ONTARIO REGULATION 27/14
made under the
HEALTH INSURANCE ACT
Made: February 12, 2014
Filed: February 14, 2014
Published on e-Laws: February 14, 2014
Printed in The Ontario Gazette: March 1, 2014
Amending Reg. 552 of R.R.O. 1990
1. Regulation 552 of the Revised Regulations of Ontario, 1990 is amended by adding the following sections:
28.0.2 (1) A therapeutic laboratory service or diagnostic laboratory test that is performed outside Ontario but within Canada for an insured person is prescribed as an insured service if that kind of service or test is not performed in Ontario but the service or test is generally accepted in Ontario as appropriate for a person in the same circumstances as the insured person.
(2) Despite subsection (1), a service or test is not prescribed as an insured service if,
(a) the service or test is experimental or the service or test is performed for research purposes; or
(b) the service or test does not constitute a test as defined in section 5 of the Laboratory and Specimen Collection Centre Licensing Act.
(3) Subject to subsection (4), an amount is payable for an insured service prescribed by subsection (1) if the service is provided to an insured person and an application for approval of payment is submitted to the General Manager on behalf of the insured person by a physician who practises medicine in Ontario and,
(a) the application includes written confirmation from the physician that, in his or her opinion, the conditions in subsection (1) are satisfied; and
(b) written approval of payment of the amount for the service is granted by the General Manager before the service is rendered and the service is rendered within the time limit set out in the written approval.
(4) Where an insured service prescribed by subsection (1) is a genetic service or test, an amount is not payable for the insured service unless the application under subsection (3) includes written confirmation from an Ontario physician who is a specialist, as defined in the schedule of benefits, in treating the medical condition to which the test or service for which approval of payment is sought relates that, in that specialist’s opinion, the conditions in subsection (1) are satisfied.
(5) The amount payable by the Plan for a service or test prescribed by subsection (1) is the amount determined by the General Manager.
(6) An insured person may be reimbursed by the Plan for an amount paid for insured services prescribed by subsection (1) on presentation to the General Manager of an account, including a detailed receipt, from the laboratory that performed the service for payment made by the person to the laboratory, or the General Manager may cause reimbursement to be made directly to the laboratory.
28.0.3 In the case of any service prescribed under sections 28 to 29, the General Manager may require information and records to be provided in order to assess and verify the claim for payment, and where such information and records are not provided to the satisfaction of the General Manager, the amount payable for the insured service is nil.
O. Reg. 76/12
2. The following provisions of Ontario Regulation 76/12 are revoked:
1. Section 3, which would amend section 27 of the Regulation.
2. Section 4, which would remake sections 28 and 28.0.1 of the Regulation.
3. Subsection 9 (1), which would amend section 29 of the Regulation.
O. Reg. 267/13
3. Section 2 of Ontario Regulation 267/13, which would amend section 28.0.3 of the Regulation, is revoked.
4. (1) Subject to subsection (2), this Regulation comes into force on the day it is filed.
(2) Section 1 comes into force on April 1, 2014.