O. Reg. 135/09: GENERAL


Published: 2009-04-01

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ontario regulation 135/09

made under the

health insurance act

Made: March 25, 2009
Filed: April 1, 2009
Published on e-Laws: April 2, 2009
Printed in The Ontario Gazette: April 18, 2009

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

(General)

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

“hospital” means, in respect of a hospital in Ontario, any hospital that is designated under this Regulation to participate in the Plan;

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

Preferred Provider Arrangements

27. (1) For the purposes of section 28,

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

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

(2) For the purposes of section 28.0.1,

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

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

(3) For the purposes of section 28.4,

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

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

(4) For the purposes of section 29,

(a) a preferred provider arrangement is a written agreement between the Minister and a physician or practitioner outside Ontario for the delivery of specified insurance services to insured persons; and

(b) a reference to the preferred provider is a reference to the physician or practitioner.

3. The heading before section 28 and section 28 of the Regulation are revoked and the following substituted:

Services Outside Ontario

28. (1) In-patient or out-patient services rendered in a hospital outside Ontario but within Canada are prescribed as insured services if,

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

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

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

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

(e) the hospital or the insured person provides to the General Manager such information and records as the General Manager may require for the purpose of assessing and verifying the claim; and

(f) the services received, including accommodation, do not constitute, in the opinion of the General Manager, the domiciliary type of care provided in a home for the aged, an infirmary or other institution of a similar character.

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

(3) The amount to be reimbursed under subsection (2) is determined as follows:

1. If the insured services are rendered in a hospital whose operator is a preferred provider, the amount payable is the amount provided in the preferred provider arrangement.

2. If the insured services are covered by a preferred provider arrangement in the province in which the services are rendered, but the insured person receives services performed by an identical or equivalent procedure in a hospital in that province whose operator is not a preferred provider, the amount payable is the lesser of the following:

i. The amount provided in the preferred provider arrangement.

ii. The amount actually paid by the insured person.

3. If the insured services are not covered by a preferred provider arrangement in the province in which the services are rendered, the amount payable is the amount payable in accordance with the applicable interprovincial reciprocal billing agreement entered into by the Minister under clause 2 (2) (b) of the Act, and if there is no such agreement, the lesser of the following:

i. The usual and customary amount charged under similar circumstances by similar facilities in the jurisdiction where the insured services are rendered.

ii. The amount actually paid by the person.

(4) If an insured person receives in-patient or out-patient services in a hospital outside Ontario but within Canada for an acute attack of tuberculosis, the Plan may reimburse the insured person for the cost of the treatment for a period not exceeding 60 days and subsection (3) applies.

(5) Subsection (3) applies, and is deemed to have always applied, with respect to services rendered on or after June 3, 2008.

28.0.1 (1) In-patient or out-patient services rendered in a health facility outside Ontario but within Canada are prescribed as insured services if the Minister has entered into a preferred provider arrangement with the operator of that facility for the delivery of those services and the services are rendered in accordance with the preferred provider arrangement.

(2) On application by the health facility or by or on behalf of the insured person, the General Manager may cause reimbursement to be made to the health facility for the rendering of insured services prescribed under subsection (1).

(3) The amount to be reimbursed under subsection (2) is the amount provided in the preferred provider arrangement.

(4) No amount shall be reimbursed if the Minister has entered into a preferred provider arrangement with the operator of a health facility outside Ontario but within Canada for the delivery of services where,

(a) a person receives services from that health facility that are covered by the preferred provider arrangement, but the services are not rendered in accordance with the preferred provider arrangement;

(b) a person receives services from that health facility that are not covered by the preferred provider arrangement; or

(c) a person receives services performed by an identical or equivalent procedure in another health facility outside Ontario but within Canada whose operator is not a preferred provider for those services.

(5) This section applies, and is deemed to have always applied, with respect to services rendered on and after June 3, 2008.

4. Section 28.4 of the Regulation is revoked and the following substituted:

28.4 (1) In this section,

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

(a) death, or

(b) medically significant irreversible tissue damage;

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

(a) is approved by the General Manager, and

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

“health facility” means,

(a) a health facility licensed as a health facility by the government in whose jurisdiction the health facility is situated in which complex medical and complex surgical procedures are routinely performed,

(b) whether or not described in clause (a), a facility licensed by the government in whose jurisdiction the facility is situated with whose operator the Minister has entered into a preferred provider arrangement;

“hospital” means a hospital licensed or approved as a hospital by the government in whose jurisdiction the hospital is situated in which complex medical and complex surgical procedures are routinely performed;

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

(2) Services that are rendered outside Canada at a hospital or health facility are prescribed as insured services if,

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

(b) the service is medically necessary;

(c) either,

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

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

(d) in the case of a hospital service or a service rendered in a health facility described in clause (a) of the definition of “health facility” in subsection (1), the service, if performed in Ontario, is one to which the insured person would be entitled without charge pursuant to section 7 in the case of an in-patient service or section 8 in the case of an out-patient service; and

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

(3) Services that are rendered outside Canada at a hospital or health facility are prescribed as insured services if,

(a)   the conditions in clauses (2) (a), (b), (d) and (e) are satisfied; and

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

(i) that are insured services under subsection (2),

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

(iii) for which written approval of payment was granted before the services are rendered, in accordance with subparagraph 1 i of subsection (4).

(4) Despite anything in this section as it read before April 1, 2009, a service is not, and is deemed never to have been, an insured service under this section unless the following conditions are satisfied:

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

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

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

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

(5) For the purposes of clause (2) (c), a service is performed in Ontario if the service can be legally obtained by an insured person in Ontario and includes, 

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

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

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

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

(6) The amount payable for insured services prescribed by subsections (2) and (3) is determined as follows:

1. If the services are rendered in a hospital whose operator is a preferred provider, the amount payable is the amount provided in the preferred provider arrangement.

2. If the services are covered by one or more preferred provider arrangements, but the insured person receives identical or equivalent services in or from a hospital or health facility whose operator is not a preferred provider, the amount payable is nil.

3. If the services are not covered by a preferred provider arrangement, the amount payable is the usual and customary amount charged by similar facilities under similar circumstances to major insurers for services rendered, to persons they insure, in facilities located in the jurisdiction where the insured services are rendered.

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

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

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

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

2. The application includes written confirmation from the physician or, in emergency circumstances only, the emergency patient referral service, that, in the opinion of the physician or emergency patient referral service, the conditions set out in clauses (2) (a) and (b) and one of the conditions set out in clause (2) (c) are satisfied.

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

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

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

i. the service is rendered in urgent circumstances in order to treat medical complications resulting or arising from services that are insured services under subsection (2), and

ii. the service is medically necessary.

(9) Subject to subsection (4), this section, as it read immediately before April 1, 2009, continues to apply to applications for approval of payment for services in circumstances that are not emergency circumstances,

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

(b) if the applications are in respect of the continuation or extension of the same services for which approval was granted before that date, as long as the services are for the same insured person and for the same medical condition.

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

(0.1)  A service rendered by a physician outside Ontario is an insured service if it is referred to in the schedule of benefits and rendered in such circumstances and under such conditions as may be specified in the schedule of benefits.

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

(10.1) Despite subsections (1) to (10), if the insured services are rendered by a physician or practitioner who is a preferred provider, the amount payable is the amount provided in the preferred provider arrangement.

(10.2) Despite subsections (1) to (10), in the case of insured services rendered outside Ontario but within Canada that are covered by a preferred provider arrangement in the province in which the services are rendered, if the insured person receives services performed by an identical or equivalent procedure from a physician or practitioner in that province who is not a preferred provider, the amount payable is the lesser of the following:

1. The amount provided in the preferred provider arrangement.

2. The amount actually billed by the physician or practitioner.

(10.3) In the case of insured services rendered outside Ontario but within Canada that are not covered by a preferred provider arrangement in the province in which the services are rendered, the amount payable is determined in accordance with subsections (1) to (10).

(10.4) Despite subsections (1) to (10), in the case of insured services rendered outside Canada that are covered by a preferred provider arrangement, if the insured person receives services performed by an identical or equivalent procedure from a physician or practitioner who is not a preferred provider, the amount payable is nil.

(10.5) Subsections (10.1) to (10.4) apply, and are deemed to have always applied, with respect to services rendered on or after June 3, 2008.

6. This Regulation comes into force on the day it is filed.