments from the Plan that are authorized under this Act. 2019, c. 15, Sched. 15, s. 16 (1).

Practitioners and health facilities, refuse to pay

(2) The General Manager may refuse to pay a claim for payment for an insured service submitted by a practitioner or health facility or may pay a reduced amount in the following circumstances:

1. If the General Manager is of the opinion that all or part of the insured service was not in fact rendered.

2. If the General Manager is of the opinion that the nature of the service is misrepresented, whether deliberately or inadvertently.

3. For a service provided by a practitioner, if the General Manager is of the opinion, after consulting with a practitioner who is qualified to provide the same service, that all or part of the service was not therapeutically necessary.

4. For a service provided by a health facility, if the General Manager is of the opinion, after consulting with a physician or practitioner, that all or part of the service was not medically or therapeutically necessary.

5. If the General Manager is of the opinion that all or part of the service was not provided in accordance with accepted professional standards and practice.

6. In such other circumstances as may be prescribed. 2019, c. 15, Sched. 15, s. 16 (1).

Practitioners and health facilities, reimbursement

(3) The General Manager may require a practitioner or health facility to reimburse the Plan for an amount paid for a service if, after the payment is made, the General Manager is of the opinion that a circumstance described in subsection (2) exists. 2019, c. 15, Sched. 15, s. 16 (1).

Exception

(4) Despite subsection (3), the General Manager shall not require a practitioner to reimburse the Plan if the sole reason for requiring the reimbursement is that a circumstance described in paragraph 3 or 5 of subsection (2) exists. 2019, c. 15, Sched. 15, s. 16 (1).

Notice, practitioners and health facilities

(5) The General Manager shall give notice to a practitioner or health facility of a decision to refuse to pay for a service, to pay a reduced amount or to require that the Plan be reimbursed. 2019, c. 15, Sched. 15, s. 16 (1).

Physicians, refusal to pay

(6) Under any of the following circumstances, the General Manager may, with respect to a claim for payment for an insured service submitted by a physician, refuse to pay the claim, pay a reduced amount with respect to the claim, pay for the service the General Manager considers to have been provided and not the service described in the claim that was submitted, or, with respect to payment for an insured service that has been made to a physician, request a hearing by the Appeal Board:

1. If the General Manager is of the opinion that any or all of the following apply:

i. all or part of the service was not in fact rendered,

ii. the service has not been rendered in accordance with the conditions and limitations set out in this Act and the regulations, or

iii. there is an absence of a record described in subsection 17.4 (1), (2) or (3).

2. If the General Manager is of the opinion that the nature of the service is misrepresented, whether deliberately or inadvertently.

3. If the General Manager is of the opinion, after consulting with a physician, that all or part of the service was not medically necessary.

4. If the General Manager is of the opinion that all or part of the service was not provided in accordance with accepted professional standards and practice.

5. In such other circumstances as may be prescribed. 2019, c. 15, Sched. 15, s. 16 (1).

Notice, physicians

(7) Where the General Manager is of the opinion that a circumstance described in subsection (6) exists and has made a decision to refuse to pay for a service or pay a reduced amount to a physician for a service, or to pay for the service the General Manager considers to have been provided and not the service described in the claim, the General Manager shall notify the physician of the decision and the action taken. 2019, c. 15, Sched. 15, s. 16 (1).

Physicians, post-payment

(8) Where the General Manager has made a payment to a physician for a service and the General Manager is, after providing the physician with the opportunity to provide written submissions, of the opinion that a circumstance described in subsection (6) exists and that reimbursement to the Plan is required, the General Manager may give notice to the Appeal Board requesting it to hold a hearing and at the same time give notice of the request for the hearing to the physician. 2019, c. 15, Sched. 15, s. 16 (1).

Not a decision

(9) For greater certainty, a refusal to pay under section 17.5 is not a decision for the purposes of this section. 2019, c. 15, Sched. 15, s. 16 (1).

Section Amendments with date in force (d/m/y)

1996, c. 1, Sched. H, s. 13 - 01/05/1996

2007, c. 10, Sched. G, s. 8 (1, 2)- 04/09/2007

2019, c. 15, Sched. 15, s. 16 (1) - 10/12/2019

Reimbursement, non-entitled person

18.0.1 The General Manager may make a decision to require a person to reimburse the Plan for an amount paid for an insured service rendered to the person if, after the payment is made, the General Manager determines that the person was not an insured person and was not entitled to have a payment paid from the Plan with respect to the service. 2019, c. 15, Sched. 15, s. 16 (1).

Section Amendments with date in force (d/m/y)

2004, c. 13, s. 1 - 01/09/2004

2007, c. 10, Sched. G, s. 9, 10 - 04/09/2007

2019, c. 15, Sched. 15, s. 16 (1) - 10/12/2019

Debt

18.0.2 A requirement to reimburse the Plan created by a decision of the General Manager under subsection 18 (3) creates a debt owed to the Crown in right of Ontario in the amount set out in the decision of the General Manager, and a requirement to reimburse the Plan created by a decision of the Appeal Board creates a debt owed to the Crown in right of Ontario in the amount set out in the decision of the Appeal Board. 2019, c. 15, Sched. 15, s. 16 (1).

Section Amendments with date in force (d/m/y)

2004, c. 13, s. 1 - 01/09/2004

2007, c. 10, Sched. G, s. 9, 10 - 04/09/2007

2019, c. 15, Sched. 15, s. 16 (1) - 10/12/2019

Transitional

18.0.3 Sections 18 and 18.0.1 apply whether the service or payment in question occurred before or after the coming into force of subsection 17 (1) of Schedule 15 to the Plan to Build Ontario Together Act, 2019. 2019, c. 15, Sched. 15, s. 16 (1).

Note: On a day to be named by proclamation of the Lieutenant Governor, section 18.0.3 of the Act is repealed. (See: 2019, c. 15, Sched. 15, s. 16 (2))

Section Amendments with date in force (d/m/y)

2004, c. 13, s. 1 - 01/09/2004

2007, c. 10, Sched. G, s. 9, 10 - 04/09/2007

2019, c. 15, Sched. 15, s. 16 (1) - 10/12/2019; 2019, c. 15, Sched. 15, s. 16 (2) - not in force

Settlement

18.0.4 Nothing in this Act prevents the General Manager and a person, physician, practitioner or health facility from entering into an agreement at any time, and despite any other provision of this Act, with respect to amounts to be paid or recovered with respect to claims for services. However, for greater certainty, the General Manager is not required to enter into any such agreement. 2019, c. 15, Sched. 15, s. 16 (1).

Section Amendments with date in force (d/m/y)

2004, c. 13, s. 1 - 01/09/2004

2007, c. 10, Sched. G, s. 9, 10 - 04/09/2007

2019, c. 15, Sched. 15, s. 16 (1) - 10/12/2019

18.0.5 Repealed:  R.S.O. 1990, c. H.6, s. 18.0.5 (2). (See:  2007, c. 10, Sched. G, s. 10.)

Section Amendments with date in force (d/m/y)

2004, c. 13, s. 1 - 01/09/2004

2007, c. 10, Sched. G, s. 10 - 04/09/2007

Settlement

18.0.6 (1) Where, during the time that any of sections 18.0.1, 18.0.2, 18.0.3 and 18.0.4 and paragraph 3 of subsection 20 (1) are in force, the General Manager and a physician come to an agreement regarding a matter to which one of those sections applies, the General Manager shall be deemed to have had the authority to enter into the agreement, and no action shall, either during the time they are in force or after, be commenced against any of the following as a result of entering into the agreement:

1. The General Manager.

2. The Minister, the Crown in right of Ontario or an employee or agent of the Crown.

3. The Medical Review Committee, any of its members, inspectors or employees or agents, if any.

4. The Appeal Board or any of its members, employees or agents.  2007, c. 10, Sched. G, s. 11 (1).

(2), (3) Repealed: 2019, c. 15, Sched. 15, s. 17.

Section Amendments with date in force (d/m/y)

2007, c. 10, Sched. G, s. 11 (1-3) - 04/09/2007

2019, c. 15, Sched. 15, s. 17 - 10/12/2019

Transitional

18.0.7 (1) Where, by virtue of subsection 18.0.2 (11) as it existed during the time it was in force, payments to a physician continued to be suspended, the suspension shall remain in effect until the physician has complied with subsections 37 (1) and (3) to the satisfaction of the General Manager.  2007, c. 10, Sched. G, s. 12.

(2) Repealed: 2019, c. 15, Sched. 15, s. 18.

Section Amendments with date in force (d/m/y)

2007, c. 10, Sched. G, s. 12 - 04/09/2007

2019, c. 15, Sched. 15, s. 18 - 10/12/2019

18.1 Repealed: 2015, c. 20, Sched. 15, s. 4.

Section Amendments with date in force (d/m/y)

1996, c. 1, Sched. H, s. 13 - 01/05/1996

2002, c. 18, Sched. I, s. 8 (1-6) - 26/11/2002

2007, c. 10, Sched. G, s. 13 (1-15) - 04/09/2007

CTS 23 OC 07 - 1

Recovery from requesting physician

18.2 If the General Manager is of the opinion that a service performed by a physician, practitioner, health facility or independent health facility is not medically necessary, and that service was requested by a physician other than the one who performed the service, the General Manager may give notice to the Appeal Board of a request to hold a hearing and at the same time give notice to the physician who requested the provision of the service. 2019, c. 15, Sched. 15, s. 19.

Section Amendments with date in force (d/m/y)

1996, c. 1, Sched. H, s. 13 - 01/05/1996

2002, c. 18, Sched. I, s. 8 (7-9) - 26/11/2002

2007, c. 10, Sched. G, s. 14 - 31/03/2010

2017, c. 25, Sched. 9, s. 97 (5) - no effect - see 2019, c. 15, Sched. 15, s. 19 - 10/12/2019

2019, c. 15, Sched. 15, s. 19 - 10/12/2019

Note: On a day to be named by proclamation of the Lieutenant Governor, the Act is amended by adding the following section:

Practitioners and health facilities

18.2.1 If the General Manager is of the opinion that a service performed by a physician, practitioner, health facility, hospital or independent health facility is not medically necessary, or is rendered in other prescribed circumstances, and that service was requested by a practitioner or health facility,

(a) the practitioner or health facility who requested the provision of the service is liable to pay to the Plan the amount paid by the Plan to the physician, practitioner, health facility, hospital or independent health facility that performed the service; and

(b) the General Manager may make a direction requiring the amount owing to be paid to the Plan, and recover the amount through any method permitted under this Act.  2009, c. 26, s. 11 (3).

See: 2009, c. 26, ss. 11 (3), 27 (2).

Note: On a day to be named by proclamation of the Lieutenant Governor, section 18.2.1 of the Act is amended by striking out “independent health facility” wherever it occurs and substituting “community health facility” in each case. (See: 2017, c. 25, Sched. 9, s. 97 (6))

Section Amendments with date in force (d/m/y)

2009, c. 26, s. 11 (3) - not in force

2017, c. 25, Sched. 9, s. 97 (6) - not in force

Interest

18.3 Where the General Manager has required reimbursement under section 18, interest accrues on the amount that is required to be paid commencing on the date of the General Manager’s decision at the rate for postjudgment interest provided for under section 127 of the Courts of Justice Act. 2019, c. 15, Sched. 15, s. 19.

Section Amendments with date in force (d/m/y)

2007, c. 10, Sched. G, s. 14 - 31/03/2010

2019, c. 15, Sched. 15, s. 19 - 10/12/2019

19 Repealed:  2019, c. 15, Sched. 15, s. 20.

Section Amendments with date in force (d/m/y)

2019, c. 15, Sched. 15, s. 20 - 10/12/2019

19.1 Repealed:  2004, c. 5, s. 39.

Section Amendments with date in force (d/m/y)

1993, c. 32, s. 2 (5) - 14/12/1993; 1996, c. 1, Sched. H, s. 14 - no effect

2004, c. 5, s. 39 - 23/09/2004

Refusal of claims, entitlement

19.2 (1) The General Manager may refuse a claim for payment for insured services if, in the opinion of the General Manager, the person who received the services was not an insured person at the time the services were rendered.

Direction by Appeal Board to pay

(2) The Appeal Board may direct the General Manager to pay any claims he or she refused to pay under subsection (1) if, after a hearing, the Appeal Board determines that the person to whom the insured services were rendered was an insured person at the time the services were rendered.  1994, c. 17, s. 71.

Section Amendments with date in force (d/m/y)

1994, c. 17, s. 71 - 18/05/1994

Hearing by Appeal Board

20 (1) The following persons may request a hearing by the Appeal Board:

1. A person who has applied to become or continue to be an insured person, in respect of the review of a decision of the General Manager refusing the application.

2. An insured person who has made a claim for payment for insured services, in respect of the review of a decision of the General Manager refusing the claim or reducing the amount so claimed to an amount less than the amount payable by the Plan.

3. A physician, in respect of a decision of the General Manager referred to in subsection 18 (7).

4. The General Manager, where the General Manager has formed an opinion under subsection 18 (8) or section 18.2.

5. A person who has been required to reimburse the Plan under section 18.0.1, in respect of the review of the decision of the General Manager requiring the reimbursement. 2019, c. 15, Sched. 15, s. 21 (1).

Notice of request

(2) A person or physician requesting a hearing under paragraph 1, 2, 3 or 5 of subsection (1) shall file a notice of the request within 30 days after receiving notice of the decision of the General Manager. 2019, c. 15, Sched. 15, s. 21 (1).

Section Amendments with date in force (d/m/y)

1996, c. 1, Sched. H, s. 15 - 01/05/1996

2002, c. 18, Sched. I, s. 8 (10, 11) - 26/11/2002

2007, c. 10, Sched. G, s. 15 - 04/09/2007

2009, c. 26, s. 11 (4) - no effect - see 2019, c. 15, Sched. 15, s. 21 (1) - 10/12/2019

2015, c. 20, Sched. 15, s. 5 (1, 2) - 29/10/2015

2019, c. 15, Sched. 15, s. 21 (1) - 10/12/2019

Powers of Appeal Board

21 (1) If a person requests a hearing under section 20, the Appeal Board shall appoint a time for and hold the hearing and following the hearing may, by order, direct the General Manager to take such action as the Appeal Board considers the General Manager should take in accordance with this Act and the regulations. 2019, c. 15, Sched. 15, s. 21 (1).

Extension of time for hearing

(2) The Appeal Board may extend the time for the giving of notice by a person requesting a hearing under this section, either before or after expiration of such time, where it is satisfied that there are apparent grounds for granting relief to the claimant pursuant to a hearing and that there are reasonable grounds for applying for the extension, and the Appeal Board may give such directions as it considers proper consequent upon the extension. 2019, c. 15, Sched. 15, s. 21 (1).

Certain hearings

(3) Despite section 13 of the Ministry of Health and Long-Term Care Appeal and Review Boards Act, 1998, a hearing under paragraph 3 or 4 of subsection 20 (1) shall be heard and decided as provided for in Schedule 1. 2019, c. 15, Sched. 15, s. 21 (1).

Interest payable by the Plan

(4) If the Appeal Board has concluded that an amount is payable by the Plan to a physician in a hearing under paragraph 3 of subsection 20 (1), interest calculated at the rate for postjudgment interest provided for under section 127 of the Courts of Justice Act accrues from the date that the claims were submitted in accordance with this Act and regulations. 2019, c. 15, Sched. 15, s. 21 (1).

Interest payable to the Plan

(5) If the Appeal Board has concluded that an amount is payable to the Plan by a physician in a hearing under paragraph 4 of subsection 20 (1), interest calculated at the rate for postjudgment interest provided for under section 127 of the Courts of Justice Act accrues from the date of the request for a hearing by the General Manager. 2019, c. 15, Sched. 15, s. 21 (1).

Transitional

(6) Where a request for a hearing had been made to the Physician Payment Review Board before the coming into force of subsection 22 (1) of Schedule 15 to the Plan to Build Ontario Together Act, 2019 and a hearing is not underway, a panel of the Appeal Board shall deal with the hearing under this section, with any necessary modification. 2019, c. 15, Sched. 15, s. 21 (1).

Note: On a day to be named by proclamation of the Lieutenant Governor, subsection 21 (6) of the Act is repealed. (See: 2019, c. 15, Sched. 15, s. 21 (2))

Section Amendments with date in force (d/m/y)

1996, c. 1, Sched. H, s. 16 - 01/05/1996

2002, c. 18, Sched. I, s. 8 (12) - 26/11/2002

2007, c. 10, Sched. G, s. 16 (1, 2)- 04/09/2007

2015, c. 20, Sched. 15, s. 6 (1, 2) - 29/10/2015

2019, c. 15, Sched. 15, s. 21 (1) - 10/12/2019; 2019, c. 15, Sched. 15, s. 21 (2) - not in force

Parties

22 (1) The General Manager is a party to all proceedings before the Appeal Board. 2015, c. 20, Sched. 15, s. 7.

Same

(2) The Appeal Board may add any other parties to a proceeding that it considers appropriate. 2015, c. 20, Sched. 15, s. 7.

Section Amendments with date in force (d/m/y)

1996, c. 1, Sched. H, s. 17 - 01/05/1996

2007, c. 10, Sched. G, s. 17 - 04/09/2007

2015, c. 20, Sched. 15, s. 7 - 29/10/2015

Evidence

Examination of documentary evidence

23 (1) A person who is a party to proceedings before the Appeal Board shall be afforded an opportunity to examine before the hearing any written or documentary evidence that will be produced or any report the contents of which will be given in evidence at the hearing.  R.S.O. 1990, c. H.6, s. 23 (1).

Board members not to have investigated prior to hearing

(2) Members of the Appeal Board holding a hearing shall not have taken part, before the hearing, in any investigation or consideration of the subject-matter of the hearing and shall not communicate directly or indirectly in relation to the subject-matter of the hearing with any person or with any party or representative of the party except upon notice to and with opportunity for all parties to participate, but the Appeal Board may seek legal advice from an adviser independent from the parties and in such case the nature of the advice should be made known to the parties in order that they may make submissions as to the law.  R.S.O. 1990, c. H.6, s. 23 (2).

Recording evidence

(3) The oral evidence taken before the Appeal Board at a hearing shall be recorded and, if so required, copies of a transcript thereof shall be furnished upon the same terms as in the Superior Court of Justice.  R.S.O. 1990, c. H.6, s. 23 (3); 2006, c. 19, Sched. C, s. 1 (1).

Findings of fact

(4) The findings of fact of the Appeal Board pursuant to a hearing shall be based exclusively on evidence admissible or matters that may be noticed under section 15 or 16 of the Statutory Powers Procedure Act.  R.S.O. 1990, c. H.6, s. 23 (4).

(5) Repealed:  1998, c. 18, Sched. G, s. 54 (5).

Release of documents, etc.

(6) Documents and things put in evidence at the hearing shall, upon the request of the person who produced them, be released to the person by the Appeal Board within a reasonable time after the matter in issue has been finally determined.  R.S.O. 1990, c. H.6, s. 23 (6).

Section Amendments with date in force (d/m/y)

1998, c. 18, Sched. G, s. 54 (5) - 01/02/1999

2006, c. 19, Sched. C, s. 1 (1) - 22/06/2006

Appeal to Divisional Court

24 (1) Any party to the proceedings before the Appeal Board under this Act may appeal from its decision or order to the Divisional Court in accordance with the rules of court.  R.S.O. 1990, c. H.6, s. 24 (1); 1998, c. 18, Sched. G, s. 54 (6).

Exception

(1.1) Despite subsection (1), a party may not appeal from a decision or order of the Appeal Board respecting a matter heard under paragraph 3 or 4 of subsection 20 (1). 2019, c. 15, Sched. 15, s. 22.

Record to be filed in court

(2) Where any party appeals from a decision or order of the Appeal Board, the Appeal Board shall forthwith file in the Divisional Court the record of the proceedings before it in which the decision was made, which, together with the transcript of evidence if it is not part of the Appeal Board’s record, shall constitute the record in the appeal.

Minister to be heard

(3) The Minister is entitled to be heard by counsel or otherwise upon the argument of an appeal under this section.

Powers of court on appeal

(4) An appeal under this section may be made on questions of law or fact or both and the court may affirm or may rescind the decision of the Appeal Board and may exercise all powers of the Appeal Board to direct the General Manager to take any action which the Appeal Board may direct the General Manager to take and as the court considers proper and for such purposes the court may substitute its opinion for that of the General Manager or of the Appeal Board, or the court may refer the matter back to the Appeal Board for rehearing, in whole or in part, in accordance with such directions as the court considers proper.  R.S.O. 1990, c. H.6, s. 24 (2-4).

(5) Repealed: 2015, c. 20, Sched. 15, s. 8.

Section Amendments with date in force (d/m/y)

1996, c. 1, Sched. H, s. 18 - 01/05/1996; 1998, c. 18, Sched. G, s. 54 (6) - 01/02/1999

2015, c. 20, Sched. 15, s. 8 - 29/10/2015

2019, c. 15, Sched. 15, s. 22 - 10/12/2019

25 Repealed: 2019, c. 15, Sched. 15, s. 23.

Section Amendments with date in force (d/m/y)

2002, c. 18, Sched. I, s. 8 (13-17) - 26/11/2002

2004, c. 5, s. 40 (1-4) - 23/09/2004

2007, c. 10, Sched. G, s. 18 - 04/09/2007

2019, c. 15, Sched. 15, s. 23 - 10/12/2019

Service of notice

26 (1) Except where otherwise provided, any notice required by or provided for in this Act may be served,

(a) by personal service;

(b) by courier;

(c) by registered mail; or

(d) by any other prescribed method.  2007, c. 10, Sched. G, s. 19.

When effective

(2) Service of a notice is effective,

(a) in the case of a notice under clauses  (1) (a) to (c), on the day of delivery; and

(b) in the case of a notice under clause (1)  (d), as provided for in the regulations.  2007, c. 10, Sched. G, s. 19.

Service by lettermail

(3) Where an attempt has been made to effect service by a method set out in subsection (1), and for any reason service could not be effected, service may be made by lettermail.  2007, c. 10, Sched. G, s. 19.

Same

(4) Service by lettermail shall be deemed to be effective 14 business days after the day of mailing, unless the person or entity on whom service is to be made establishes that the notice was not received until a later date for reasons that he, she or it could not control, in which case service is effective on the day that the notice is actually received.  2007, c. 10, Sched. G, s. 19.

Section Amendments with date in force (d/m/y)

2007, c. 10, Sched. G, s. 19- 04/09/2007

26.1 Repealed:  1996, c. 1, Sched. H, s. 19.

Section Amendments with date in force (d/m/y)

1996, c. 1, Sched. H, s. 19 - 01/05/1996

Proposed revision of O.M.A. schedule of fees

27 At least six months before any proposed revision of the schedule of fees of the Ontario Medical Association, the Ontario Medical Association shall notify the Minister of the proposed revision and the Minister shall arrange and implement discussions with representatives of the said Association respecting the details and extent of any proposed changes in the schedule of fees.  R.S.O. 1990, c. H.6, s. 27.

Contributions to the Plan

27.1 (1) Every physician, practitioner and health facility who provides insured services shall make such contribution to the Plan as may be prescribed relating to the amount of fees payable to him, her or it under the Plan during such prior period as may be prescribed.

Amount

(2) The amount of the basic contribution from each physician, practitioner or health facility shall be determined in accordance with the regulations.

Adjustment

(3) The basic contribution from a physician, practitioner or health facility may be increased or decreased as provided in the regulations based upon such factors as may be prescribed.

Exemption

(4) Such classes of physicians, practitioners or health facilities as may be prescribed are exempt from making a contribution to the Plan.  1996, c. 1, Sched. H, s. 20.

Section Amendments with date in force (d/m/y)

1996, c. 1, Sched. H, s. 20 - 01/05/1996

Payments, etc., to the Plan

27.2 (1) The General Manager may obtain or recover money that a physician, practitioner or health facility owes to the Plan by set off against any money payable to him, her or it under the Plan.  1996, c. 1, Sched. H, s. 21.

(2) Repealed: 2019, c. 15, Sched. 15, s. 24.

(3), (4) Repealed:  2004, c. 5, s. 41.

Section Amendments with date in force (d/m/y)

1996, c. 1, Sched. H, s. 21 - 01/05/1996

2004, c. 5, s. 41 - 23/09/2004

2007, c. 10, Sched. G, s. 20 - 04/09/2007

2015, c. 20, Sched. 15, s. 9 - 29/10/2015

2019, c. 15, Sched. 15, s. 24 - 10/12/2019

Payment by contribution to annual expenditures

28 Any amounts payable to or on behalf of an insured person under the Plan in respect of insured services provided by or in a hospital or health facility may be paid in the form of the payment by the Province of all or any part of the annual expenditures of such hospital or health facility, where such payment by the Province is authorized under any Act.  R.S.O. 1990, c. H.6, s. 28.

Disclosure authorized

29 (1) Every insured person shall be deemed to have authorized his or her physician or practitioner, a hospital or health facility which provided a service to the insured person and any other prescribed person or organization to give the General Manager particulars of services provided to the insured person,

(a) for the purpose of obtaining payment under the Plan for the services;

(b) for the purpose of enabling the General Manager to monitor and control the delivery of insured services;

(c) for the purpose of enabling the General Manager to monitor and control payments made under the Plan or otherwise for insured services; and

(d) for such other purposes as may be prescribed.  1996, c. 1, Sched. H, s. 22.

Immunity

(2) No action lies against a person or organization for giving information to the General Manager under the Act.  1996, c. 1, Sched. H, s. 22.

(3) Repealed: 2019, c. 15, Sched. 15, s. 25.

Section Amendments with date in force (d/m/y)

1996, c. 1, Sched. H, s. 22 - 01/05/1996

2004, c. 3, Sched. A, s. 85 (2) - 01/11/2004

2019, c. 15, Sched. 15, s. 25 - 10/12/2019

29.1-29.8 Repealed:  2007, c. 10, Sched. G, s. 21.

Section Amendments with date in force (d/m/y)

1996, c. 1, Sched. H, s. 23 - no effect

2007, c. 10, Sched. G, s. 21 - 04/09/2007

Subrogation

Subrogation

30 (1) Where, as the result of the negligence or other wrongful act or omission of another, an insured person suffers personal injuries for which he or she receives insured services under this Act, the Plan is subrogated to any right of the insured person to recover the cost incurred for past insured services and the cost that will probably be incurred for future insured services, and the General Manager may bring action in the name of the Plan or in the name of that person for the recovery of such costs.

Payment by Plan recoverable by insured

(2) For the purposes of subsection (1), the payment by the Plan for insured services shall not be construed to affect the right of the insured person to recover the amounts so paid in the same manner as if such amounts are paid or to be paid by the insured person.

Cost of hospital services

(3) For the purposes of this section, the cost of insured services rendered to an insured person in or by a hospital or health facility shall be at the rate charged by the hospital or health facility to a person who is not an insured person.  R.S.O. 1990, c. H.6, s. 30 (1-3).

Exception

(4) Despite subsection (1), the Plan is not subrogated to the rights of an insured person in respect of personal injuries arising directly or indirectly from the use or operation, after the 21st day of June, 1990 and before the day section 267.1 of the Insurance Act comes into force, of an automobile in Canada, the United States of America or any other jurisdiction designated in the Statutory Accident Benefits Schedule under the Insurance Act.  1993, c. 10, s. 53.

Exception

(5) Despite subsection (1), the Plan is not subrogated to the rights of the insured person, as against a person who is insured under a motor vehicle liability policy issued in Ontario, in respect of personal injuries arising directly or indirectly from the use or operation, after section 29 of the Automobile Insurance Rate Stability Act, 1996 comes into force, of an automobile in Ontario or in any other jurisdiction designated in the Statutory Accident Benefits Schedule under the Insurance Act.

Definition

(6) In subsection (5),

“motor vehicle liability policy” has the same meaning as in the Insurance Act.  1996, c. 21, s. 51.

Section Amendments with date in force (d/m/y)

1993, c. 10, s. 53 - 1/01/1994; 1996, c. 21, s. 51 - 1/11/1996

Subrogated claim included in action

31 (1) Any person who commences an action to recover for loss or damages arising out of the negligence or other wrongful act of a third party, to which the injury or disability in respect of which insured services have been provided is related shall, unless otherwise advised in writing by the General Manager, include a claim on behalf of the Plan for the cost of the insured services.  R.S.O. 1990, c. H.6, s. 31 (1).

Recovery paid to Ontario

(2) Where a person recovers a sum in respect of the cost of insured services, the person shall forthwith pay the sum recovered to the Minister of Finance.  R.S.O. 1990, c. H.6, s. 31 (2); 2006, c. 19, Sched. L, s. 11 (5).

Section Amendments with date in force (d/m/y)

2006, c. 19, Sched. L, s. 11 (5) - 22/06/2006

Motor Vehicle Accident Claims Fund

32 The Plan is not an insurer within the meaning of the Insurance Act, as referred to in section 22 of the Motor Vehicle Accident Claims Act, and may be awarded payment from the Motor Vehicle Accident Claims Fund.  R.S.O. 1990, c. H.6, s. 32.

Judge to divide award

33 The judge at trial shall, if the evidence permits, apportion the elements of the injured person’s loss and damages so as to clearly designate the amount of the Plan’s recovery for the past cost of insured services and separate it from the amount of the Plan’s recovery of future cost of insured services, if any.  R.S.O. 1990, c. H.6, s. 33.

Release not to bind Plan

34 No release or settlement of a claim for damages for personal injuries in a case where the injured person has received insured services under this Act shall be binding on the Plan unless the General Manager has approved the release or settlement.  R.S.O. 1990, c. H.6, s. 34.

Insurer to pay Ontario

35 A liability insurer shall notify the General Manager of negotiations for settlement of any claim for damages including insured services and may pay to the Minister of Finance any amount referable to a claim for recovery of the cost of insured services and such payment discharges the obligation of the liability insurer to pay that amount to the insured person.  R.S.O. 1990, c. H.6, s. 35; 2006, c. 19, Sched. L, s. 11 (5).

Section Amendments with date in force (d/m/y)

2006, c. 19, Sched. L, s. 11 (5) - 22/06/2006

Future insured services

36 Where a judgment or settlement includes future cost of insured services, the Plan shall provide the future insured services included in the judgment or settlement.  R.S.O. 1990, c. H.6, s. 36.

Direct Recovery

Direct cause of action

36.0.1 (1) If the Plan has paid for insured services as a result of the negligence or other wrongful act or omission of a person, the Plan has a right, independent of its subrogated right under subsections 30 (1) and 46 (5), to recover, directly against that person, the costs for insured services that have been incurred in the past and that will probably be incurred in the future as a result of the negligence or the wrongful act or omission.

Action

(2) The General Manager may bring an action in the name of the Plan or the Minister may bring an action in his or her own name for recovery of the costs referred to in subsection (1).

Exception

(3) The Plan shall not recover costs under this section,

(a) against a physician if the negligence or wrongful act or omission of the physician occurred while the physician was acting within the scope of his or her practice and in such circumstances as may be prescribed;

(b) against a hospital under the Public Hospitals Act or a laboratory under the Laboratory and Specimen Collection Centre Licensing Act if the negligence or wrongful act or omission upon which the action is based occurred in the course of providing services that the hospital is approved to provide, or that the laboratory is licensed to provide, as the case may be, and in such circumstances as may be prescribed; or

(c) against such other persons or entities as may be prescribed in such circumstances as may be prescribed.

Preservation of rights of insured persons

(4) An action under this section shall not prevent an insured person from recovering the cost or damages to which the person would otherwise be entitled.

Cost of hospital services

(5) For the purposes of this section, the cost of insured services rendered in or by a hospital or health facility shall be at the rate charged by the hospital or health facility to persons who are not insured.

Disclosure of information

(6) To the extent that any information relating to insured services is produced in a proceeding under this section, the information shall be produced in a manner that protects the identity of the insured person and of the provider of insured services.  1999, c. 10, s. 1.

Section Amendments with date in force (d/m/y)

1999, c. 10, s. 1 - 05/01/2000

Third Party Services

Third party service

36.1 (1) For the purposes of this section and sections 36.2 to 36.4, a third party service is a service that,

(a) is provided by a service provider in connection or partly in connection with,

(i) a request or requirement, made by a person or entity, that information or documentation relating to an insured person be provided, or

(ii) a request or requirement, made by a person or entity, that an insured person obtain a service from a service provider;

(b) is not an insured service or is deemed, by a regulation made under clause 45 (1) (i), not to be an insured service; and

(c) is prescribed as a third party service or is prescribed as a third party service in circumstances specified in the regulation.

Third party

(2) For the purposes of this section and sections 36.2 to 36.4, a third party is a person or entity who makes a request or requirement referred to in clause (1) (a).

Service provider

(3) For the purposes of this section and sections 36.2 to 36.4, a service provider is a physician, practitioner, hospital or health facility, or an independent health facility as defined in the Independent Health Facilities Act.

Note: On a day to be named by proclamation of the Lieutenant Governor, subsection 36.1 (3) of the Act is amended by striking out “or an independent health facility as defined in the Independent Health Facilities Act” at the end and substituting “or a community health facility within the meaning of the Oversight of Health Facilities and Devices Act, 2017”. (See: 2017, c. 25, Sched. 9, s. 97 (7))

Regulations re third parties

(4) Despite subsection (2), a regulation may be made, in relation to a specified third party service or in relation to a third party service provided in specified circumstances,

(a) prescribing another person or entity as a third party instead of or in addition to the person or entity who makes the request or requirement referred to in clause (1) (a);

(b) if more than one person or entity make the request or requirement referred to in clause (1) (a), prescribing one or more of them as third parties and providing that the others are not third parties; or

(c) providing that there is no third party.

Deemed requirement or request

(5) For the purpose of subsection (1), a person or entity shall be deemed to have required or requested that information or a document relating to the insured person be provided, or that the insured person obtain a service from a service provider, if providing the information or document or obtaining the service is related to the person or entity doing or not doing anything in relation to the insured person or related to the insured person receiving or not receiving anything from the third party.  1993, c. 32, s. 2 (7).

Section Amendments with date in force (d/m/y)

1993, c. 32, s. 2 (7) - 14/12/1993

2017, c. 25, Sched. 9, s. 97 (7) - not in force

Third party liable

36.2 (1) If a service provider who provides a third party service to an insured person renders an account for payment to the third party, the third party is liable for payment of the account, subject to subsection 36.3 (3).

Same

(2) If an insured person pays all or part of an account rendered to him or her by a service provider for a third party service provided to the insured person, the third party is liable to reimburse the insured person for the amount paid, subject to subsection 36.3 (4).

Insured person’s liability to pay

(3) Nothing in this section affects any liability of an insured person to pay a service provider’s account for a third party service.

Right to render account at time of service

(4) Nothing in sections 36.1 to 36.4 affects any right of a service provider to render an account for a third party service at the time the service is rendered.

No double recovery

(5) The total amount that the service provider recovers in respect of a third party service shall not exceed the amount of the account rendered.  1993, c. 32, s. 2 (7).

Section Amendments with date in force (d/m/y)

1993, c. 32, s. 2 (7) - 14/12/1993

Amounts owing by third parties

Application of section

36.3 (1) This section applies to,

(a) an amount owing by a third party to a service provider under subsection 36.2 (1);

(b) an amount owing by a third party to an insured person under subsection 36.2 (2); and

(c) an amount owing by an insured person to a service provider for a third party service provided to the insured person by the service provider.

Proceeding to recover payment

(2) An amount referred to in subsection (1) may be recovered in a court proceeding or, if a body is designated or established under clause 45 (1.1) (f), in a proceeding before the body.

Court, body may reduce amount payable

(3) In a proceeding to recover an amount referred to in clause (1) (a) or (c), the court or body, in addition to any other order it may make, may order the third party or the insured person, as the case may be, to pay the service provider an amount that is less than the amount charged by the service provider for the third party service if the court or body finds that the amount charged by the service provider for the third party service is excessive.

Same

(4) In a proceeding to recover an amount referred to in clause (1) (b), the court or body, in addition to any other order it may make, may order the third party to pay the insured person an amount that is less than the amount paid by the insured person to the service provider for the third party service if the court or body finds that the amount charged by the service provider for the third party service is excessive.

Determining whether excessive

(5) In determining whether an amount charged by a service provider other than a physician for a third party service is excessive, the court or body shall consider any applicable guidelines respecting third party services and any applicable schedule of fees, and may consider any other relevant factors.

Same

(6) In determining whether an amount charged by a physician for a third party service is excessive, the court or body shall consider the Ontario Medical Association’s guidelines respecting third party services and its schedule of fees, and may consider any other relevant factors.

Same

(7) The Lieutenant Governor in Council may, in a regulation, provide that the court or body shall consider other matters in addition to or instead of the guidelines and schedules of fees referred to in subsections (5) and (6).

Adding service provider as party

(8) No order shall be made under subsection (4) unless the service provider has been added as a party to the proceeding.

Same

(9) The service provider may be added as a party to the proceeding referred to in subsection (4) on such terms as the court or body considers just.  1993, c. 32, s. 2 (7).

Section Amendments with date in force (d/m/y)

1993, c. 32, s. 2 (7) - 14/12/1993

Service provider to reimburse insured person

36.4 If, under subsection 36.3 (4), the court or body orders the third party to pay the insured person an amount that is less than the amount paid by the insured person to the service provider for the third party service, the service provider is liable to repay the difference to the insured person.  1993, c. 32, s. 2 (7).

Section Amendments with date in force (d/m/y)

1993, c. 32, s. 2 (7) - 14/12/1993

General

37 Repealed: 2019, c. 15, Sched. 15, s. 26.

Section Amendments with date in force (d/m/y)

1996, c. 1, Sched. H, s. 30 - 01/05/1996

2006, c. 19, Sched. L,s. 3 (6) - 22/06/2006

2007, c. 10, Sched. G, s. 22 (1, 2) - 04/09/2007; 2007, c. 10, Sched. P, s. 16 - 1/07/2015

2009, c. 26, s. 11 (5) - no effect - see 2019, c. 15, Sched. 15, s. 38 - 10/12/2019

2017, c. 25, Sched. 9, s. 97 (8, 9) - no effect - see 2019, c. 15, Sched. 15, s. 39 - 10/12/2019

2019, c. 15, Sched. 15, s. 26 - 10/12/2019

37.1 Repealed: 2019, c. 15, Sched. 15, s. 26.

Section Amendments with date in force (d/m/y)

1996, c. 1, Sched. H, s. 31 - 01/05/1996

2002, c. 18, Sched. I, s. 8 (18, 19) - 26/11/2002

2007, c. 10, Sched. G, s. 23 (1-5) - see Table of Public Statute Provisions Repealed Under Section 10.1 of the Legislation Act, 2006 - 31/12/2017; 2007, c. 10, Sched. G, s. 23 (6) - no effect - see 2015, c. 20, Sched. 15, s. 19 - 04/06/2015; 2007, c. 10, Sched. G, s. 23 (7) - 31/03/2010

2009, c. 26, s. 11 (6-10) - no effect - see 2019, c. 15, Sched. 15, s. 38 - 10/12/2019

2015, c. 20, Sched. 15, s. 10 - 29/10/2015

2017, c. 25, Sched. 9, s. 97 (10) - no effect - see 2019, c. 15, Sched. 15, s. 26 - 10/12/2019

2019, c. 15, Sched. 15, s. 26 - 10/12/2019

Information confidential

38 (1) The persons listed in subsection (1.1) shall preserve secrecy with respect to all matters that come to their knowledge in the course of their employment or duties pertaining to insured persons and any insured services rendered and the payments made for those services, and shall not communicate any such matters to any other person except as otherwise provided in this Act, the Personal Health Information Protection Act, 2004 and the Freedom of Information and Protection of Privacy Act.  2007, c. 10, Sched. G, s. 24 (1).

Persons referred to in subs. (1)

(1.1) The following are listed for the purposes of subsection (1):

1. The members of the Appeal Board.

2. The employees and agents, if any, of the Appeal Board.

3. The General Manager and persons engaged in the administration of this Act.  2007, c. 10, Sched. G, s. 24 (1); 2015, c. 20, Sched. 15, s. 11 (1, 2); 2019, c. 15, Sched. 15, s. 27 (1).

(2), (3) Repealed:  2007, c. 10, Sched. G, s. 24 (2).

(4) Repealed: 2019, c. 15, Sched. 15, s. 27 (2).

Section Amendments with date in force (d/m/y)

1992, c. 32, s. 15 - 3/04/1995; 1998, c. 18, Sched. G, s. 54 (7) - 01/02/1999

2002, c. 18, Sched. I, s. 8 (20) - 26/11/2002

2006, c. 19, Sched. L, s. 11 (3) - 22/06/2006

2007, c. 10, Sched. G, s. 24 (1-4) - 04/09/2007

2015, c. 20, Sched. 15, s. 11 (3) - 29/10/2015

2019, c. 15, Sched. 15, s. 27 (1, 2) - 10/12/2019

Filing with court

38.1 (1) A copy of any of the following may be filed with the Superior Court of Justice after the time in which an appeal may be made has passed, and once filed shall be entered in the same way as a judgment or order of the Superior Court of Justice and is enforceable as an order of that court:

1. A decision of the Appeal Board made under this Act.

2. Repealed: 2019, c. 15, Sched. 15, s. 28 (1).

3. An agreement to reimburse the Plan signed by a physician.

4. Repealed: 2019, c. 15, Sched. 15, s. 28 (2).

2007, c. 10, Sched. G, s. 25; 2019, c. 15, Sched. 15, s. 28 (1, 2).

Personal property charge

(2) Anything that may be filed under subsection (1) may also be entered as a lien and charge with the registrar under the Personal Property Security Act. 2019, c. 15, Sched. 15, s. 28 (3).

Set-off

(3) For greater certainty, nothing under this section affects any right of set-off that the General Manager possesses under this Act. 2019, c. 15, Sched. 15, s. 28 (3).

Section Amendments with date in force (d/m/y)

2004, c. 5, s. 42 - 23/09/2004

2007, c. 10, Sched. G, s. 25 - 04/09/2007

2009, c. 26, s. 11 (11) - no effect - see 2019, c. 15, Sched. 15, s. 38 - 10/12/2019

2019, c. 15, Sched. 15, s. 28 (1-3) - 10/12/2019

Limitation of liability

39 (1) No action or other proceeding shall be commenced against the Crown, the Minister, the General Manager, any employee or agent of the Crown or a reviewer for anything done or omitted to be done in good faith in the execution or intended execution of a power or duty under this Act. 2019, c. 15, Sched. 15, s. 29.

No remedy

(2) Despite any other Act or law, no costs, compensation or damages are owing or payable to any person and no remedy, including but not limited to a remedy in contract, restitution, tort or trust, is available to any person against the Crown, the Minister, the General Manager, any employee or agent of the Crown or a reviewer in connection with anything referred to in subsection (1) except as otherwise provided under this Act. 2019, c. 15, Sched. 15, s. 29.

Section Amendments with date in force (d/m/y)

1998, c. 18, Sched. G, s. 54 (8) - 01/02/1999

2007, c. 10, Sched. G, s. 26 (1) - 04/09/2007; 2007, c. 10, Sched. G, s. 26 (2) - 01/09/2009

2015, c. 20, Sched. 15, s. 12 - 29/10/2015

2019, c. 15, Sched. 15, s. 29 - 10/12/2019

Limitations on remedies

39.1 (1) No cause of action arises as a direct or indirect result of,

(a) the enactment or repeal of any provision of this Act; or

(b) the making or revocation of any provision of the regulations made under this Act. 2019, c. 15, Sched. 15, s. 29.

No remedy

(2) No costs, compensation or damages are owing or payable to any person and no remedy, including but not limited to a remedy in contract, restitution, tort or trust, is available to any person in connection with anything referred to in clause (1) (a) or (b). 2019, c. 15, Sched. 15, s. 29.

Proceedings barred

(3) No proceeding, including but not limited to any proceeding in contract, restitution, tort or trust, that is directly or indirectly based on or related to anything referred to in subsection (1) may be brought or maintained against any person. 2019, c. 15, Sched. 15, s. 29.

Same

(4) Subsection (3) applies regardless of whether the cause of action on which the proceeding is purportedly based arose before or after that subsection came into force. 2019, c. 15, Sched. 15, s. 29.

Person defined

(5) In this section,

“person” includes the Crown and its employees and agents and members of the Executive Council. 2019, c. 15, Sched. 15, s. 29.

Section Amendments with date in force (d/m/y)

1996, c. 1, Sched. H, s. 33 - 01/05/1996

2002, c. 18, Sched. I, s. 8 (21) - 26/11/2002

2007, c. 10, Sched. G, s. 27 (1-4) - 04/09/2007

2015, c. 20, Sched. 15, s. 13 - 29/10/2015

2019, c. 15, Sched. 15, s. 29 - 10/12/2019

No Crown liability

39.2 (1) No cause of action arises against the Crown, a minister of the Crown, a Crown employee, a Crown agent or the General Manager as a result of any act or omission of a person who is not a minister of the Crown, a Crown employee, a Crown agent or the General Manager if the act or omission is related, directly or indirectly, to the activities or affairs of a reviewer or to the administration of this Act. 2019, c. 15, Sched. 15, s. 29.

No proceeding

(2) No proceeding for damages, including but not limited to a proceeding for a remedy in contract, restitution, tort or trust, shall be instituted against the Crown, a minister of the Crown, a Crown employee, a Crown agent or the General Manager by a person who has suffered any damages, injury or other loss based on or related to any act or omission described in subsection (1). 2019, c. 15, Sched. 15, s. 29.

Section Amendments with date in force (d/m/y)

2019, c. 15, Sched. 15, s. 29 - 10/12/2019

Amendments apply despite agreements

39.3 The amendments to this Act made by Schedule 15 to the Plan to Build Ontario Together Act, 2019, and any regulations made in consequence of those amendments, apply despite any agreement or arrangement entered into by the Minister, regardless of when the agreement or arrangement might have been made. 2019, c. 15, Sched. 15, s. 29.

Section Amendments with date in force (d/m/y)

2019, c. 15, Sched. 15, s. 29 - 10/12/2019

Publication

39.4 (1) Subject to the regulations, if any, the General Manager is authorized to publish information, including personal information other than personal health information, that relates to any payments under this Act to a physician, practitioner or health facility, including payments that are made to a person or entity pursuant to an arrangement under clause 2 (2) (a) or a direction under section 16.1. 2019, c. 15, Sched. 15, s. 29.

Exception

(2) This section does not authorize the publication by the General Manager or the Minister of information concerning an opinion that the General Manager has formed under subsection 18 (8) or section 18.2, or a hearing that the General Manager has requested in connection with such an opinion. 2019, c. 15, Sched. 15, s. 29.

Section Amendments with date in force (d/m/y)

2019, c. 15, Sched. 15, s. 29 - 10/12/2019

40 Repealed: 2015, c. 20, Sched. 15, s. 13.

Section Amendments with date in force (d/m/y)

1996, c. 1, Sched. H, s. 34 - 01/05/1996

2007, c. 10, Sched. G, s. 28 - 04/09/2007

2015, c. 20, Sched. 15, s. 13 - 29/10/2015

40.1 Repealed: 2015, c. 20, Sched. 15, s. 13.

Section Amendments with date in force (d/m/y)

1996, c. 1, Sched. H, s. 34 - 01/05/1996

2007, c. 10, Sched. G, s. 29 (1-3) - 04/09/2007

2009, c. 33, Sched. 6, s. 61 - 1/06/2011

2015, c. 20, Sched. 15, s. 13 - 29/10/2015

40.2 Repealed: 2015, c. 20, Sched. 15, s. 13.

Section Amendments with date in force (d/m/y)

1996, c. 1, Sched. H, s. 34 - 01/05/1996

2007, c. 10, Sched. G, s. 30 (1, 2) - 04/09/2007

2015, c. 20, Sched. 15, s. 13 - 29/10/2015

Suspension of payments

40.3 The General Manager may suspend payments or a portion of payments to a physician, practitioner or heath facility from the Plan,

(a) during any period when they fail to comply with section 17.3, whether or not they are convicted of an offence;

(b) during any period where they fail to co-operate with a reviewer; or

(c) during any other period as may be prescribed, or for any other reason as may be prescribed. 2019, c. 15, Sched. 15, s. 30.

Section Amendments with date in force (d/m/y)

2007, c. 10, Sched. G, s. 31 - 31/03/2010 

2019, c. 15, Sched. 15, s. 30 - 10/12/2019

Appointment of reviewers

41 (1) The Minister or the General Manager may appoint, in writing, one or more persons as reviewers for the purposes of this Act and the regulations. 2019, c. 15, Sched. 15, s. 31 (1).

Other reviewers

(2) Every inspector appointed by the Director or Minister under the Independent Health Facilities Act is, by virtue of office, also a reviewer for the purposes of this Act. 2019, c. 15, Sched. 15, s. 31 (1).

Note: On a day to be named by proclamation of the Lieutenant Governor, subsection 41 (2) of the Act is repealed and the following substituted: (See: 2019, c. 15, Sched. 15, s. 31 (2))

Other reviewers

(2) Every inspector appointed by the executive officer under the Oversight of Health Facilities and Devices Act, 2017 is, by virtue of office, also a reviewer for the purposes of this Act. 2019, c. 15, Sched. 15, s. 31 (2).

Certificate of appointment

(3) The Minister or General Manager shall issue to every reviewer, other than reviewers mentioned in subsection (2), a certificate of appointment which the reviewer shall produce, upon request, when acting in the performance of their duties.  A reviewer mentioned in subsection (2) shall produce their certificate of appointment issued under the Independent Health Facilities Act. 2019, c. 15, Sched. 15, s. 31 (1).

Note: On a day to be named by proclamation of the Lieutenant Governor, subsection 41 (3) of the Act is repealed and the following substituted: (See: 2019, c. 15, Sched. 15, s. 31 (2))

Certificate of appointment

(3) The Minister or General Manager shall issue to every reviewer, other than reviewers mentioned in subsection (2), a certificate of appointment which the reviewer shall produce, upon request, when acting in the performance of their duties.  A reviewer mentioned in subsection (2) shall produce their certificate of appointment issued under the Oversight of Health Facilities and Devices Act, 2017. 2019, c. 15, Sched. 15, s. 31 (2).

Purpose of inspection

(4) In order to conduct inspections for the purpose of ensuring compliance with this Act and the regulations, a reviewer may, at any reasonable time, enter any place where a physician, practitioner or health facility provides services or any place where a physician, practitioner or health facility or any person on their behalf may maintain any record that relates in any manner to the provision of services for which they submit or have submitted claims to the Plan. 2019, c. 15, Sched. 15, s. 31 (1).

Physicians

(5) Despite anything else in this section, only a reviewer who is a physician may enter a place for the purpose of conducting an inspection to ensure compliance with this Act and the regulations by a physician. 2019, c. 15, Sched. 15, s. 31 (1).

Dwellings

(6) No reviewer shall enter a part of a place that is being used as a dwelling, except with the consent of the occupier of the part of the place or under the authority of an order under section 42.1. 2019, c. 15, Sched. 15, s. 31 (1).

Use of force

(7) A reviewer is not entitled to use force to enter and inspect a place. 2019, c. 15, Sched. 15, s. 31 (1).

Powers of reviewer

(8) A reviewer conducting an inspection may, if the reviewer considers it to be relevant to the inspection,

(a) examine records or anything else;

(b) demand the production of a record or any other thing;

(c) upon providing a receipt, remove a record or any other thing for review, examination or copying;

(d) in order to produce a record in readable form, use data storage, information processing or retrieval devices or systems that are normally used in carrying on business in the place;

(e) take photographs or make any other kind of recording but only in a manner that does not intercept any private communication and that is in keeping with reasonable expectations of privacy;

(f) question a person about a matter relevant to the inspection; and

(g) call upon experts who may enter the premises and provide assistance to the reviewer in carrying out the inspection in any manner that the reviewer considers necessary. 2019, c. 15, Sched. 15, s. 31 (1).

Written demand

(9) A demand under this section that a record or any other thing be produced must be in writing and must include,

(a) a statement of the nature of the record or thing required; and

(b) a statement of when the records and other things are to be produced. 2019, c. 15, Sched. 15, s. 31 (1).

Obligation to produce and assist

(10) If a reviewer demands that a record or any other thing be produced under this section, the person who has custody of the record or thing shall produce it and, in the case of a record, shall, on request, provide any assistance that is reasonably necessary to interpret the record or to produce it in a readable form. 2019, c. 15, Sched. 15, s. 31 (1).

Records and things removed from place

(11) A record or other thing that has been removed for review, examination or copying,

(a) shall be made available to the person from whom it was removed on request and at a time and place that are convenient for the person and for the reviewer; and

(b) shall be returned to the person within a reasonable time. 2019, c. 15, Sched. 15, s. 31 (1).

Co-operation

(12) Every person shall give all reasonable assistance to a reviewer in the exercise of the reviewer’s powers or the performance of the reviewer’s duties under this Act or the regulations. 2019, c. 15, Sched. 15, s. 31 (1).

Confidentiality

(13) A reviewer shall keep confidential all information that comes to his or her knowledge in the course of his or her duties under this section and shall not communicate any information to any other person except as permitted or required by law or except where the communication is to the General Manager or a person employed in or performing services for the Ministry. 2019, c. 15, Sched. 15, s. 31 (1).

Inspection report

(14) Within a reasonable period of time after completing an inspection, the reviewer shall make a report in writing to the General Manager. 2019, c. 15, Sched. 15, s. 31 (1).

Record

(15) In this section,

“record” means any document or record of information, in any form, including a record that contains personal information. 2019, c. 15, Sched. 15, s. 31 (1).

Section Amendments with date in force (d/m/y)

2000, c. 26, Sched. H, s. 1 (7) - 06/12/2000

2019, c. 15, Sched. 15, s. 31 (1) - 10/12/2019; 2019, c. 15, Sched. 15, s. 31 (2) - not in force

Copy constitutes evidence

42 (1) In any proceeding, other than a prosecution, a copy of an inspection report that appears to be signed by a reviewer or the General Manager, or a copy of a decision of the General Manager made under this Act or the regulations, is admissible as evidence of the inspection report or decision and of the facts appearing in the document without further proof. 2019, c. 15, Sched. 15, s. 31 (1).

Same

(2) In any proceeding, other than a prosecution, a copy of a record or thing made under clause 41 (7) (c) that appears to be certified as a true copy of the original by a reviewer is admissible as evidence of the record or thing and of the facts appearing in it without further proof. 2019, c. 15, Sched. 15, s. 31 (1).

Same, prosecution

(3) In any prosecution, a copy of a decision, direction or inspection report made under this Act or the regulations that appears to be signed by a reviewer or the General Manager is admissible as evidence, in the absence of evidence to the contrary, of the decision, direction or inspection report and of the facts appearing in the document without further proof. 2019, c. 15, Sched. 15, s. 31 (1).

Same

(4) In any prosecution, a copy of a record or thing made under clause 41 (7) (c) that appears to be certified as a true copy of the original by a reviewer is admissible as evidence, in the absence of evidence to the contrary, of the record or thing and of the facts appearing in it without further proof. 2019, c. 15, Sched. 15, s. 31 (1).

Transition

(5) This section applies, with necessary modification, to any notice of the General Manager issued under subsection 18 (14) or (15) of this Act as they existed before subsection 32 (1) of Schedule 15 to the Plan to Build Ontario Together Act, 2019 came into force. 2019, c. 15, Sched. 15, s. 31 (1).

Section Amendments with date in force (d/m/y)

2000, c. 26, Sched. H, s. 1 (7) - 06/12/2000

2019, c. 15, Sched. 15, s. 31 (1) - 10/12/2019

Order to enter

42.1 (1) On application without notice, a justice may issue an order authorizing a reviewer named in the order to enter a place specified in the order and to exercise any of the powers mentioned in subsection 41 (7), if the justice is satisfied on information under oath that the reviewer has been prevented from entering a place that may be entered under section 41, or has been prevented from exercising a power mentioned in subsection 41 (7), or that there are reasonable grounds to believe that the reviewer will be prevented from entering the place or exercising the power. 2019, c. 15, Sched. 15, s. 31 (1).

Expiry

(2) An order shall name a date on which it expires, which shall not be later than 30 days after the order is issued. 2019, c. 15, Sched. 15, s. 31 (1).

Extension of time

(3) A justice may extend the date on which an order expires for an additional period of no more than 30 days, upon application without notice by the reviewer named in the order. 2019, c. 15, Sched. 15, s. 31 (1).

Police assistance

(4) A reviewer named in an order may call upon a police officer for assistance in executing the order and the police officer may use whatever force the police officer considers necessary to execute the order. 2019, c. 15, Sched. 15, s. 31 (1).

Time of execution

(5) An order may be executed only between 6 a.m. and 9 p.m. unless the order specifies otherwise. 2019, c. 15, Sched. 15, s. 31 (1).

Other matters

(6) Subsections 41 (3) to (4) and (6) to (14) apply, with necessary modifications, to the execution of an order. 2019, c. 15, Sched. 15, s. 31 (1).

Section Amendments with date in force (d/m/y)

2019, c. 15, Sched. 15, s. 31 (1) - 10/12/2019

Obstruction offence

42.2 Where a reviewer is conducting an inspection under section 41 or executing an order under section 42.1 or where a provincial offences officer is executing a warrant under section 158 or 158.1 of the Provincial Offences Act with respect to a matter relevant to this Act, no person shall,

(a) hinder, obstruct or interfere with the reviewer or officer, or otherwise impede the reviewer or officer;

(b) destroy or alter a record or other thing that has been demanded under clause 41 (8) (b) or that is the subject of a warrant under section 158 or 158.1 of the Provincial Offences Act; or

(c) fail to do anything required under subsections 41 (9) or (11) or subsection 42.3 (7). 2019, c. 15, Sched. 15, s. 31 (1).

Section Amendments with date in force (d/m/y)

2019, c. 15, Sched. 15, s. 31 (1) - 10/12/2019

Production order

42.3 (1) On application without notice by a provincial offences officer, a justice may issue a production order to a person, other than a person under investigation for an offence, requiring the person to,

(a) produce documents or copies of documents, certified by affidavit to be true copies, or produce data; or

(b) prepare a document based on documents or data already in existence and produce it. 2019, c. 15, Sched. 15, s. 31 (1).

Contents of order

(2) A production order must stipulate when, where and how the documents or data are to be produced, and to whom they are to be produced. 2019, c. 15, Sched. 15, s. 31 (1).

Grounds

(3) A justice may make a production order if satisfied by information given under oath or affirmation that there are reasonable grounds to believe that,

(a) an offence under this Act has been or is being committed;

(b) the document or data will provide evidence respecting the offence or suspected offence; and

(c) the person who is subject to the order has possession or control of the document or data. 2019, c. 15, Sched. 15, s. 31 (1).

Conditions

(4) A production order may contain any conditions the justice considers advisable. 2019, c. 15, Sched. 15, s. 31 (1).

Evidence

(5) A copy of a document or data produced under this section, on proof by affidavit that it is a true copy, is admissible in evidence in proceedings under this Act and has the same probative force as the original document or data would have if it had been proved in the ordinary way. 2019, c. 15, Sched. 15, s. 31 (1).

No return of copies

(6) Copies of documents or data produced under this section are not required to be returned to the person who provided them. 2019, c. 15, Sched. 15, s. 31 (1).

Compliance required

(7) A person to whom a production order is directed shall comply with the order according to its terms. 2019, c. 15, Sched. 15, s. 31 (1).

Section Amendments with date in force (d/m/y)

2019, c. 15, Sched. 15, s. 31 (1) - 10/12/2019

Not compellable witness

42.4 A reviewer or person who, at the request of a reviewer, accompanies a reviewer in doing anything authorized under this Act is not a compellable witness in a civil suit or any proceeding respecting any information or material furnished, obtained, made or received by them under this Act while acting within the scope of their employment. 2019, c. 15, Sched. 15, s. 31 (1).

Section Amendments with date in force (d/m/y)

2019, c. 15, Sched. 15, s. 31 (1) - 10/12/2019

Protection of information

42.5 In a prosecution for an offence under this Act or where documents or materials provided for under section 42.3 of this Act or sections 158 to 160 of the Provincial Offences Act are filed with a court in relation to an inspection or an investigation into an offence under this Act, the court may, at any time, take precautions to avoid the disclosure by the court or any person of any personal information about an individual, including, where appropriate,

(a) removing the identifying information of any person whose personal information is referred to in any documents or materials;

(b) receiving representations without notice;

(c) conducting hearings or parts of hearings in private; or

(d) sealing all or part of the court files. 2019, c. 15, Sched. 15, s. 31 (1).

Section Amendments with date in force (d/m/y)

2019, c. 15, Sched. 15, s. 31 (1) - 10/12/2019

Certain documents

42.6 (1) In any proceeding under this Act, the Commitment to the Future of Medicare Act, 2004 or the Independent Health Facilities Act, a document purporting to be an extract of data or information from any database maintained and used by the Ministry in the ordinary course of business to record and track information about claims made under this Act or the Independent Health Facilities Act and payments made under this Act or that Act that appears to be certified as a true extract by the General Manager is admissible as evidence of the information contained in the extract and of the facts appearing in it without further proof. 2019, c. 15, Sched. 15, s. 31 (1).

Note: On a day to be named by proclamation of the Lieutenant Governor, subsection 42.6 (1) of the Act is amended by striking out “Independent Health Facilities Act” wherever it appears and substituting in each case “Oversight of Health Facilities and Devices Act, 2017”. (See: 2019, c. 15, Sched. 15, s. 31 (3))

Prosecutions

(2) Subsection (1) does not apply in respect of a prosecution. 2019, c. 15, Sched. 15, s. 31 (1).

Section Amendments with date in force (d/m/y)

2019, c. 15, Sched. 15, s. 31 (1) - 10/12/2019; 2019, c. 15, Sched. 15, s. 31 (3) - not in force

Offence, payment without entitlement

43 (1) No person shall obtain or attempt to obtain payment for any insured service that the person knows or ought to have known they are not entitled to obtain under this Act or the regulations. 2019, c. 15, Sched. 15, s. 32.

Offence, benefits without entitlement

(2) No person shall receive or attempt to receive the benefit of any insured service that the person knows or ought to have known they are not entitled to receive under this Act or the regulations. 2019, c. 15, Sched. 15, s. 32.

False information

(3) No person shall give information that they knew or ought to have known was false in an application, return, statement, account or claim for payment provided to the Plan or to the General Manager in respect of any matter under this Act or the regulations, including in any information provided under section 17.3. 2019, c. 15, Sched. 15, s. 32.

Section Amendments with date in force (d/m/y)

2019, c. 15, Sched. 15, s. 32 - 10/12/2019

Mandatory reporting

43.1 (1) A prescribed person who, in the course of his or her professional or official duties, has knowledge that an event referred to in subsection (2) has occurred shall promptly report the matter to the General Manager.

Events

(2) Subsection (1) applies to the following events:

1. An ineligible person receives or attempts to receive an insured service as if he or she were an insured person.

2. An ineligible person obtains or attempts to obtain reimbursement by the Plan for money paid for an insured service as if he or she were an insured person.

3. An ineligible person, in an application, return or statement made to the Plan or the General Manager, gives false information about his or her residency.

Definition, “ineligible person”

(3) In subsection (2),

“ineligible person” means a person who is neither an insured person nor entitled to become one.

Defence

(4) It is a defence to a proceeding for failure to make a report required by subsection (1) that the prescribed person delayed making the report because he or she believed, on reasonable grounds, that making the report might be a direct and immediate cause of serious bodily harm to a person, and made the report as soon as he or she was of the opinion that the danger no longer existed.

Voluntary reporting

(5) A prescribed person may report to the General Manager any matter relating to the administration or enforcement of this Act or the regulations.

Subss. (1) and (5) prevail

(6) Subsections (1) and (5) apply even if the information reported is confidential or privileged and despite any Act, regulation or other law prohibiting disclosure of the information.

Protection from liability

(7) No proceeding for making a report under subsection (1) or (5) or for providing information in connection with the report shall be commenced against a person unless he or she acts maliciously and the information on which the report is based is not true.

Exception: solicitor-client privilege

(8) Nothing in this section abrogates any privilege that may exist between a solicitor and his or her client.  1993, c. 32, s. 2 (8).

Section Amendments with date in force (d/m/y)

1993, c. 32, s. 2 (8) - 14/12/1993

General penalty, individual

44 (1) Every individual who contravenes any provision of this Act or the regulations for which no penalty is specifically provided is guilty of an offence and is liable,

(a) for a first offence, to a fine of not more than $50,000 or to imprisonment for a term of not more than 12 months, or to both; and

(b) for a subsequent offence, to a fine of not more than $100,000 or to imprisonment for a term of not more than 12 months, or to both. 2019, c. 15, Sched. 15, s. 33.

No imprisonment for record-keeping offences

(2) Despite subsection (1), no person may be sentenced to a term of imprisonment for failing to keep or maintain records under section 17.4. 2019, c. 15, Sched. 15, s. 33.

Same, corporation

(3) Every corporation that contravenes any provision of this Act or the regulations for which no penalty is specifically provided is guilty of an offence and is liable to a fine of not more than $100,000 for a first offence and to a fine of not more than $500,000 for a subsequent offence. 2019, c. 15, Sched. 15, s. 33.

Compensation or restitution

(4) The court that convicts a person of an offence under this section may, in addition to any other penalty, order that the person pay compensation or make restitution to any person who suffered a loss as a result of the offence. 2019, c. 15, Sched. 15, s. 33.

No limitation

(5) Section 76 of the Provincial Offences Act does not apply to a prosecution under this Act. 2019, c. 15, Sched. 15, s. 33.

Presiding judge

(6) The Crown may, by notice to the clerk of the Ontario Court of Justice, require that a provincial judge preside over a proceeding in respect of an offence under subsection (1). 2019, c. 15, Sched. 15, s. 33.

Section Amendments with date in force (d/m/y)

2002, c. 18, Sched. I, s. 8 (22) - 26/11/2002

2007, c. 10, Sched. G, s. 32 - 04/09/2007

2019, c. 15, Sched. 15, s. 33 - 10/12/2019

Regulations

45 (1) The Lieutenant Governor in Council may make regulations,

(a) respecting the form of the health card, and governing the issuance, possession, submission, surrender and destruction of the health card, including measures to protect its security;

(a.1) providing for the registration of persons as insured persons and prescribing waiting periods for registration;

Note: On a day to be named by proclamation of the Lieutenant Governor, subsection (1) is amended by adding the following clause:

(a.2) governing the issuance and use of general requisition numbers, including, without being limited to,

(i) requiring their use, and governing the circumstances in which they are to be used,

(ii) respecting applying for them, and the information that must be supplied in an application, and

(iii) specifying that a general requisition number may be the same as the billing number defined in subsection 16 (5);

See: 2009, c. 26, ss. 11 (12), 27 (2).

(b) defining “resident”, “dependant”, “spouse” and “member of the Canadian Forces” for the purposes of this Act or any provision of this Act;

Note: On a day to be named by proclamation of the Lieutenant Governor, clause (b) is repealed and the following substituted:

(b) defining “resident”, “dependant”, “spouse”, “member of the Canadian Forces” and “requested by a practitioner or health facility” for the purposes of this Act or any provision of this Act;

See: 2009, c. 26, ss. 11 (13), 27 (2).

(b.1) prescribing the personal information that may be collected, used or disclosed under clause 2 (3) (b);

(c) providing for the continuation and termination of insurance coverage in respect of insured persons who cease to be eligible;

(c.1) Repealed: 2015, c. 20, Sched. 15, s. 14 (1).

(c.2) enabling the General Manager to set requirements, including requirements to provide documentation, relating to registration or renewal of registration as an insured person, or to verify a person’s continuing eligibility to remain registered as an insured person, and making the meeting of any such requirements a condition of being or continuing to be an insured person;

(d) designating disciplines for the purpose of section 16;

(e) governing insured services, including specifying those services that are not insured services;

(f) governing fees payable for insured services;

(g) governing payments for insured services;

(h)-(j) Repealed:  1996, c. 1, Sched. H, s. 35 (1).

(k) providing for the making of claims for payment of the cost of insured services and prescribing the information that shall be furnished in connection therewith;

(l) prescribing the co-payments that shall be made by or on behalf of an insured person to qualify the person to receive those insured services specified in the regulations as requiring co-payments;

(m) providing for the times when and manner in which physicians shall submit accounts directly to the Plan under section 15;

(n) providing for the times when and manner in which practitioners shall submit accounts directly to the Plan under section 16;

(o) exempting any class of accounts from the application of section 15 or any provision thereof;

(p) exempting any class of accounts from the application of section 16 or any provision thereof;

(q) defining or clarifying the meaning of any word or expression used in this Act but not otherwise defined in this Act;

(q.1) respecting section 16.2, including, without being limited to,

(i) governing the process of applying for billing privileges,

(ii) governing the information that may be required by the General Manager;

(r) prescribing facilities that are health facilities for the purposes of this Act in addition to those referred to in the definition of “health facility” in section 1;

(r.1) governing service for the purposes of section 26, including prescribing anything that may be prescribed under that section and providing for situations in which service shall be deemed to have been made;

(r.2) Repealed:  2007, c. 10, Sched. G, s. 33 (2).

(s) prescribing procedures for the enforcement of and recovery under rights to which the Plan is subrogated and without restricting the generality of the foregoing,

(i) requiring the insured person and his or her solicitor to act on behalf of the Plan in any action,

(ii) requiring such notices as are prescribed,

(iii) providing for the terms and conditions under which an action to enforce such rights may be begun, conducted and settled,

(iv) prescribing the portion of the costs of an insured person incurred in an action for the recovery of such rights that shall be borne by the Plan;

(t) assigning additional duties to the General Manager and the Appeal Board;

(u) prescribing forms for the purposes of this Act and providing for their use;

(v) designating classes for the purpose of subsection 11 (3);

(w) prescribing persons for the purpose of subsection 11.1 (2);

(x) Repealed: 2015, c. 20, Sched. 15, s. 14 (3).

(x.1) governing the costs that may be recovered under section 36.0.1, including the determination of those costs, and the evidence that is admissible to prove those costs in an action under that section;

(y) prescribing persons for the purpose of subsections 43.1 (1) and (5);

(z) prescribing the co-payments for accommodation referred to in subsection 46 (2);

(z.1) providing for and governing anything that this Act refers to as being prescribed or provided for in the regulations, or as being required to be done in accordance with the regulations or as being subject to the regulations. R.S.O. 1990, c. H.6, s. 45 (1); 1993, c. 32, s. 2 (9); 1994, c. 17, s. 72 (1, 2); 1996, c. 1, Sched. H, s. 35 (1, 2, 4); 1999, c. 10, s. 2; 2004, c. 5, s. 43 (1, 2); 2006, c. 19, Sched. L, s. 3 (7); 2007, c. 10, Sched. C, s. 3; 2007, c. 10, Sched. G, s. 33 (1-4); 2007, c. 16, Sched. B, s. 2; 2009, c. 33, Sched. 18, s. 11 (9); 2015, c. 20, Sched. 15, s. 14 (1-3); 2019, c. 15, Sched. 15, s. 34.

Regulations

(1.1) The Lieutenant Governor in Council may make regulations,

(a)-(c) Repealed: 2015, c. 20, Sched. 15, s. 14 (4).

(d) prescribing services that meet the requirements of clauses 36.1 (1) (a) and (b) as third party services, or prescribing them as third party services in specified circumstances, and specifying the circumstances;

(e) in relation to a specified third party service or in relation to a third party service provided in specified circumstances,

(i) prescribing another person or entity as a third party instead of or in addition to the person or entity who makes the request or requirement referred to in clause 36.1 (1) (a),

(ii) if more than one person or entity make the request or requirement referred to in clause 36.1 (1) (a), prescribing one or more of them as third parties and providing that the others are not third parties, or

(iii) providing that there is no third party;

(f) designating or establishing a body that shall have power to decide disputes about payment for third party services, including power to summon witnesses and require the production of documents and power to award costs and interest;

(g) governing the composition of the body referred to in clause (f), the qualifications, appointment, functions and remuneration of its members and their immunity from liability;

(h) prescribing the parties to a proceeding before the body referred to in clause (f) and the rules governing practice, procedure and evidence in a proceeding before the body, including prescribing whether or not the body is required to hold a hearing;

(i) prescribing the duties and powers of the body referred to in clause (f) in relation to making decisions and orders;

(j) providing that a court or body acting under subsection 36.3 (4) shall consider other matters in addition to or instead of the guidelines and schedules of fees referred to in subsections 36.3 (5) and (6), and specifying those other matters.  1993, c. 32, s. 2 (10); 1996, c. 1, Sched. H, s. 35 (5, 6); 2015, c. 20, Sched. 15, s. 14 (4).

Classes

(1.2) A regulation may create different classes of persons, facilities, accounts, fees payable or payments and may establish different entitlements for or relating to each class or impose different requirements, conditions or restrictions on or relating to each class.  1996, c. 1, Sched. H, s. 35 (7).

Adoption of schedules of fees

(2) A regulation may adopt by reference in whole or in part, with such changes as the Lieutenant Governor in Council considers necessary, the fees in any schedule of fees as prescribed amounts payable in whole or in part, by the Plan.  R.S.O. 1990, c. H.6, s. 45 (2).

Ministerial order

(2.1) Upon the advice of the General Manager, and where the Minister considers it to be in the public interest to do so, the Minister may make an order amending a schedule of fees or benefits that has been adopted in a regulation in any manner the Minister considers appropriate for the purposes of the regulation.  2004, c. 5, s. 43 (3).

Duration

(2.2) An order made under subsection (2.1) remains in force until the earliest of the following events occurs:

1. The order is cancelled by an order made under subsection (2.3).

2. A regulation is made adopting a schedule of fees or benefits or an amendment to the schedule of fees or benefits in which essentially the same subject-matter is addressed.

3. Twelve months have elapsed from the making of the order.  2004, c. 5, s. 43 (3).

Cancellation

(2.3) Upon the advice of the General Manager, and where the Minister considers it to be in the public interest to do so, the Minister may make an order cancelling an order under subsection (2.1).  2004, c. 5, s. 43 (3).

Not a regulation

(2.4) An order made under subsection (2.1) or (2.3) is not a regulation for the purposes of Part III (Regulations) of the Legislation Act, 2006, but has the same effect as if the schedule of fees or benefits as amended by the order had been adopted by regulation.  2004, c. 5, s. 43 (3); 2006, c. 21, Sched. F, s. 136 (1).

Publication

(2.5) The Minister shall publish an order made under subsection (2.1) or (2.3) in The Ontario Gazette, and in any other manner the Minister considers appropriate, and the order is effective from the publication date of the issue of the Gazette in which publication is made, unless paragraph 2 or 3 of subsection (2.2) applies first.  2004, c. 5, s. 43 (3).

Variation

(2.6) An amendment made by an order under subsection (2.1) may be varied at any time by regulation.  2004, c. 5, s. 43 (3).

Restriction

(2.7) An order under subsection (2.1) may not be made more than once with respect to essentially the same subject-matter.  2004, c. 5, s. 43 (3).

When regulation may be effective

(3) A regulation is, if it so provides, effective with reference to a period before it is filed.  R.S.O. 1990, c. H.6, s. 45 (3).

Exemptions

(3.1) A regulation may exempt a class of persons or facilities from the application of a specified provision of the Act or regulations.  1996, c. 1, Sched. H, s. 35 (8).

Note: On a day to be named by proclamation of the Lieutenant Governor, subsection (3.1) is repealed and the following substituted:

Exemptions

(3.1) The Lieutenant Governor in Council may make regulations exempting any person, facility or entity or class of persons, facilities or entities from the application of any provision of this Act, and may make such an exemption subject to any condition that may be provided for in the regulations.  2009, c. 26, s. 11 (14).

See: 2009, c. 26, ss. 11 (14), 27 (2).

Insured services

(3.2) Without limiting the generality of clause (1) (e), a regulation made under it may provide the following:

1. Which services rendered in or by hospitals and health facilities are insured services.

2. Which constituent elements form part of an insured service rendered by physicians or practitioners.

3. Which constituent elements shall be deemed not to form part of an insured service rendered by a physician or practitioner.  1996, c. 1, Sched. H, s. 35 (8).

Restriction

(3.3) A regulation made under clause (1) (e) or (g) shall not include a provision that would disqualify the Province of Ontario, under the Canada Health Act, for contribution by the Government of Canada because the Plan would no longer satisfy the criteria under that Act.  1996, c. 1, Sched. H, s. 35 (8).

Services designated without prescribing amounts payable

(4) The Lieutenant Governor in Council may make regulations under clause (1) (e) prescribing services that are insured services without prescribing any amounts payable by the Plan for those services.  R.S.O. 1990, c. H.6, s. 45 (4).

Fees related to independent health facilities

(5) A regulation may prescribe an amount payable by the Plan for an insured service rendered in a hospital that has been approved under the Public Hospitals Act without prescribing an amount payable if the service is rendered in a health facility operated by a person to whom subsection 7 (7) of the Independent Health Facilities Act applies.  R.S.O. 1990, c. H.6, s. 45 (5).

Note: On a day to be named by proclamation of the Lieutenant Governor, subsection 45 (5) of the Act is repealed. (See: 2017, c. 25, Sched. 9, s. 97 (11))

Circumstances

(6) A regulation made under clause (1) (l) may specify the circumstances in which it applies and may establish different entitlements or impose different requirements, conditions or restrictions in the specified circumstances.  1996, c. 1, Sched. H, s. 35 (9).

(7) Repealed:  1996, c. 1, Sched. H, s. 35 (9).

(8) Repealed:  1996, c. 1, Sched. H, s. 35 (10).

Section Amendments with date in force (d/m/y)

1993, c. 32, s. 2 (9), (10) - 14/12/1993; 1994, c. 17, s. 72 (1) - 01/04/1994; 1994, c. 17, s. 72 (2) - 18/05/1994; 1996, c. 1, Sched. H, s. 35 (1), (2), (4)-(10) - 01/05/1996; 1996, c. 1, Sched. H, s. 35 (3) - no effect; 1999, c. 10, s. 2 - 05/01/2000

2004, c. 5, s. 43 (1-3) - 23/09/2004

2006, c. 19, Sched. L, s. 3 (7) - 22/06/2006; 2006, c. 21, Sched. F, s. 136 (1) - 25/07/2007

2007, c. 10, Sched. C, s. 3 (1, 2) - 04/06/2007; 2007, c. 10, Sched. G, s. 33 (1-3) - 04/09/2007; 2007, c. 10, Sched. G, s. 33 (4) - 31/03/2010; 2007, c. 10, Sched. G, s. 33 (5) - see Table of Public Statute Provisions Repealed Under Section 10.1 of the Legislation Act, 2006 - 31/12/2017; 2007, c. 16, Sched. B, s. 2 - 03/12/2007

2009, c. 26, s. 11 (12-14) - not in force; 2009, c. 33, Sched. 18, s. 11 (9) - 15/12/2009

2017, c. 25, Sched. 9, s. 97 (11) - not in force

2019, c. 15, Sched. 15, s. 34 (1-3) - 10/12/2019

No appeal

45.1 (1) Every decision by a body designated or established under clause 45 (1.1) (f) respecting a dispute about payment for third party services shall be final and binding and shall not be subject to appeal.  1993, c. 32, s. 2 (11).

Enforcement of decision

(2) The body designated or established under clause 45 (1.1) (f) or a party to a proceeding before the body may file a copy of the decision or order of the body, excluding the reasons, in the Superior Court of Justice or, if the amount ordered to be paid does not exceed the monetary jurisdiction of the Small Claims Court, in the Small Claims Court and, when so filed, the decision or order may be enforced as an order of the court in which it is filed.  1993, c. 32, s. 2 (11); 2006, c. 19, Sched. C, s. 1 (1).

Section Amendments with date in force (d/m/y)

1993, c. 32, s. 2 (11) - 14/12/1993

2006, c. 19, Sched. C, s. 1 (1) - 22/06/2006

Mental Illness

Mental illness

Definition

46 (1) In this section,

“hospital” means a psychiatric facility under the Mental Health Act.  R.S.O. 1990, c. H.6, s. 46 (1); 2009, c. 33, Sched. 18, s. 11 (10).

Insured person entitled

(2) An insured person who is entitled to insured services under this Act and the regulations and who is admitted to a hospital under this section is entitled to such services as are required for the person’s maintenance, care, diagnosis and treatment in accordance with this Act and the regulations without being required to pay or have paid on his or her behalf any premium or other charge other than a co-payment for accommodation prescribed in the regulations. 1994, c. 17, s. 73.

Exceptions

(3) Despite subsection (2), an insured person in respect of whom, but for this Act, the Government of Canada would have assumed the cost of the maintenance, care, diagnosis and treatment provided under this section is not entitled to receive insured services in a hospital as an insured person.

Accounts

(4) The General Manager shall keep the accounts, if any, of insured persons who receive hospital services under this section separate from the accounts of patients who receive insured services under the Plan.

Subrogation

(5) Where, as the result of negligence or other wrongful act or omission of another, an insured person suffers personal injuries for which he or she receives services under this section, the Plan is subrogated to any right of the insured person to recover the cost incurred for such services, past or future, and the provisions of this Act and the regulations applying to subrogation of the Plan for the cost of insured services apply with necessary modifications to subrogation of the Plan for the cost of services under this section.  R.S.O. 1990, c. H.6, s. 46 (3-5).

Section Amendments with date in force (d/m/y)

1994, c. 17, s. 73 - 18/05/1994

2009, c. 33, Sched. 18, s. 11 (10) - 15/12/2009

SCHEDULE 1
PHYSICIAN PAYMENT REVIEW PROCESS

Definitions

1 In this Schedule,

“review panel” means a panel selected under subsection 2 (1); (“comité de révision”)

“the Act” means the Health Insurance Act. (“la Loi”)

Request for a hearing, general

2 (1) When the Appeal Board receives a notice that requests a hearing under paragraph 3 or 4 of subsection 20 (1) of the Act and proof of service of the notice, the chair of the Appeal Board or, in his or her absence, a vice chair shall select a panel in accordance with section 4 to hear and determine the matter before it.

Timing

(2) A panel selected under subsection (1) shall conduct the hearing in a timely manner within the prescribed time, if any, and shall make an order with written reasons within 30 business days of the close of submissions, or, if another time has been prescribed, within that time.

Parties

(3) The parties to a hearing under subsection (1) are the General Manager and the physician or physicians named in the notice that requests a hearing.

Order of Appeal Board

(4) An order of a review panel is for all purposes an order of the Appeal Board.

Period of review

3 The physician under review shall only be required to reimburse the Plan for services provided in a period that is no more than 24 months in duration and that commenced no more than five years before the General Manager’s request for a review.

Panels

4 A review panel shall consist of three members of the Appeal Board selected as follows:

1. The chair of the Appeal Board or, in his or her absence, a vice chair shall select the members of the panel that will conduct the hearing and determine the matter before it. The chair or the vice chair may be a member of a panel.

2. One of the members must be a physician, but no more than one.

3. At least one member must be a member of the Law Society of Ontario who is licensed to practise law in Ontario as a barrister and solicitor.

4. The chair or vice chair of the Appeal Board, as the case may be, shall designate one of the members of the review panel as the chair of the panel.

Hearing by review panel

5 A review panel shall hear and determine the matter before it.

Orders

6 (1) The review panel may, as an order of the Appeal Board, make any order that it considers appropriate, including, without being limited to, any one or more of the following:

1. An order determining the proper amount, if any, to be paid to the physician in accordance with the Act and the regulations for the service provided, and requiring that the General Manager pay the account in the amount set out in the order or that the physician reimburse the Plan in the amount set out in the order.

2. An order that, in the future, the physician submit claims for insured services to the Plan or to insured persons in accordance with the order of the Appeal Board.

3. An order that the physician’s entitlement to submit claims for insured services to the Plan or to receive payments from an insured person cease or be suspended for a period of time provided for in the order.

Additional orders

(2) The General Manager may enter in evidence before the review panel a random sample of claims submitted by the physician to the Plan in respect of a fee code during the period of review and, in addition to any other order it may make under subsection (1), the review panel may, in circumstances that it considers appropriate, order that the General Manager calculate the amount to be reimbursed for that fee code for that period, or a portion of that period, by assuming the results observed in the random sample are representative of all the claims during the period in question, where the review panel determines that,

(a) the physician is liable to reimburse the Plan; and

(b) the sample was random and had a reasonable confidence interval.

Effect of suspension, etc.

(3) If a physician is the subject of an order under paragraph 3 of subsection (1), all insured services rendered by him or her during the period the order is in effect are deemed to be insured services payable at nil.

2019, c. 15, Sched. 15, s. 35.

Section Amendments with date in force (d/m/y)

2007, c. 10, Sched. G, s. 34 - 31/03/2010

CTS 23 OC 07 - 2

2019, c. 15, Sched. 15, s. 35 - 10/12/2019

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