Page 1 - Canada Health Act Annual Report 2007-2008

Newfoundland and Labrador

Introduction

The majority of publicly funded health services in Newfoundland and Labrador are delivered through four regional health authorities. They focus on the full continuum of care including health promotion and protection, public health, community services, acute and long-term care services.

The provincial government appoints Boards of Trustees to the regional health authorities who serve in a voluntary capacity. These authorities are responsible for delivering health and community services to their regions, and in some cases, to the province as a whole. Regional authorities interact with the public and community partners to determine health needs. The regional authorities receive their funding from the Department of Health & Community Services and are accountable to the Minister. The Department of Health and Community Services provides the regional authorities with policy direction, financial resources and monitors programs and services.

In Newfoundland and Labrador, almost 19,000 health care providers and administrators provide health services to 505,000 residents (based on 2006 census).

The re-registration of the province's Medical Care Plan (MCP) concluded in July 2007 with over 488,850 individuals, representing 97 per cent of the population, receiving new cards. This measure ensures that only eligible beneficiaries permanently residing in the province are able to avail themselves of medical care and hospital coverage under the MCP. All residents of the province were required to complete a re-registration form in order to receive a new MCP card. Each new card has an expiry date which will allow the government to effectively monitor MCP claims and ensure that only eligible residents of Newfoundland and Labrador are receiving services under the provincial plan. This was the first major change to the program since it began in 1969.

Other key initiatives during the year included:

• The government invested $800,000 through Budget 2007 to support the new Mental Health Care and Treatment Act which took effect on October 1, 2007. It contains several significant changes including the provision of a range of individual rights and protections and the provision of community treatment orders.
  
• As part of the province's Poverty Reduction Strategy, the government extended eligibility for the Children's Dental Health Plan to children aged 13 to 17 years in families with low incomes.
  
  
• Investments worth $67 million were made in health infrastructure. Construction is continuing on new long-term care homes in Clarenville, Corner Brook and Happy Valley/Goose Bay. A new primary health centre in Grand Bank and a provincial addictions centre in Corner Brook are also being built.
  
• New enhancements to the Medical Transportation Assistance Program will provide increased financial assistance for residents who incur substantial costs when travelling for insured medical services.
  
• The government launched the Provincial Healthy Aging Policy Framework to support its vision of an age-friendly province which enables seniors to live independently and experience good health and well-being. The priority directions are the Recognition of Older Persons, Celebrating Diversity, Supportive Communities, Financial Well-being, Health and Well-being and Employment, Education and Research.
  
• The government released planning guidelines to enhance the protection of the public in the event of a public health emergency with a view to developing detailed operational plans at the community level.
  
• The Newfoundland and Labrador Prescription Drug Program added an Assurance Plan for residents with high drug costs. This offers all residents protection against the financial burden of drug costs by ensuring that their annual drug expenses are capped at a percentage of their net family income. The Assurance Plan costs an additional $17.5 million annually.
  
• The government launched an $8 million initiative to provide an enhanced board and lodging supplement for adults with disabilities residing with their own family. Approximately 2,500 individuals would be eligible for this increase of up to $362 per month or $4,344 annually.
  
• Budget 2007 provided $1.4 million to cover the cost of insulin pumps and supplies for children with Type 1 diabetes up to the age of 18 years.
  

1.0 Public Administration

1.1 Health Care Insurance Plan and Public Authority

Health care insurance plans managed by the Department include the Hospital Insurance Plan and the Medical Care Plan (MCP). Both plans are non-profit and publicly administered.

The Hospital Insurance Agreement Act is the legislation that enables the Hospital Insurance Plan. The Act gives the Minister of Health and Community Services the authority to make Regulations for providing insured services on uniform terms and conditions to residents of the province under the conditions specified in the Canada Health Act and Regulations.

The Medical Care Insurance Act (1999) empowers the Minister to administer a plan of medical care insurance for residents of the province. It provides for the development of regulations to ensure that the provisions of the statute meet the requirements of the Canada Health Act as it relates to administering the Medical Care Plan.

The Medical Care Plan facilitates the delivery of comprehensive medical care to all residents of the province by implementing policies, procedures and systems that permit appropriate compensation to providers for rendering insured professional services. The Medical Care Plan operates in accordance with the provisions of the Medical Care Insurance Act (1999) and Regulations, and in compliance with the Canada Health Act.

There were no legislative amendments to the Medical Care Insurance Act (1999) or the Hospital Insurance Agreement Act in 2007-2008.

1.2 Reporting Relationship

The Department is mandated with administering the Hospital Insurance and Medical Care Plans. The Department reports on these plans through the regular legislative processes; e.g., Public Accounts and the Estimates Committee of the House of Assembly.

The Department will be tabling its 2007-2008 Annual Report in the House of Assembly in Fall 2008 as well as those of the four regional health authorities.

The Department's Annual Report highlights the accomplishments of 2007-2008 and provides an overview of the initiatives and programs that will continue to be developed in 2008-2009. The report is a public document and is circulated to stakeholders. It is available on the department's website at:
www.health.gov.nl.ca/health
Health and Community Services

1.3 Audit of Accounts

Each year, the Province's Auditor General independently examines provincial public accounts. MCP expenditures are now considered a part of the public accounts. The Auditor General has full and unrestricted access to MCP records.

The four regional health authorities are subject to Financial Statement Audits, Reviews and Compliance Audits. Financial Statement Audits are performed by independent auditing firms that are selected by the health authorities under the terms of the Public Tendering Act. Review engagements, compliance audits and physician audits were carried out by personnel from the Department under the authority of the Newfoundland Medical Care Insurance Act (1999). Physician records and professional medical corporation records were reviewed to ensure that the records supported the services billed and that the services are insured under the MCP.

Beneficiary audits were performed by personnel from the Department under the Medical Care Insurance Act (1999). Individual providers are randomly selected on a bi-weekly basis for audit.

2.0 Comprehensiveness

2.1 Insured Hospital Services

The Hospital Insurance Agreement Act and the Hospital Insurance Regulations 742/96 (1996) provide for insured hospital services in Newfoundland and Labrador.

Insured hospital services are provided for in- and out-patients in 14 hospitals, 22 community health centres and 14 community clinics. Insured services include: accommodations and meals at the standard ward level; nursing services; laboratory, radiology and other diagnostic procedures; drugs, biologicals and related preparations; medical and surgical supplies, operating room, case room and anaesthetic facilities; rehabilitative services (e.g., physiotherapy, occupational therapy, speech language pathology and audiology); outpatient and emergency visits; and day surgery.

The coverage policy for insured hospital services is linked to the coverage policy for insured medical services. The Department of Health and Community Services manages the process of adding or de-listing a hospital service from the list of insured services based on direction from the Minister. There were no services added or de-listed in 2007-2008.

2.2 Insured Physician Services

The enabling legislation for insured physician services is the Medical Care Insurance Act (1999).

Other governing legislation under the Medical Care Insurance Act includes:

• the Medical Care Insurance Insured Services Regulations;
  
  
• the Medical Care Insurance Beneficiaries and Inquiries Regulations; and
  
  
• the Medical Care Insurance Physician and Fees Regulations.

Licensed medical practitioners are allowed to provide insured physician services under the insurance plan. A physician must be licensed by the College of Physicians and Surgeons of Newfoundland and Labrador to practice in the province. In 2007-2008, there were 989 physicians registered in the province.

An insured service is defined as one that is: listed in section 3 of the Medical Care Insurance Insured Services Regulations; medically necessary; and/or recommended by the Department of Health and Community Services. There are no limitations on the services covered, subject to these criteria.

For purposes of the Act, the following services are covered:

• all services properly and adequately provided by physicians to beneficiaries suffering from an illness requiring medical treatment or advice;
  
  
• group immunizations or inoculations carried out by physicians at the request of the appropriate authority; and
  
  
• diagnostic and therapeutic x-ray and laboratory services in facilities approved by the appropriate authority that are not provided under the Hospital Insurance Agreement Act and Regulations made under the Act.

Physicians can choose not to participate in the health care insurance plan as outlined in subsection 12(1) of the Medical Care Insurance Act (1999), namely:

1. Where a physician providing insured services is not a participating physician, and the physician provides an insured service to a beneficiary, the physician is not subject to this Act or the regulations relating to the provision of insured services to beneficiaries or the payment to be made for the services except that he or she shall:
   
   
   1. before providing the insured service, if he or she wishes to reserve the right to charge the beneficiary for the service an amount in excess of that payable by the Minister under this Act, inform the beneficiary that he or she is not a participating physician and that the physician may so charge the beneficiary; and
      
      
   2. provide the beneficiary to whom the physician has provided the insured service with the information required by the minister to enable payment to be made under this Act to the beneficiary in respect of the insured service.
   
   
   
2. Where a physician who is not a participating physician provides insured services through a professional medical corporation, the professional medical corporation is not, in relation to those services, subject to this Act or the regulations relating to the provision of insured services to beneficiaries or the payment to be made for the services and the professional medical corporation and the physician providing the insured services shall comply with subsection (1).

As of March 31, 2008, there were no physicians who had opted out of the MCP.

Ministerial direction is required to add to or to de-insure a physician service from the list of insured services. This process is managed by the Department in consultation with various stakeholders, including the provincial medical association and the public. There were no services added or deleted during the 2007-2008 fiscal year to the list of insured physician services.

2.3 Insured Surgical-Dental Services

The provincial Surgical-Dental Program is a component of the Medical Care Plan (MCP). Surgical-dental treatments provided to a beneficiary and carried out in a hospital by a licensed oral surgeon or dentist are covered by MCP if the treatment is specified in the Surgical-Dental Services Schedule.

All oral surgeons or dentists licensed to practice in Newfoundland and Labrador and who have hospital privileges are allowed to provide surgical-dental services. The dentist's license is issued by the Newfoundland and Labrador Dental Board. In 2007-08, there were 25 dentists with hospital privileges registered in the province.

Dentists may opt out of the Medical Care Plan. These dentists must advise the patient of their opted-out status, stating the fees expected, and provide the patient with a written record of services and fees charged.

Because the Surgical-Dental Program is a component of the MCP, management of the Program is linked to the MCP process regarding changes to the list of insured services.

Addition of a surgical-dental service to the list of insured services must be approved by the Department.

2.4 Uninsured Hospital, Physician and Surgical-Dental Services

Hospital services not covered by MCP include: preferred accommodation at the patient's request; cosmetic surgery and other services deemed to be medically unnecessary; ambulance or other patient transportation before admission or upon discharge; private duty nursing arranged by the patient; non-medically required x-rays or other services for employment or insurance purposes; drugs (except anti-rejection and AZT drugs) and appliances issued for use after discharge from hospital; bedside telephones, radios or television sets for personal, non-teaching use; fibreglass splints; services covered by the Workplace Health, Safety and Compensation Commission or by other federal or provincial legislation; and services relating to therapeutic abortions performed in non-accredited facilities or facilities not approved by the College of Physicians and Surgeons of Newfoundland and Labrador.

The use of the hospital setting for any services deemed not insured by the Medicare Plan are also uninsured under the Hospital Insurance Plan.

For purposes of the Medical Care Insurance Act (1999), the following is a list of non-insured physician services:

• any advice given by a physician to a beneficiary by telephone;
  
  
• the dispensing by a physician of medicines, drugs or medical appliances and the giving or writing of medical prescriptions;
  
  
• the preparation by a physician of records, reports or certificates for, or on behalf of, or any communication to, or relating to, a beneficiary;
  
  
• any services rendered by a physician to the spouse and children of the physician;
  
  
• any service to which a beneficiary is entitled under an Act of the Parliament of Canada, an Act of the Province of Newfoundland and Labrador, an Act of the legislature of any province of Canada, or any law of a country or part of a country;
  
  
• the time taken or expenses incurred in travelling to consult a beneficiary;
  
  
• ambulance service and other forms of patient transportation;
  
  
• acupuncture and all procedures and services related to acupuncture, excluding an initial assessment specifically related to diagnosing the illness proposed to be treated by acupuncture;
  
  
• examinations not necessitated by illness or at the request of a third party except as specified by the appropriate authority;
  
  
• plastic or other surgery for purely cosmetic purposes, unless medically indicated;
  
  
• testimony in a court;
  
  
• visits to optometrists, general practitioners and ophthalmologists solely for determining whether new or replacement glasses or contact lenses are required;
  
  
• the fees of a dentist, oral surgeon or general practitioner for routine dental extractions performed in hospital;
  
  
• fluoride dental treatment for children under four years of age;
  
  
• excision of xanthelasma; circumcision of newborns; hypnotherapy;
  
  
• medical examination for drivers;
  
  
• alcohol/drug treatment outside Canada;
  
  
• consultation required by hospital regulation;
  
  
• therapeutic abortions performed in the province at a facility not approved by the College of Physicians and Surgeons of Newfoundland and Labrador;
  
  
• sex reassignment surgery, when not recommended by the Clarke Institute of Psychiatry;
  
  
• in vitro fertilization and OSST (ovarian stimulation and sperm transfer);
  
  
• reversal of previous sterilization procedure;
  
  
• surgical, diagnostic or therapeutic procedures not provided in facilities other than those listed in the Schedule to the Hospitals Act or approved by the appropriate authority under paragraph 3(d); and
  
  
• other services not within the ambit of section 3 of the Act.

The majority of diagnostic services (e.g., laboratory services and x-ray) are performed within public facilities in the province. Hospital policy concerning access ensures that third parties are not given priority access.

Medical goods and services that are implanted and associated with an insured service are provided free of charge to the patient and are consistent with national standards of practice. Patients retain the right to financially upgrade the standard medical goods or services. Standards for medical goods are developed by the hospitals providing those services in consultation with service providers.

Surgical-dental and other services not covered by the Surgical-Dental Program include the dentist's fee and the oral surgeon's or general practitioner's fees for routine dental extractions in a hospital.

3.0 Universality

3.1 Eligibility

Residents of Newfoundland and Labrador are eligible for coverage under the Medical Care Insurance Act (1999) and the Hospital Insurance Agreement Act. The Medical Care Insurance Act (1999) defines a "resident" as a person lawfully entitled to be or to remain in Canada, who makes his or her home and is ordinarily present in the province, but does not include tourists, transients or visitors to the province.

The Medical Care Insurance Beneficiaries and Inquiries Regulations (Regulation 20/96) identify those residents eligible to receive coverage under the plans. MCP has established rules to ensure that the Regulations are applied consistently and fairly in processing applications for coverage. MCP applies the standard that persons moving to Newfoundland and Labrador from another province become eligible on the first day of the third month following the month of their arrival.

Persons not eligible for coverage under the plans include: students and their dependants already covered by another province or territory; dependants of residents if covered by another province or territory; certified refugees and refugee claimants and their dependants; foreign workers with Employment Authorizations and their dependants who do not meet the established criteria; foreign students and their dependants; tourists, transients, visitors and their dependants; Canadian Forces and Royal Canadian Mounted Police (RCMP) personnel; inmates of federal prisons; and armed forces personnel from other countries who are stationed in the province.

3.2 Registration Requirements

Registration under the MCP and possession of a valid MCP card is required to access insured services. New residents are advised to apply for coverage as soon as possible on arriving in Newfoundland and Labrador. A re-registration of the province's MCP plan was completed in 2007. All residents of the province were required to complete a re-registration form in order to receive a new MCP card.

It is the parent's responsibility to register a newborn or adopted child. The parents of a newborn child will be given a registration application upon discharge from hospital. Applications for newborn coverage will require, in most instances, a parent's valid MCP number. A birth or baptismal certificate will be required where the child's surname differs from either parent's surname.

Applications for coverage of an adopted child require a copy of the official adoption documents, the birth certificate of the child, or a Notice of Adoption Placement from the department. Applications for coverage of a child adopted outside Canada require Permanent Resident documents for the child.

3.3 Other Categories of Individual

Foreign workers, clergy and dependants of North Atlantic Treaty Organization (NATO) personnel are eligible for benefits. Holders of Minister's permits are also eligible, subject to MCP approval. International students studying in the province became eligible for coverage in the MCP program in June 2007.

4.0 Portability

4.1 Minimum Waiting Period

Insured persons moving to Newfoundland and Labrador from other provinces or territories are entitled to coverage on the first day of the third month following the month of arrival.

Persons arriving from outside Canada to establish residence are entitled to coverage on the day of arrival. The same applies to discharged members of the Canadian Forces, the RCMP and individuals released from federal penitentiaries. For coverage to be effective, however, registration is required under MCP. Immediate coverage is provided to persons from outside Canada authorized to work in the province for one year or more.

4.2 Coverage During Temporary Absences in Canada

Newfoundland and Labrador is a party to the Agreement on Eligibility and Portability regarding matters pertaining to portability of insured services in Canada.

Sections 12 and 13 of the Hospital Insurance Regulations (1996) define portability of hospital coverage during temporary absences both within and outside Canada. Portability of medical coverage during temporary absences both within and outside Canada is defined in Departmental policy.

The eligibility policy for insured hospital services is linked to the eligibility policy for insured physician services, although there is no formalized process.

Coverage is provided to residents during temporary absences within Canada. The Government has entered into formal agreements (i.e. the Hospital Reciprocal Billing Agreement) with other provinces and territories for the reciprocal billing of insured hospital services. In-patient costs are paid at standard rates approved by the host province or territory. In-patient, high-cost procedures and out-patient services are payable based on national rates agreed to by provincial and territorial health plans through the Interprovincial Health Insurance Agreements Coordinating Committee (IHIACC).

Except for Quebec, medical services incurred in all provinces or territories are paid through the Medical Reciprocal Billing Agreement at host province or territory rates. Claims for medical services received in Quebec are submitted by the patient to the MCP for payment at host province rates.

In order to qualify for out-of-province coverage, a beneficiary must comply with the legislation and MCP rules regarding residency in Newfoundland and Labrador. A resident must reside in the province at least four consecutive months in each 12-month period to qualify as a beneficiary. Generally, the rules regarding medical and hospital care coverage during absences include the following:

• Before leaving the province for extended periods, a resident must contact the MCP to obtain an out-of-province coverage certificate.
  
  
• Beneficiaries leaving for vacation purposes may receive an initial out-of-province coverage certificate of up to 12 months. Upon return, beneficiaries are required to reside in the province for a minimum four consecutive months. Thereafter, certificates will only be issued for up to eight months of coverage.
  
  
• Students leaving the province may receive a certificate, renewable each year, provided they submit proof of full-time enrolment in a recognized educational institution located outside the province.
  
  
• Persons leaving the province for employment purposes may receive a certificate for coverage up to 12 months. Verification of employment may be required.
  
  
• Persons must not establish residence in another province, territory or country while maintaining coverage under the Newfoundland MCP.
  
  
• For out-of-province trips of 30 days or less, an out-of-province coverage certificate is not required, but will be issued upon request.
  
  
• For out-of-province trips lasting more than 30 days, a certificate is required as proof of a resident's ability to pay for services while outside the province.

Failure to request out-of-province coverage or failure to abide by the residency rules may result in the resident having to pay for medical or hospital costs incurred outside the province.

Insured residents moving permanently to other parts of Canada are covered up to and including the last day of the second month following the month of departure. Coverage is immediately discontinued when residents move permanently to other countries.

In 2007/2008, the total amount paid by MCP for physician services received by residents in another province or territory was $6,320,000.

4.3 Coverage During Temporary Absences Outside Canada

The Province provides coverage to residents during temporary absences outside Canada. Out-of-country insured hospital in- and out-patient services are covered for emergencies, sudden illness and elective procedures at established rates. Hospital services are considered under the Plan when the insured services are provided by a recognized facility (licensed or approved by the appropriate authority within the state or country in which the facility is located) outside Canada. The maximum amount payable by the Government's hospitalization plan for outof-country in-patient hospital care is $350 per day, if the insured services are provided by a community or regional hospital. Where insured services are provided by a tertiary care hospital (a highly specialized facility), the approved rate is $465 per day. The approved rate for out-patient services is $62 per visit and hæmodialysis is $220 per treatment. The approved rates are paid in Canadian funds.

The total amount spent in 2007/2008 for insured hospital services outside of Canada was approximately $1,148,560.

Physician services are covered for emergencies or sudden illness and are also insured for elective services not available in the province or within Canada. Physician services are paid at the same rate as would be paid in Newfoundland and Labrador for the same service. If the services are not available in Newfoundland and Labrador, they are usually paid at Ontario rates, or at rates that apply in the province where they are available.

The total amount spent by MCP in 2007/2008 for insured physician services provided outside Canada was $300,000.

4.4 Prior Approval Requirement

Prior approval is not required for medically necessary insured services provided by accredited hospitals or licensed physicians in the other provinces and territories. If a resident of the province has to seek specialized hospital care outside the country because the insured service is not available in Canada, the provincial health insurance plan will pay the costs of services necessary for the patient's care. However, it is necessary in these circumstances for such referrals to receive prior approval from the Department. The referring physicians must contact the Department or the MCP for prior approval.

Prior approval is not required for physician services; however, it is suggested that physicians obtain prior approval from the MCP so that patients may be made aware of any financial implications. General practitioners and specialists may request prior approval on behalf of their patients. Prior approval is not granted for out-of-country treatment of elective services if the service is available in the province or elsewhere within Canada.

5.0 Accessibility

5.1 Access to Insured Health Services

Access to insured health services in Newfoundland and Labrador is provided on uniform terms and conditions. There are no co-insurance charges for insured hospital services and no extra-billing by physicians in the province.

5.2 Access to Insured Hospital Services

As of March 31, 2008, regional health authorities (RHAs) directly employed approximately 19,500 people in Newfoundland and Labrador. This figure is comprised of 7,600 nurses (licensed practical nurses and registered nurses, 730 social workers, 385 medical laboratory technologists, 305 medical radiation technologists, a further 475 health service providers of various occupations, 980 managers, and approximately 9,000 support staff (housekeeping, laundry, facilities, dietary, etc.) Additionally, approximately 989 physicians work in the province, with about one-third employed directly by RHAs in salaried positions (these are not included in the figure of 19,500 people).

The Department of Health and Community Services works closely with educational institutions within the province to maintain an appropriate supply of health professionals. The province also works with external organizations for health professionals not trained in this province.

Insured hospital services are provided by 36 hospitals and health centres across Newfoundland and Labrador. All facilities provide 24 hour emergency services, out-patient clinics, laboratory and x-ray services. The other services vary by facility and range from general surgery, internal medicine and obstetrics to specialized services such as cardiology and neurology. Quaternary care is not offered in Newfoundland and Labrador and provincial residents travel to other jurisdictions to access services. Insured services are also provided in 14 nursing stations.

The government continued to improve capacity through a $22.3 million investment in 2007 for new diagnostic and capital equipment including two new linear accelerators to expand radiation treatment capacity at the Dr. H. Bliss Murphy Cancer Centre in St. John's.

As of March 31, 2008, Newfoundland and Labrador was within the national benchmarks for cardiac care, joint replacement, and cancer care between 78% to 100% of the time, demonstrating that the four regional health authorities are providing access to these services within close proximity to the target timeframe.

The government provided $2 million in 2007 to improve access to health services, including extended hours of operation for MRI services in St. John's and Corner Brook, enhanced mammography and CT services in Carbonear and expanded endoscopy services in Gander and Grand Falls-Windsor. An additional $11.5 million was allocated to regional health authorities to address utilization pressures and invest in new initiatives including additional long-term care and acute care beds, implementation of a new bilateral cochlear implant service in St. John's, establishing a specialized medical flight team for the province's air ambulance service and enhanced services for dialysis, stroke care, respiratory therapy and laboratory.

Newfoundland and Labrador has implemented the Picture Archiving and Communications System (PACS) and by December 2007 had achieved the goal of having 95% of diagnostic images available digitally throughout the province to authorized health care providers.

Targeted recruitment incentives are in place to attract health professionals. Several programs have been established to provide targeted sign-on bonuses, bursaries, opportunities for upgrading, and other incentives for a wide variety of health occupations.

The provincial Primary Health Care (PHC) framework, Moving Forward Together: Mobilizing Primary Health Care, continues to provide direction for remodelling primary health care in Newfoundland and Labrador through a population-health based approach to service delivery, and using a voluntary and incremental approach. PHC services include all the health services delivered in a geographic area (minimum population 6,000 to maximum population of 25,000) from primary prevention through to, and including, acute and episodic illness at the PHC service delivery level.

5.3 Access to Insured Physician and Surgical-Dental Services

A pilot pediatric dental clinic, Operation Tooth, was held in Labrador in January 2008. A surgical team travelled to the Labrador Health Centre in Happy Valley-Goose Bay to perform 38 surgeries for children who were wait listed for dental surgery and who would normally have to fly to St. John's for services.

A new Dental Bursary Program will support an increase in the number of dentists practising throughout the province, particularly in rural areas. The government invested $150,000 to implement the program in 2008 and $275,000 annually for the programs two components: the Rural Dental Bursary Program and Specialist Bursary Program.

The number of physicians practicing in the province has been relatively stable, with an upward trend since 2003. The Department is committed to working with regional health authorities to develop a provincial human resource plan for physicians based on the principle of access to services.

As of March 31, 2008, there were 480 general practitioners and 509 specialists in practice, compared with 481 general practitioners and 504 specialists as of March 31, 2007.

The Department has initiated several measures to improve access for insured physician services. Some of these include:

• funding for the Provincial Office of Recruitment;
  
  
• retention bonuses for salaried physicians based on geography and years of service; and
  
  
• an annual bursary program valued at $575, 000 for medical residents and students (matched to Family Practice in Canadian Resident Matched Services (CaRMS)) willing to commit to provide medical services in areas of need within the province. During fiscal year 2007-2008, 27 bursaries were funded.

5.4 Physician Compensation

The legislation governing payments to physicians and dentists for insured services is the Medical Care Insurance Act (1999).

The current methods of remuneration to compensate physicians for providing insured health services include fee-for-service, salary, contract and sessional block funding.

Compensation agreements are negotiated between the provincial government and the Newfoundland and Labrador Medical Association (NLMA), on behalf of all physicians. Representatives from the regional health authorities play a significant role in this process. The current agreement with the provincial association is due to expire in 2009.

5.5 Payments to Hospitals

The Department is responsible for funding regional health authorities for ongoing operations and capital acquisitions. Funding for insured services is provided to the regional health authorities as an annual global budget. Payments are made in accordance with the Hospital Insurance Agreement Act (1990) and the Hospitals Act. As part of their accountability to the Government, the health authorities are required to meet the Department's annual reporting requirements, which include audited financial statements and other financial and statistical information. The global budgeting process devolves the budget allocation authority, responsibility and accountability to all appointed boards in the discharge of their mandates.

Throughout the fiscal year, the regional health authorities forwarded additional funding requests to the Department for any changes in program areas or increased workload volume. These requests were reviewed and, when approved by the Department, funded at the end of each fiscal year. Any adjustments to the annual funding level, such as for additional approved positions or program changes, were funded based on the implementation date of such increases and the cash flow requirements.

Regional health authorities are continually facing challenges in addressing increased demands due to inflation and increased workload. Higher patient expectations and new technology is creating new demands for time, resources and funding. Regional health authorities continue to work with the Department to address these issues and provide effective, efficient and quality health services.

6.0 Recognition Given to Federal Transfers

Funding provided by the federal government through the Canada Health Transfer (CHT) and the Canada Social Transfer (CST) has been recognized and reported by the Government of Newfoundland and Labrador in the annual provincial budget, through press releases, government websites and various other documents. For fiscal year 2007-2008, these documents included:

• the 2007-2008 Public Accounts;
  
  
• the Estimates 2007-2008; and
  
  
• the Budget Speech 2007.

The Public Accounts and Estimates, tabled by the Government in the House of Assembly, are publicly available to Newfoundland and Labrador residents and have been shared with Health Canada for information purposes.

7.0 Extended Health Care Services

7.1 Long-Term Care, Home Intermediate Care and Adult Residential Care Newfoundland and Labrador

Newfoundland and Labrador has established long-term residential and community-based programs for persons discharged from hospital, seniors, and persons with disabilities. These programs are provided by the regional health authorities. Services include the following:

• Long-term residential accommodations are provided for residents with high care needs in three hospitals (including a psychiatric facility), 17 community health centres and 20 homes. There are approximately 2,747 beds located in these facilities. Residents pay a maximum of $2,800 per month based on each client's assessed ability to pay, using provincial financial assessment criteria. The balance of funding required to operate these facilities is provided by the Department.
  
  
• Persons requiring supervised care or minimal assistance with activities of daily living can avail themselves of residential services in personal care homes. There are approximately 3,529 beds located in 104 homes across the province. These homes are operated by the private for-profit sector. Residents are subsidized to a maximum of $1,534 per month, based on an individual client assessment using standardized financial criteria.
  
  

7.2 Home Care Services

Home Care Services include professional and non-professional supportive care to enable people to remain in their own homes for as long as possible without risk. Professional services include nursing and some rehabilitative programs. These services are publicly funded and delivered by staff employed by the four regional health authorities. Non-professional services include personal care, household management, respite and behavioural management. These services are delivered by home support workers through agency or self-managed care arrangements. Eligibility for non-professional services is determined through a client financial assessment using provincial criteria. The monthly ceiling for home support services in fiscal 2007-2008 was $2,707 for seniors and $3,875 for persons with disabilities.

7.3 Ambulatory Health Care Services

• The Air Ambulance Program provides air transport for patients requiring emergency care who could not be transported by a commercial airline or by road ambulance because of urgency or time, or remoteness of location. This program uses two fixed-wing aircraft and five chartered helicopters. These helicopters are also used for routine transportation of doctors and nurses to remote communities for clinics. A third fixed-wing aircraft is used in Labrador for regional medical services transports, including routine appointments by coastal residents in Happy Valley/Goose Bay, Labrador.
  
  
• Residents who travel by commercial air to access medically necessary insured services that are not available within their area of residence or within the province, may qualify for financial assistance under the Medical Transportation Assistance Program. This program is administered by the Department. Kidney donors and bone marrow/ stem-cell donors are eligible for financial assistance, as administered by Eastern Health, when the recipient is a Newfoundland and Labrador resident eligible for coverage under the provincial Hospital Insurance and Medical Care Plans.
  
  
• The Dental Health Plan incorporates a children's dental component and an Income Support component. The children's program covers the following dental services for all children up to and including the age of 12: examinations at six-month intervals; cleanings at 12-month intervals; fluoride applications at 12-month intervals for children aged 6 to 12; x-rays (some limitations); fillings and extractions; and some other specific procedures that require approval before treatment. Services are available to recipients of Income Support or eligible families with low incomes who are 13 to 17 years of age: examinations (every 24 months); x-rays (with some limitations); routine fillings and extractions; emergency extractions, when the patient is seen for pain, infection or trauma. Adults receiving income support are eligible for emergency care and extractions.
  
  
• The Newfoundland and Labrador Prescription Drug Program (NLPDP) provides prescription drugs and additional drug benefits approved by the Department of Health and Community Services which are listed in the Newfoundland and Labrador Prescription Drug Program Benefit List. These approved benefits are supplied as part of the Foundation Plan, 65 Plus Plan, Special Needs Plan, Access Plan and Assurance Plan for eligible residents.
  
  
• The Foundation Plan provides prescription drug coverage for residents of the province who qualify for full benefit coverage under the Department of Human Resources, Labour and Employment. Coverage is also provided for residents who, due to the high cost of their medications, may qualify for drug card only benefits, residents in Government subsidized Long Term Care Facilities, children in care, and youth corrections. The Income Support Component covers the full cost of benefit prescription items, including a set mark-up amount and dispensing fee.
  
  
• The 65 Plus Plan provides prescription drug coverage for residents who are 65 years of age or over, who are in receipt of the federal Guaranteed Income Supplement (GIS) and who are registered for the Old Age Security (OAS) benefits. The plan covers defined ingredient cost only for identified benefits. Any additional cost, such as dispensing fees, is the client's responsibility.
  
  
• Ostomy Subsidy benefits are available to those senior citizens who qualify for a drug card under the 65 Plus Plan or Foundation Plan . Government will reimburse eligible senior citizens for 75% of the retail cost of items that are benefits. Eligible seniors are responsible for the remaining costs.
  
  
• The Special Needs Plan provides universal coverage for patients with Cystic Fibrosis and Growth Hormone Deficiency. The Special Needs Plan covers the full cost for identified benefits -- disease-related prescription drugs, enzymes, foods, medical supplies, and equipment -- supplied through the Health Sciences Central Supply and Pharmacy.
  
  
• The Access Plan provides prescription drug coverage for residents of Newfoundland and Labrador who are eligible for and in receipt of a MCP card and who fall within specific income thresholds. The Access Plan covers a percentage of drug costs (ranging from 30-80%) dependant upon family income.
  
  
• The Assurance Plan caps annual drug expenses at a percentage of net family income.
  

Registered Persons

Insured Hospital Services Within Own Province or Territory

Insured Hospital Services Provided to Residents in Another Province or Territory

Insured Hospital Services Provided Outside Canada

Insured Physician Services Within Own Province or Territory

Insured Physician Services Provided to Residents in Another Province or Territory

Insured Physician Services Provided Outside Canada

Insured Surgical-Dental Services Within Own Province or Territory

Prince Edward Island

Introduction

The Ministry of Health is a system of integrated services whose aim is to protect, maintain and improve the health and well-being of Prince Edward Islanders. Health services in Prince Edward Island are delivered through a single management model centralized under the Department of Health.

The Ministry is responsible for providing a variety of health services to Islanders to promote and help foster their optimal health, including public health services, primary care, acute care, community hospital and continuing care services. These services are delivered by over 4,500 dedicated professional staff through a large number of facilities and programs across the province. Included are:

• acute care facilities;
  
  
• community hospitals;
  
  
• provincial manors;
  
  
• an in-patient mental health facility;
  
  
• a provincial addictions treatment facility and community programs;
  
  
• family health centres;
  
  
• public health, home care, community addictions programs;
  
  
• community mental health;
  
  
• the Chief Health Officer; and
  
  
• Vital Statistics and regulatory services.

A Minister of the Crown is ultimately accountable to the rest of government and the citizens of PEI for the Department of Health and its performance and results. The Department is managed by a Departmental Management Committee comprised of the Deputy Minister, the Assistant Deputy Minister of Health Operations, and nine eight senior directors whose responsibility it is to direct the overall departmental management and day-to-day operations. A summary of the principal roles of division is outlined below.

Acute Care: Provides regional and provincial secondary, specialty services, and in-patient mental health services to residents of PEI. Facilities include Prince County Hospital (PCH), the Queen Elizabeth Hospital (QEH) and Hillsborough Hospital. Administratively, one Executive Director is responsible for PCH and one Executive Director is responsible for QEH / Hillsborough Hospital, both of whom are members of the Departmental Management Committee.

Community Hospitals and Continuing Care:
Provides acute care services to rural communities and supportive services to adults and seniors in need of continuing care on PEI. Programs and facilities include five rural community hospitals, provincial manors, home care, palliative care, dialysis, and adult protection. Administratively, the Director of Community Hospitals and Continuing Care is responsible for this division and is a member of the Departmental Management Committee.

Additionally, each of the five community hospitals is governed by a Community Hospital Authority. Each board is accountable to the Minister, and is responsible for ensuring the completion of annual business plans and reporting on facility performance and results to the Minister and their local communities.

Medical Programs: Provides for the delivery of medical programs and services which include the provincial Medicare Program, physician services, physician referrals, physician billing assessment and payment, Out-of-Province Liaison Program, emergency medical services, In-Province and Out-of-Province medicare claims. Administratively, the Director of Medical Programs is responsible for this division and is a member of the Departmental Management Committee.

Primary Care: Provides primary health services to citizens of PEI. Programs and facilities include: seven Family Health Centres, Public Health Nursing, and Chronic Disease Prevention. Administratively, the Director of Primary Care is responsible for this division and is a member of the Departmental Management Committee

Chief Health Office: Provides delivery of programs and services in the areas of Epidemiology and Health Research, Environmental Health, Vital Statistics and Reproductive Care. This office is also responsible for the administration and enforcement of the Public Health Act, supervision of related public health programs and disease surveillance and control.

Recruitment and Retention Secretariat: Provides health human resource planning and undertakes recruitment and retention efforts to meet the current and future needs for physicians, nurses and allied health professionals.

1.0 Public Administration

1.1 Health Care Insurance Plan and Public Authority

The Hospital Care Insurance Plan, under the authority of the Minister of Health, is the vehicle for delivering hospital care insurance in Prince Edward Island. The enabling legislation is the Hospital and Diagnostic Services Insurance Act (1988), which insures services as defined under section 2 of the Canada Health Act.

The role of the Department is to provide sound leadership in innovation and ongoing improvement, quality administration and regulatory services, and delivery of client-centred health services, consistent with community needs.

The Department of Health is responsible for service delivery and operates hospitals, health centres, manors and mental health facilities. The Public Service Commission hires physicians, nurses and other health related workers.

1.2 Reporting Relationship

An annual report is submitted by the Department to the Minister responsible who tables it in the Legislative Assembly. The Report provides information on the operating principles of the Department and its legislative responsibilities, as well as an overview and description of the operations of the departmental divisions and statistical highlights for the year.

The community hospital authority boards are accountable to the Minister pursuant to the Community Hospital Authorities Act and must submit annual business plans and provide information to the Minister as and when required.

1.3 Audit of Accounts

The provincial Auditor General conducts annual audits of the Public Accounts of the province of Prince Edward Island. The Public Accounts of the province include the financial activities, revenues and expenditures of the Department of Health.

The provincial Auditor General, through the Audit Act, has the discretionary authority to conduct further audit reviews on a comprehensive or program specific basis. Community hospital authorities are reporting entities under the Financial Administration Act.

2.0 Comprehensiveness

2.1 Insured Hospital Services

Insured hospital services are provided under the Hospital and Diagnostic Services Insurance Act (1988). The accompanying Regulations (1996) define the insured in- and out-patient hospital services available at no charge to a person who is eligible. Insured hospital services include: necessary nursing services; laboratory; radiological and other diagnostic procedures; accommodations and meals at a standard ward rate; formulary drugs, biologicals and related preparations prescribed by an attending physician and administered in hospital; operating room, case room and anaesthetic facilities; routine surgical supplies; and radiotherapy and physiotherapy services performed in hospital.

The process to add a new hospital service to the list of insured services involves extensive consultation and negotiation between the Department and key stakeholders. A business plan would be developed which when approved by the Minister would be taken to Treasury Board for funding approval. The Cabinet has the final authority in adding new services.

As of March 2008, there were seven acute care facilities participating in the province's Insurance Plan. In addition to 427 acute care beds, these facilities house 20 rehabilitative beds and 20 day surgery beds, as defined under the Hospitals Act (1988), for a total of 467 beds.

2.2 Insured Physician Services

The enabling legislation that provides for insured physician services is the Health Services Payment Act (1988). Amendments were passed in 1996. Changes were made to include the physician resource planning process.

Insured physician services are provided by medical practitioners licensed by the College of Physicians and Surgeons. The total number of practitioners, including locums, who billed the Insurance Plan as of March 31, 2008, was 309.

Under section 10 of the Health Services Payment Act, a physician or practitioner who is not a participant in the Insurance Plan is not eligible to bill the Plan for services rendered. When a non-participating physician provides a medically required service, section 10(2) requires that physicians advise patients that they are not participating physicians or practitioners and provide the patient with sufficient information to enable recovery of the cost of services from the Minister of Health.

Under section 10.1 of the Health Services Payment Act, a participating physician or practitioner may determine, subject to and in accordance with the Regulations and in respect of a particular patient or a particular basic health service, to collect fees outside the Plan or selectively opt out of the Plan. Before the service is rendered, patients must be informed that they will be billed directly for the service. Where practitioners have made that determination, they are required to inform the Minister thereof and the total charge is made to the patient for the service rendered.

As of March 31, 2008, no physicians had opted out of the Health Care Insurance Plan.

Any basic health services rendered by physicians that are medically required are covered by the Health Care Insurance Plan. These include most physicians' services in the office, at the hospital or in the patient's home; medically necessary surgical services, including the services of anaesthetists and surgical assistants where necessary; obstetrical services, including pre- and post-natal care, newborn care or any complications of pregnancy such as miscarriage or Caesarean section; certain oral surgery procedures performed by an oral surgeon when it is medically required, with prior approval that they be performed in a hospital; sterilization procedures, both female and male; treatment of fractures and dislocations; and certain insured specialist services, when properly referred by an attending physician.

The process to add a physician service to the list of insured services involves negotiation between the Department and the Medical Society. A business plan would be developed which when approved by the Minister would be taken to Treasury Board for funding approval. Cabinet has the final authority in adding new services.

2.3 Insured Surgical-Dental Services

Dental services are not insured in the Health Care Insurance Plan. Only oral maxillofacial surgeons are paid through the Plan. There are currently two surgeons in that category. Surgical-dental procedures included as basic health services in the Tariff of Fees are covered only when the patient's medical condition requires that they be done in hospital or in an office with prior approval as confirmed by the attending physician.

2.4 Uninsured Hospital, Physician and Surgical-Dental Services

Provincial hospital services not covered by the Hospital Services Plan include:

• services that persons are eligible for under other provincial or federal legislation;
  
  
• mileage or travel, unless approved by the Department;
  
  
• advice or prescriptions by telephone, except anticoagulant therapy supervision;
  
  
• examinations required in connection with employment, insurance, education, etc.;
  
  
• group examinations, immunizations or inoculations, unless prior approval is received from the Department;
  
  
• preparation of records, reports, certificates or communications, except a certificate of committal to a psychiatric, drug or alcoholism facility;
  
  
• testimony in court;
  
  
• travel clinic and expenses;
  
  
• surgery for cosmetic purposes unless medically required;
  
  
• dental services other than those procedures included as basic health services;
  
  
• dressings, drugs, vaccines, biologicals and related materials;
  
  
• eyeglasses and special appliances;
  
  
• physiotherapy, chiropractic, podiatry, optometry, chiropody, osteopathy, psychology, naturopathy, audiology, acupuncture and similar treatments;
  
  
• reversal of sterilization procedures;
  
  
• in vitro fertilization;
  
  
• services performed by another person when the supervising physician is not present or not available;
• services rendered by a physician to members of the physician's own household, unless approval is obtained from the Department; and
  
  
• any other services that the Department may, upon the recommendation of the negotiation process between the Department and the Medical Society, declare non-insured.

Provincial hospital services not covered by the Hospital Services Plan include private or special duty nursing at the patient's or family's request; preferred accommodation at the patient's request; hospital services rendered in connection with surgery purely for cosmetic reasons; personal conveniences, such as telephones and televisions; drugs, biologicals and prosthetic and orthotic appliances for use after discharge from hospital; and dental extractions, except in cases where the patient must be admitted to hospital for medical reasons with prior approval of the Department.

The process to de-insure services by the Health Care Insurance Plan is done in collaboration with the Medical Society and the Department. No services were de-insured during the 2007/2008 fiscal year.

All Island residents have equal access to services. Third parties such as private insurers or the Workers' Compensation Board of Prince Edward Island do not receive priority access to services through additional payment.

Prince Edward Island has no formal process to monitor compliance; however, feedback from physicians, hospital administrators, medical professionals and staff allows the Department to monitor usage and service concerns.

3.0 Universality

3.1 Eligibility

The Health Services Payment Act and Regulations, section 3, define eligibility for the health care insurance plans. The plans are designed to provide coverage for eligible Prince Edward Island residents. A resident is anyone legally entitled to remain in Canada and who makes his or her home and is ordinarily present on an annual basis for at least six months plus a day, in Prince Edward Island.

All new residents must register with the Department in order to become eligible. Persons who establish permanent residence in Prince Edward Island from elsewhere in Canada will become eligible for insured hospital and medical services on the first day of the third month following the month of arrival.

Residents who are ineligible for coverage under the Health Care Insurance Plan in Prince Edward Island are members of the Canadian Forces, Royal Canadian Mounted Police (RCMP), inmates of federal penitentiaries and those eligible for certain services under other government programs, such as Workers' Compensation or the Department of Veterans Affairs' programs.

Ineligible residents may become eligible in certain circumstances. Members of the Canadian Forces or RCMP become eligible on discharge or completion of rehabilitative leave. Penitentiary inmates become eligible upon release. In such cases, the province where the individual in question was stationed at the time of discharge or release, or release from rehabilitative leave, would provide initial coverage during the customary waiting period of up to three months. Parolees from penitentiaries will be treated in the same manner as discharged parolees.

Foreign students, tourists, transients or visitors to Prince Edward Island do not qualify as residents of the province and are, therefore, not eligible for hospital and medical insurance benefits.

3.2 Registration Requirements

New or returning residents must apply for health coverage by completing a registration application from the Department. The application is reviewed to ensure that all necessary information is provided. A health card is issued and sent to the resident within two weeks. Renewal of coverage takes place every five years and residents are notified by mail six weeks before renewal.

The number of residents registered for the Health Care Insurance Plan in Prince Edward Island as of March 31, 2008, was 146,518.

3.3 Other Categories of Individual

Foreign students, temporary workers, refugees and Minister's Permit holders are not eligible for health and medical coverage. Kosovar refugees are an exception to this category and are eligible for both health and medical coverage in Prince Edward Island.

4.0 Portability

4.1 Minimum Waiting Period

Insured persons who move to Prince Edward Island are eligible for health insurance on the first day of the third month following the month of arrival in the province.

4.2 Coverage During Temporary Absences in Canada

Persons absent each year for winter vacations and similar situations involving regular absences must reside in Prince Edward Island for at least six months plus a day each year in order to be eligible for sudden illness and emergency services while absent from the province, as allowed under section 5.(1)(e) of the Health Services Payment Act.

The term "temporarily absent" is defined as a period of absence from the province for up to 182 days in a 12 month period, where the absence is for the purpose of a vacation, a visit or a business engagement. Persons leaving the province under the above circumstances must notify the Registration Department before leaving.

Prince Edward Island participates in the Hospital Reciprocal Billing Agreement and the Medical Reciprocal Billing Agreement. The total amount paid under these agreements in 2007/2008 was $29,776,625.

The payment rate currently ranges from $772 at the community hospitals to $780 at Prince County Hospital and $990 at the Queen Elizabeth Hospital per day for hospital stays. The standard interprovincial outpatient rate is $169. The methodology used to derive these rates is as if the patient had the services provided in Prince Edward Island.

4.3 Coverage During Temporary Absences Outside Canada

The Health Services Payment Act is the enabling legislation that defines portability of health insurance during temporary absences outside Canada, as allowed under section 5.(1)(e) of the Health Services Payment Act.

Insured residents may be temporarily out of the country for a 12 month period one time only. Students attending a recognized learning institution in another country must provide proof of enrolment from the educational institution on an annual basis. Students must notify the Registration Department upon returning from outside the country.

For Prince Edward Island residents leaving the country for work purposes for longer than one year, coverage ends the day the person leaves.

For Island residents travelling outside Canada, coverage for emergency or sudden illness will be provided at Prince Edward Island rates only, in Canadian currency. Residents are responsible for paying the difference between the full amount charged and the amount paid by the Department. In 2007-2008, the total amounts paid for in-patient claims was $49,616 and $27,533 for out-patient claims.

4.4 Prior Approval Requirement

Prior approval is required from the Department before receiving non-emergency, out-of-province medical or hospital services. Island residents seeking such required services may apply for prior approval through a Prince Edward Island physician. Full coverage may be provided for (Prince Edward Island insured) non-emergency or elective services, provided the physician completes an application to the Department. Prior approval is required from the Medical Director of the Department to receive out-of-country hospital or medical services not available in Canada.

5.0 Accessibility

5.1 Access to Insured Health Services

Both of Prince Edward Island's hospital and medical services insurance plans provide services on uniform terms and conditions on a basis that does not impede or preclude reasonable access to those services by insured persons.

5.2 Access to Insured Hospital Services

Prince Edward Island has a publicly administered and funded health system that guarantees universal access to medically necessary hospital and physician services as required by the Canada Health Act.

Prince Edward Island has two referral hospitals and five community hospitals, with a combined total of 463 beds. Along with nine government manors (and facilities) that house 558 (plus 10 respite) long-term care nursing beds, Islanders have access to an additional 389 (plus 11 temporary beds) in nine private nursing homes. The system also operates several addictions and mental health facilities, including the provincial in-patient psychiatric Hillsborough Hospital which has 18 acute care beds and 57 long term care beds.

This past year saw renovations undertaken to the Emergency Departments at the Prince County Hospital and the Kings County Memorial Hospital. As well, the engineering and design work on Phase I of a $52 million multi-phase redevelopment plan to upgrade the 25-year-old Queen Elizabeth Hospital is underway and construction is expected to begin in mid-2008. This redevelopment will take up to seven years to complete and will ultimately result in a major redesign of the emergency department and support services, an addition to the Cancer Treatment Centre, and enhancements to ambulatory care and day surgery, among other improvements.

The public sector health workforce on PEI has approximately 4,500 employees. Through the Health Recruitment and Retention Secretariat, there is ongoing recruitment to address vacancies in the physician complement in this province. This challenge is being met in part by continuing to develop a long-term physician resource plan, by providing salary options to new graduates and existing physicians, and by engaging in more communication with PEI students and medical residents through the Medical Education Program.

Prince Edward Island launched the Medical Residency Program to provide ongoing training opportunities to medical school graduates who are training as a family physician. The intent is to better integrate our medical students so that they will want to stay and practice in the province.

In addition to the aforementioned programs, other current initiatives include:

• Nurse Recruitment Strategy;
  
  
• Provider Registry;
  
  
• Musco-skeletal Injury Prevention Program (Workplace safety);
  
  
• Wait Times Strategy;
  
  
• Youth Addictions Strategy;
  
  
• Clinical Information System interoperable;
  
  
• Patient Safety Strategy;
  
  
• Rural Physician Stabilization Initiative; and
  
• Pandemic Planning.

Research indicates that our population is aging and exhibiting a variety of modifiable risk factors relating to physical inactivity, unhealthy eating, alcohol consumption, smoking and obesity. As in previous years, the rate of chronic diseases continues to rise. As the population ages, so too will the number of people affected by chronic disease. A variety of initiatives are in place which directly or indirectly address current and future levels of chronic disease. Examples include primary care redesign, which includes the continued establishment of family health centres; innovations and improvements in the areas of Pharmacare, home care, wait time guarantees being developed and implemented; and the Clinical Information System /Electronic Health Record to improve health care provider access to timely and accurate information. This ongoing work will improve the overall quality of care and health outcomes for patients. Furthermore, models of service delivery and health care provider roles continue to evolve. Increased adoption of collaborative/inter-disciplinary approaches as well as enhancements in the areas of ambulatory care (including the multi-year QEH redevelopment project) and primary health care will contribute to chronic disease prevention, treatment, and management.

Collaborative strategies focussed on promoting healthier lifestyles include:

• the Cancer Control Strategy, which includes a partnership with the PEI Cancer Control Committee, which works to reduce the burden of cancer on PEI by identifying priorities, coordinating efforts, monitoring progress and communicating results from the strategy;
  
  
• the PEI Strategy for Healthy Living, which focuses on tobacco reduction and promoting exercise and good nutrition; and
  
  
• PEI Active Living Alliance, which promotes physical activity through a variety of community.

As PEI is primarily a rural province where a large segment of the population resides outside the main service centres, local access to health services, including acute services delivered through community hospitals, is important to small communities. Rural hospitals have historically played an important role in health care delivery and serve vital and central roles in their respective communities. Rural hospitals and other health services delivered in these areas face a number of challenges, such as the recruitment and retention of health care providers and keeping pace with evolving standards of care and quality.

5.3 Access to Insured Physician and Surgical-Dental Services

Physician services are accessible throughout the province except for specialties where there are vacancies. Recruitment processes have been undertaken for family physicians, anaesthetists, radiologists, radiation and medical oncologists, psychiatrists, and a pathologist and plastic surgeon.

An enhanced Physician Recruitment/Retention and Medical Education Strategy was announced to build on existing initiatives and address the financial, professional, and lifestyle concerns of today's physicians. These enhancements are targeted towards physicians in training, physicians being recruited to Prince Edward Island, and physicians currently in practice on PEI.

As of March 31, 2008 there were the following vacancies in the physician complement: Family Medicine, Emergency Medicine, Addiction Services, Psychiatry, Radiology, Pathology, Physical Medicine, Ophthalmology and Radiation Oncology, overall totalling 13.8 vacancies. Recruitment to find suitable placements for these positions is ongoing.

5.4 Physician Compensation

A collective bargaining process is used to negotiate physician compensation. Bargaining teams are appointed by both physicians and the government to represent their interests in the process. The Physician Master Agreement expired March 31, 2007. A negotiation team has been appointed and a number of meetings have been held to work towards a negotiated settlement. The government continues to make additional investments to address areas that will make the health system more competitive so that it can maintain services and increase the success of recruitment and retention efforts for physicians.

The legislation governing payments to physicians and dentists for insured services is the Health Services Payment Act.

Many physicians continue to work on a fee-forservice basis. However, alternate payment plans have been developed and some physicians receive salary, contract and sessional payments. Alternate payment modalities are growing and seem to be the preference for new graduates. Currently almost 60 percent of physicians are compensated under salary or sessional payments.

5.5 Payments to Hospitals

The community hospital authorities are responsible for delivering hospital services in the province under the Community Hospital Authorities Act. The financial (budgetary) requirements are established annually through annual business plans approved by the Minister and are subject to approval by the Legislative Assembly through the annual budget process.

Payments (advances) to provincial hospitals and the community hospital authorities for hospital services are approved for disbursement by the Department in line with cash requirements and are subject to approved budget levels.

The usual funding method includes using a global budget adjusted annually to take into consideration increased costs related to such items as labour agreements, drugs, medical supplies and facility operations.

6.0 Recognition Given to Federal Transfers

The Government of Prince Edward Island acknowledged the federal contributions provided through the Canada Health Transfer in its 2007-2008 Annual Budget and related budget documents and its 2007-2008 Public Accounts, which were tabled in the Legislative Assembly and are publicly available to Prince Edward Island residents.

7.0 Extended Health Care Services

Extended health care services are not insured services, except for the insured chronic care beds noted in section 2.1.

7.1 Nursing Home Intermediate Care and Adult Residential Care Services

Nursing home services are available on approval from regional admission and placement committees for placement into public manors and licensed private nursing homes. There are currently 18 long-term care facilities in the province, nine public manors and 8 licensed private nursing homes, with a total of 997 beds, including respite and temporary beds. Nursing home admission is for individuals who require 24 hour registered nurse (nursing care) supervision and care management. The standardized Seniors Assessment Screening Tool is used to determine service needs of residents for all admissions to nursing homes.

Significant changes were made last year to long-term nursing care funding and subsidization. First, self-paying residents in nursing homes are no longer required to cover the health care portion of their cost and are only required to cover their accommodation cost. Secondly, eligibility for subsidization was changed to be based on an assessment of income rather than on the applicant's total financial resources which previously included income and assets. When a resident of a facility or someone coming into a facility does not have the financial resources to pay for their own care, they can apply for financial assistance under the Social Assistance Act Regulations, Part II. The Province subsidizes 78 percent of residents in nursing homes. The federal government subsidizes approximately 8.2 percent of nursing home residents through Veterans Affairs Canada. The remaining 13.8 percent finance their own care.

In addition to nursing home facilities, there are 37 licensed community care facilities in Prince Edward Island. As of March 31, 2008, the total number of licensed community care facility beds was 1,112. A Community Care Facility is a privately operated, licensed establishment with five or more residents. These facilities provide semi-dependent seniors and semi-dependent physically and mentally challenged adults with accommodation, housekeeping, supervision of daily living activities, meals and personal care assistance for grooming and hygiene. Care needs are assessed using the Seniors Assessment Screening Tool and are at Level 1, 2 or 3. Residents are eligible to apply for financial assistance under the Social Assistance Act Regulations, Part I. It should be noted that payment to community care is the responsibility of the individual. Clients lacking adequate financial resources may apply for financial assistance under the Prince Edward Island Social Assistance Act.

7.2 Home Care Services

Home Care and Support provides assessment and care planning to medically stable individuals, and defined groups of individuals with specialized needs, who, without the support of the formal system, are at risk of being unable to stay in their own home, or are unable to return to their own home from a hospital or other care setting. Services provided through Home Care and Support include nursing, personal care, respite, occupational and physical therapies, adult protection, palliative care, home and community-based dialysis, assessment for nursing home placement and community support. The Senior's Assessment Screening Tool is used to determine the nature and type of service needed. Professional services in home care are currently provided at no cost to the client. Visiting homemaker services are subject to a sliding fee scale based on an individual's income assessment, which is generally waived for palliative care clients.

7.3 Ambulatory Health Care Services

Prince Edward Island has public Adult Day Programs that provide services such as recreation, education and socialization for dependent elders. Individuals who require this service are assessed by regional Home Care staff. The overall purpose of adult day programs, is to allow clients to remain in their homes as long as possible, provide respite for care givers, monitor client's health and provide social interaction. There are Adult Day Programs located across Prince Edward Island.

The Prince Edward Island Dialysis Program is a community-based service that operates under the medical direction and supervision of the Nephrology team at the Queen Elizabeth II Health Sciences Centre in Halifax.

There are five hemo-dialysis clinics in the province. This is a publicly funded service. Prince Edward Island also offers a hemo-dialysis service to out-of-province/country visitors from the existing clinic locations. The provision of this service is based on the capacity within the clinics and the availability of human resources to provide this treatment at the time of the request. Cost of the service is covered through reciprocal billing if from another Canadian jurisdiction and by the visitor if from out of Canada.

Significant ambulatory care services are also delivered from the two provincial referral hospitals on an outpatient basis. These services include asthma education, cardio-pulmonary testing and treatment, endoscopy, surgery clinics, nursing clinics, nutrition counselling and oncology.

Registered Persons

Insured Hospital Services Within Own Province or Territory

Insured Hospital Services Provided to Residents in Another Province or Territory

Insured Hospital Services Provided Outside Canada

Insured Physician Services Within Own Province or Territory

Insured Physician Services Provided to Residents in Another Province or Territory

Insured Physician Services Provided Outside Canada

Insured Surgical-Dental Services Within Own Province or Territory

Nova Scotia

Introduction

The Nova Scotia Department of Health's mission is, through leadership and collaboration, to ensure an appropriate, effective and sustainable health system that promotes, maintains and improves the health of Nova Scotians. This requires that health care services in Nova Scotia are integrated, community-based and sustainable.

In February 2006, the Government of Nova Scotia created a new Department of Health Promotion and Protection that brought together two areas from the Department of Health, the Office of the Chief Medical Officer of Health and Public Health branch, with Nova Scotia Health Promotion.

The Health Authorities Act, Chapter 6 of the Acts of 2000, established the province's nine District Health Authorities (DHAs) and their community-based supports, Community Health Boards (CHBs). DHAs are responsible for governing, planning, managing, delivering and monitoring health services within each district and for providing planning support to the CHBs. Services delivered by the DHAs include acute and tertiary care, mental health, and addictions.

The province's thirty-seven CHBs develop community health plans with primary health care and health promotion as their foundation. DHAs draw two thirds of their board nominations from CHBs. Their community health plans are part of the DHAs annual business planning process. In addition to the nine DHAs, the IWK Health Centre continues to have separate board, administrative and service delivery structures.

The Department of Health is responsible for setting the strategic direction and standards for health services; ensuring availability of quality health care, monitoring, evaluating and reporting on performance and outcomes; and funding health services. The Department of Health is directly responsible for physician and pharmaceutical services, emergency health, continuing care, and many other insured and publicly funded health programs and services.

Under the Health Authorities Act, the DHAs are required to provide the Minister of Health with monthly and quarterly financial statements and audited year-end financial statements. They are also required to submit annual reports, which provide updates on implementing DHA business plans. These provisions ensure greater financial accountability. The sections of the Health Authorities Act related to financial reporting and business planning came into effect on April 1, 2001.

In January, 2007, the PHSOR Report was officially released. 103 recommendations came out of the report in order to transform Nova Scotia's health care system, making it more effective, efficient, and sustainable for all Nova Scotians, now and in the future. The Government of Nova Scotia supported all 103 recommendations and released a response document which outlined the Government's commitment to health transformation.

Pursuant to the Provincial Finance Act (2000) and government policies and guidelines, the Department of Health is required to release annual accountability reports outlining outcomes against its business plan for that fiscal year. The 2007-2008 accountability report will be released in December 2008.

Nova Scotia faces a number of challenges in the delivery of health care services. Nova Scotia's population is aging. Approximately 14.1% of the Nova Scotian population is sixty-five or over and this figure is expected to nearly double by 2026. In response to the needs of our aging population, Nova Scotia has expanded its basket of publicly insured services to include home care, long-term care, and enhanced pharmaceutical coverage. Nova Scotia also has much higher than average rates of chronic diseases, such as cancers and diabetes, which contribute to the rising costs of health care delivery in Nova Scotia.

Other major cost drivers are a highly competitive labour market for health human resources, the increasing costs of pharmaceuticals and aging facility infrastructure.

Despite these ever-increasing pressures and challenges, Nova Scotia continues to be committed to the delivery of medically necessary services consistent with the principles of the Canada Health Act.

Additional information related to health care in Nova Scotia may be obtained from the Department of Health website at:
www.gov.ns.ca/health
Nova Scotia Department of Health

1.0 Public Administration

1.1 Health Care Insurance Plan and Public Authority

Two plans cover insured health services in Nova Scotia: the Hospital Insurance Plan (HSI) and the Medical Services Insurance Plan (MSI). The Department of Health administers the HSI Plan, which operates under the Health Services and Insurance Act, Chapter 197, Revised Statutes of Nova Scotia, 1989: sections 3(1), 5, 6, 10, 15, 16, 17(1), 18 and 35.

The MSI is administered and operated by an authority consisting of the Department of Health and Medavie Blue Cross (formerly called Atlantic Blue Cross), under the above-mentioned Act (sections 8, 13, 17(2), 23, 27, 28, 29, 30, 31, 32 and 35).

Section 3 of the Health Services and Insurance Act states that subject to this Act and the Regulations, all residents of the province are entitled to receive insured hospital services from hospitals on uniform terms and conditions. As well, all residents of the province are insured on uniform terms and conditions in respect of the payment of insured professional services to the extent of the established tariff. Section 8 of the Act gives the Minister of Health, with approval of the Governor in Council, the power to enter into agreements and vary, amend or terminate the same with such person or persons as the Minister deems necessary to establish, implement and carry out the MSI Plan.

The Department of Health and Medavie Blue Cross entered into a new service level agreement, effective August 1, 2005. This new ten-year agreement replaced the 1992 Memorandum of Agreement between Medavie and the Department of Health. Under the agreement, Medavie is responsible for operating and administering programs contained under MSI, Pharmacare Programs and Health Card Registration Services.

1.2 Reporting Relationship

Medavie is obliged to provide reports to the Department under various Statement of Requirements for each Business Service Description as listed in the contract.

Section 17(1)(i) of the Health Services and Insurance Act, and sections 11(1) and 12(1) of the Hospital Insurance Regulations, under this Act, set out the terms for reporting by hospitals and hospital boards to the Minister of Health.

1.3 Audit of Accounts

The Auditor General audits all expenditures of the Department of Health. A contract is in place to have an annual audit performed on the Insured Prescription Drug Plan Trust Fund. The Department of Health has a service level agreement in place with Medavie Blue Cross, effective August 1, 2005. An audit plan is under development for this agreement, including Medicare payments, which has been recommended by the Auditor General's office.

All long-term care facilities, home care and home support agencies are required to provide the Department with annual audited financial statements.

Under section 34(5) of the Health Authorities Act, every hospital board is required to submit to the Minister of Health by July 1st each year, an audited financial statement for the preceding fiscal year.

The June, 2007 Report of the Auditor General of Nova Scotia contained audits with respect to:

• Management of Diagnostic Imaging Equipment for the Capital District Health Authority and the Cape Breton District Health Authority
• Emergency Health Services
• Long Term Care -- Nursing Homes and Homes for the Aged

1.4 Designated Agency

Medavie Blue Cross Care administers and has the authority to receive monies to pay physician accounts under a new service level agreement with the Department of Health, effective August 1, 2005. Medavie Blue Cross Care receives written authorization from the Department for the physicians to whom it may make payments. The rates of pay and specific amounts depend on the physician contract negotiated between Doctors Nova Scotia and the Department of Health.

All Medavie Blue Cross Care system development for MSI and Pharmacare is controlled through a joint committee. All MSI and Pharmacare transactions are subject to a review by the Office of the Auditor General.

2.0 Comprehensiveness

2.1 Insured Hospital Services

Nine District Health Authorities and the IWK Health Centre (Women and Children's Tertiary Care Hospital) deliver insured hospital services to both in- and out-patients in Nova Scotia in a total of 35 facilities.¹

Accreditation is not mandatory, but all facilities are accredited at a facility or district level. The enabling legislation that provides for insured hospital services in Nova Scotia is the Health Services and Insurance Act, Chapter 197, Revised Statutes of Nova Scotia, 1989: sections 3(1), 5, 6, 10, 15, 16, 17(1), 18 and 35, passed by the Legislature in 1958. Hospital Insurance Regulations were made pursuant to the Health Services and Insurance Act.

In-patient services include:

• accommodation and meals at the standard ward level;
  
  
• necessary nursing services;
  
  
• laboratory, radiological and other diagnostic procedures;
  
  
• drugs, biologicals and related preparations, when administered in a hospital;
  
  
• routine surgical supplies;
  
  
• use of operating room(s), case room(s) and anaesthetic services;
  
  
• use of radiotherapy and physiotherapy services for inpatients, where available; and
  
  
• blood or therapeutic blood fractions.

Out-patient services include:

• laboratory and radiological examinations;
  
  
• diagnostic procedures involving the use of radio-pharmaceuticals;
  
  
• electroencephalographic examinations;
  
  
• use of occupational and physiotherapy facilities, where available;
  
  
• necessary nursing services;
  
  
• drugs, biologicals and related preparations;
  
  
• blood or therapeutic blood fractions;
  
  
• hospital services in connection with most minor medical and surgical procedures;
  
  
• day-patient diabetic care;
  
  
• services provided by the Nova Scotia Hearing and Speech Clinics where available;
  
  
• ultrasonic diagnostic procedures;
  
  
• home parenterel nutrition where available; and
  
  
• haemodialysis and peritoneal dialysis, where available.

In order to add a new hospital service to the list of insured hospital services, District Health Authorities are required to submit a New and/or Expanded Program Proposal² to the Department of Health. This process is carried out annually by request through the business planning process. A Department-developed process format is forwarded to the Districts for their guidance. A Department working group reviews and prioritizes all requests received. Based on available funding, a number of top priorities may be approved by the Minister of Health.

2.2 Insured Physician Services

The legislation covering the provision of insured physician services in Nova Scotia is the Health Services and Insurance Act, sections 3(2), 5, 8, 13, 13A, 17(2), 22, 27-31, 35 and the Medical Services Insurance Regulations.

The Health Services and Insurance Act was amended in 2002-2003 to include section 13B stating that: "Effective November 1, 2002, any agreement between a provider and a hospital, or predecessors to a hospital, stipulating compensation for the provision of insured professional services, for the provider undertaking to be on-call for the provision of such services or for the provider to relocate or maintain a presence in proximity to a hospital, excepting agreements to which the Minister and the Society are a party, is null and void and no compensation is payable pursuant to the agreement, including compensation otherwise payable for termination of the agreement."

Under the Health Services and Insurance Act, persons who can provide insured physician services include: general practitioners, who are persons who engage in the general practice of medicine; physicians, who are not specialists within the meaning of the clause; and specialists, who are physicians and are recognized as specialists by the appropriate licensing body of the jurisdiction in which he or she practises.

Physicians (general practitioner or specialist) must be licensed by the College of Physicians and Surgeons in Nova Scotia in order to be eligible to bill the MSI system. Dentists receiving payment under the MSI Plan must be registered with the Provincial Dental Board and be recognized as dentists. In 2007-2008, 2,290 physicians and 27 dentists were paid through the MSI Plan.

Physicians retain the ability to opt into or out of the MSI Plan. In order to opt out, a physician notifies MSI, relinquishing his or her billing number. MSI reimburses patients who pay the physician directly due to opting out. As of March 31, 2008, no physicians had opted out.

Insured services are those medically necessary to diagnose, treat, rehabilitate or otherwise alter a disease pattern. There are no limitations on medically necessary insured services.

No new large-scale services were added to the list of insured physician services in 2007-2008. On an as needed basis, new specific fee codes are approved that represent enhancements, new technologies or new ways of delivering a service.

The addition of new fee codes to the list of insured physician services is accomplished through a committee structure. Physicians wishing to have a new fee code recognized or established must first present their cases to Doctors Nova Scotia, which puts a suggested value on the proposed new fee.

The proposal is then passed to the Joint Fee and Tariff Committee for review and approval. The Joint Committee is comprised of equal representation from Doctors Nova Scotia and the Department of Health. When approved by the Joint Fee Schedule Committee, the approved proposed new fee is forwarded to the Department of Health for final approval and Medavie Blue Cross Care is directed to add the new fee to the schedule of insured services payable by the MSI Plan.

2.3 Insured Surgical-Dental Services

Under the Nova Scotia Health Services and Insurance Act, a dentist is defined as a person lawfully entitled to practice dentistry in a place where such practice is carried on by that person.

To provide insured surgical-dental services under the Health Services and Insurance Act, dentists must be registered members of the Nova Scotia Dental Association and must also be certified competent in the practice of dental surgery. The Health Services and Insurance Act is so written that a dentist may choose not to participate in the MSI Plan. To participate, a dentist must register with MSI. A participating dentist who wishes to reverse election to participate must advise MSI in writing and is then no longer eligible to submit claims to MSI. As of March 31, 2008, no dentists had opted out. In 2007-2008, 27 dentists were paid through the MSI Plan for providing insured surgical-dental services.

Insured surgical-dental services must be provided in a health care facility. Insured services are detailed in the Department of Health (DoH) MSI Dentist Manual (Dental Surgical Services Program) and are reviewed annually through the Acute and Tertiary Care Branch as required by Insured Dental Services Tariff Regulations. Services under this program are insured when the conditions of the patient are such that it is medically necessary for the procedure to be done in a hospital and the procedure is of a surgical nature. Generally included as insured surgical-dental services are orthognathic surgery, surgical removal of impacted teeth and oral and maxillary facial surgery. Requests for an addition to the list of surgical-dental services are accomplished by first approaching the Dental Association of Nova Scotia and having them put forward a proposal to the Department of Health for the addition of a new procedure. The Department of Health, in consultation with specific experts in the field, renders the decision as to whether or not the new procedure becomes an insured service.

Effective February 15, 2005. "Other extraction services" (routine extractions) at public expense were approved for the following groups of patients, 1) cardiac patients, 2) transplant patients, 3) immunocompromised patients, and 4) radiation patients.

Routine extractions for these patients will be provided at public expense when and only when, the following criteria have been met. These patients: must be undergoing active treatment in a hospital setting and the attendant medical procedure must require the removal of teeth that would otherwise be considered routine extractions and not paid at public expense. It is critical/vital to the claims approval process that the dental treatment plans include the name of the Medical Specialist providing the care and that he/she has indicated in writing in the patient's medical treatment plan that the routine dental extractions are required prior to performing the medical treatment/procedure.

Other newly approved service includes coverage for all precancerous or cancerous dental surgical biopsies.

2.4 Uninsured Hospital, Physician and Surgical-Dental Services
Uninsured hospital services include:

• preferred accommodation at the patient's request;
  
  
• telephones;
  
  
• televisions;
  
  
• drugs and biologicals ordered after discharge from hospital;
  
  
• cosmetic surgery;
  
  
• reversal of sterilization procedures;
  
  
• surgery for sex reassignment;
  
  
• in-vitro fertilization;
  
  
• procedures performed as part of clinical research trials;
  
  
• services such as gastric bypass for morbid obesity, breast reduction/augmentation and newborn circumcision.*; and
  
  
• services not deemed medically necessary that are required by third parties, such as insurance companies.

* These services may be insured when approved as special consideration for medical reasons only.

Uninsured physician services include:

• services eligible for coverage under the Workers' Compensation Act or under any other federal or provincial legislation;
  
  
• mileage, travel or detention time;
  
  
• telephone advice or telephone renewal of prescriptions;
  
  
• examinations required by third parties;
  
  
• group immunizations or inoculations unless approved by the Department;
  
  
• preparation of certificates or reports;
  
  
• testimony in court;
  
  
• services in connection with an electrocardiogram, electromyogram or electroencephalogram, unless the physician is a specialist in the appropriate specialty;
  
  
• cosmetic surgery;
  
  
• acupuncture;
  
  
• reversal of sterilization; and
  
  
• in-vitro fertilization.

Major third party agencies purchasing medically necessary health services in Nova Scotia include Workers' Compensation, Department of National Defence, the Royal Canadian Mounted Police .

All residents of the province are entitled to services covered under the Health Services and Insurance Act. If enhanced goods and services, such as foldable intraocular lens or fiber glass casts are offered as an alternative, the specialist/physician is responsible to ensure that the patient is aware of their responsibility for the additional cost. Patients are not denied service based on their inability to pay. The Province provides alternatives to any of the enhanced goods and services. The Province provides alternatives to any of the enhanced goods and services.

The Department of Health also carefully reviews all patient complaints or public concerns that may indicate that the general principles of insured services are not being followed.

The de-insurance of insured physician services is accomplished through a negotiation process between the Doctors Nova Scotia and the Physician Services Branch of Department of Health, who jointly evaluate a procedure or process to determine whether the service should remain an insured benefit. If a process or procedure is deemed not to be medically necessary, it is removed from the physician fee schedule and will no longer be reimbursed to physicians as an insured service. Once a service has been de-insured, all procedures and testing relating to the provision of that service also become de-insured. The same process applies to dental and hospital services. The last time there was any significant de-insurance of services was in 1997.

3.0 Universality

3.1 Eligibility

Eligibility for insured health care services in Nova Scotia is outlined under section 2 of the Hospital Insurance Regulations made pursuant to section 17 of the Health Services and Insurance Act. All residents of Nova Scotia are eligible. A resident is defined as anyone who is legally entitled to stay in Canada and who makes his or her home and is ordinarily present in Nova Scotia.

A person is considered to be "ordinarily present" in Nova Scotia if the person:

• makes his or her permanent home in Nova Scotia;
  
  
• is physically present in Nova Scotia for at least 183 days in any calendar year (short term absences under 30 days, within Canada, are not monitored); and
  
  
• is a Canadian citizen or "Permanent Resident" as defined by Citizenship and Immigration Canada.

Persons moving to Nova Scotia from another Canadian province will normally be eligible for MSI on the first day of the third month following the month of their arrival. Persons moving permanently to Nova Scotia from another country are eligible on the date of their arrival in the province, provided they are Canadian citizens or hold "Permanent Resident" status as defined by Citizenship and Immigration Canada.

Members of the RCMP, members of the Canadian Forces and federal inmates are ineligible for MSI coverage. When their status changes, they immediately become eligible for provincial Medicare.

There were no changes to eligibility requirements in 2007-2008.

3.2 Registration Requirements

To obtain a health card in Nova Scotia, residents must register with MSI. Once eligibility has been determined, an application form is generated. The applicant (and spouse if applicable) must sign the form before it can be processed. The applicant must indicate on the application the name and mailing address of a witness. The witness must be a Nova Scotia resident who can confirm the information on the application. The applicant must include proof of Canadian citizenship or provide a copy of an acceptable immigration document.

When the application has been approved, health cards will be issued to each family member listed. MSI registration information is maintained as a family unit. Each health card number is unique and is issued for the lifetime of the applicant. Health cards expire every four years. The health card number also acts as the primary health record identifier for all health service encounters in Nova Scotia for the life of the recipient. Proof of eligibility for insured services is required before residents are eligible to receive insured services. Renewal notices are sent to most cardholders three months before the expiry date of the current health card. Upon return of a signed renewal notice, MSI will issue a new health card.

There is no legislation in Nova Scotia forcing residents of the province to apply for MSI. There may be residents of Nova Scotia who, therefore, are not members of the health insurance plan.

In 2007-2008, the total number of residents registered with the health insurance plan was 970,450.

3.3 Other Categories of Individual

The following persons may also be eligible for insured health care services in Nova Scotia, once they meet the specific eligibility criteria for their situations:

Immigrants: Persons moving from another country to live permanently in Nova Scotia, are eligible for health care on the date of arrival. They must possess a landed immigrant document. These individuals, formerly called "landed immigrants", are now referred to as "Permanent Residents".

Convention Refugees and Non-Canadians married to Canadian Citizens/Permanent Residents (copy of Marriage Certificate required), who possess any other document and who have applied within Canada for Permanent Resident status, will be eligible on the date of application for Permanent Resident status -- provided they possess a letter or documentation from Citizenship and Immigration Canada stating that they have applied for Permanent Residence.

Non-Canadians married to Canadian Citizens/ Permanent Residents (copy of Marriage Certificate required), who possess any other document and who have applied outside Canada for Permanent Resident status, will be eligible on the date of arrival -- provided they possess a letter or documentation from Citizenship and Immigration Canada stating that they have applied for Permanent Residence.

In 2007-2008, there were 25,951 Permanent Residents registered with the health care insurance plan.

Work Permits: Persons moving to Nova Scotia from outside the country who possess a work permit can apply for coverage on the date of arrival in Nova Scotia, providing they will be remaining in Nova Scotia for at least one full year. A declaration must be signed to confirm that the worker will not be outside Nova Scotia for more than 31 consecutive days, except in the course of employment. MSI coverage is extended for a maximum of 12 months at a time. Each year a copy of their renewed immigration document must be presented and a declaration signed. Dependants of such persons, who are legally entitled to remain in Canada, are granted coverage on the same basis.

Once coverage has terminated, the person is to be treated as never having qualified for health services coverage as herein provided and must comply with the above requirements before coverage will be extended to him/her--or their dependents.

In 2007-2008, there were 1,733 individuals with Employment Authorizations covered under the health care insurance plan.

Study Permits: Persons moving to Nova Scotia from another country, who possess a Study Permit will be eligible for MSI on the first day of the thirteenth month following the month of their arrival, provided they have not been absent from Nova Scotia for more than 31 consecutive days, except in the course of their studies. MSI coverage is extended for a maximum of 12 months at a time and only for services received within Nova Scotia. Each year, a copy of their renewed immigration document must be presented and a declaration signed. Dependants of such persons, who are legally entitled to remain in Canada, will be granted coverage on the same basis, once the student has gained entitlement.

In 2007-2008, there were 868 individuals with Student Authorizations covered under the health care insurance plan.

Refugees: Refugees are eligible for MSI if they possess either a work permit or study permit.

4.0 Portability

4.1 Minimum Waiting Period

Persons moving to Nova Scotia from another Canadian province or territory will normally be eligible for MSI on the first day of the third month following the month of their arrival.

4.2 Coverage During Temporary Absences in Canada

The Interprovincial Agreement on Eligibility and Portability is followed in all matters pertaining to portability of insured services.

Generally, the Nova Scotia MSI Plan provides coverage for residents of Nova Scotia who move to other provinces or territories for a period of three months as per the Interprovincial Agreement on Eligibility and Portability. Students, and their dependants, who are temporarily absent from Nova Scotia and in full-time attendance at an educational institution, may remain eligible for MSI on a yearly basis. To qualify for MSI, the student must provide, to MSI, a letter directly from the educational institution, which states that they are registered as full-time students. MSI coverage will be extended on a yearly basis pending receipt of this letter.

Workers who leave Nova Scotia to seek employment elsewhere will still be covered by MSI for up to 12 months, provided they do not establish residence in another province, territory or country. Services provided to Nova Scotia residents in other provinces or territories are covered by reciprocal agreements. Nova Scotia participates in the 'Hospital Reciprocal Billing Agreement' and the 'Medical Reciprocal Billing Agreement'. Quebec is the only province that does not participate in the medical reciprocal agreement. Nova Scotia pays for services provided by Quebec physicians to Nova Scotia residents at Quebec rates if the services are insured in Nova Scotia. The majority of such claims are received directly from Quebec physicians. In-patient hospital services are paid through the interprovincial reciprocal billing arrangement at the standard ward rate of the hospital providing the service. The total amounts paid by the plan in 2007-2008, for in- and out-patient hospital services received in other provinces and territories was $25,673,241. Nova Scotia pays the host province rates for insured services in all reciprocal-billing situations.

There were no changes made in Nova Scotia in 2007-2008 regarding in-Canada portability.

4.3 Coverage During Temporary Absences Outside Canada

Nova Scotia adheres to the Agreement on Eligibility and Portability for dealing with insured services for residents temporarily outside Canada. Provided a Nova Scotia resident meets eligibility requirements, out-of-country services will be paid, at a minimum, on the basis of the amount that would have been paid by Nova Scotia for similar services rendered in this province. Ordinarily, to be eligible for coverage, residents must not be outside the country for more than six months in a calendar year. In order to be covered, procedures of a non-emergency nature must have prior approval before they will be covered by MSI.

Students and their dependants who are temporarily absent from Nova Scotia and in full-time attendance at an educational institution outside Canada may remain eligible for MSI on a yearly basis. To qualify for MSI, the student must provide to MSI, a letter obtained from the educational institution that verifies the student's attendance there in each year for which MSI coverage is requested.

Persons who engage in employment (including volunteer/missionary work/research) outside Canada, which does not exceed 24 months, are still covered by MSI; providing the person has already met the residency requirements.

Emergency out-of-country services are paid at a minimum on the basis of the amount that would have been paid by Nova Scotia for similar services rendered in this province. The total amount spent in 2007-2008 for insured in-patient services provided outside Canada was $1,257,620.

There were no changes made in Nova Scotia in 2007-2008 regarding out-of-Canada portability.

4.4 Prior Approval Requirement

Prior approval must be obtained for elective services outside the country. Application for prior approval is made to the Medical Director of the MSI Plan by a specialist in Nova Scotia on behalf of an insured resident. The medical consultant reviews the terms and conditions and determines whether or not the service is available in the province, or if it can be provided in another province or only out-of-country. The decision of the Medical Consultant is relayed to the patient's referring specialist. If approval is given to obtain service outside the country, the full cost of that service will be covered under MSI.

5.0 Accessibility

5.1 Access to Insured Health Services

Insured services are provided to Nova Scotia residents under uniform terms and conditions. There are no user charges or extra charges allowed under the plan.

Nova Scotia continually reviews access situations across Canada to ensure equitability of access. In areas where improvement is deemed necessary, depending on the Province's financial situation, extra funding is generally allocated to that need. Based on the previous acceptance of the recommendations of the Provincial Osteoporosis Committee report, which included placing new bone density units in Sydney and Yarmouth and operating the Truro unit at full capacity, an additional five units have been operationalized across the province. In Fiscal 2007/08, the provision of bilateral cochlear implants was approved for both children and adults who meet the requirements. To address the issue of ever increasing orthopaedic wait lists the Department of Health approved a contract with a private surgical facility to carry out minor orthopaedic surgeries. The procedures are done by Capital District surgeons and anaesthetists. The patients are taken from the current public wait lists; there is no queue jumping and there is no charge for the patients. The facility operates as an extension of the Capital Health Department of Surgery. It is a one year demonstration project that is undergoing a strict evaluation. It is anticipated that in excess of 500 patients will be seen at this facility with the added benefit of freeing up space at Capital Health for more joint replacements. In addition to this project the Department of Health and Capital Health are embarking on the establishment of an Orthopaedic Assessment Clinic with the involvement of Bone & Joint Decade Canada. This is being undertaken to address the long orthopaedic wait list in the Halifax area. In addition to the latest diffusion of the four MRIs located in four rural areas (Antigonish, New Glasgow, Kentville, and Yarmouth) to increase rural access and reduce provincial wait times and the replacement of two MRIs at the Capital District Health Authority in Halifax, four (4) new sixty-four (64) slice computed tomography units have been installed/replaced in Halifax (2) and two rural sites. The previously approved Positron Emission Tomography Program (PET/CT) became operational on June 13, 2008. Initially, approval funding is to provide a maximum of 1500 scans per year. In addition to the PET/CT project, the province has approved funding for a Cyclotron to provide local access to the required isotopes. It is expected that the cyclotron will be operational in the third quarter of fiscal year 2009/2010.

5.2 Access to Insured Hospital Services

The Government of Nova Scotia continues to emphasize the provision of sustainable, quality health care services to its citizens.

In 2007-2008, a total of $11.0 million in funding was provided to train, recruit and retain nurses. Since the start of the nursing strategy, at least 80% or more new graduates have renewed their license to practice in Nova Scotia.

Table 1 provides a breakdown of key health professions that are licensed to practice in Nova Scotia. Not all of these health professionals were actively involved in delivering insured health services.

Table 1: Health Personnel in Nova Scotia

Health Occupation	Registered/Licensed to Practice3
Physicians	2,455
Dentists 4	511
Registered Nurses	9,650
Licensed Practical Nurses	3,271
Medical Radiation Technolologists	551
Respiratory Therapists	132
Pharmacists	788
Occupational Therapists	317
Speech-Language Pathologists	174
Chiropractors	103
Opticians	199
Optometrists	92
Denturists	44
Dietitians	436
Psychologists	439
Physiotherapists	532

5.3 Access to Insured Physician and Surgical-Dental Services

In 2007-2008, 2,290 physicians and 27 dentists actively provided insured services under the Canada Health Act or provincial legislation. Innovative funding solutions such as block funding and personal services contracts have enhanced recruitment.

The Province has increased the capacity for medical education for both Canadian medical students and internationally educated physicians, coordinates ongoing recruitment activities and has provided funding to create a re-entry program for general practitioners wishing to enter specialty training after completing two years of general practice service in the province.

5.4 Physician Compensation

The Health Services and Insurance Act, RS Chapter 197 governs payment to physicians and dentists for insured services. Physician payments are made in accordance with a negotiated agreement between Doctors Nova Scotia and the Nova Scotia Department of Health. Doctors Nova Scotia is recognized as the sole bargaining agent in support of physicians in the province. When negotiations take place, representatives from Doctors Nova Scotia and the Department of Health negotiate the total funding and other terms and conditions. The agreement lays out what the medical services unit value will be for physician services and addresses other issues such as Canadian Medical Protective Association, membership benefits, emergency department payments, on-call funding, specific fee adjustments, dispute resolution processes, and other process or consultation issues.

Fee-for-service is still the most prevalent method of payment for physician services. However, there has been significant growth in the number of alternative payment arrangements in place in Nova Scotia.

Over the past number of years, we have seen a significant shift toward alternative payment. In the 1997-1998 fiscal year, about 9 percent of our doctors were paid solely through alternative funding. In 2007-2008 it is estimated that 33 percent of physicians continue to be remunerated through alternative funding , while approximately 76 percent of physicians receive some portion of their remuneration through alternative funding. They can be broken down into three groups:

1. Academic Funding Plan -- (these physicians are mainly located in Halifax at the QEII and the IWK centres). Most of the Academic Specialist groups are on alternate funding arrangements with the exception of Urology, Adult Radiology and Ophthalmology.
   
   
2. Currently there are regional specialist contracts for anaesthesiology, geriatrics, neonatology, paediatrics, obstetrics/gynaecology, and palliative care.
   
   
3. There are also contract arrangements available to general practitioners in certain rural areas and General Practitioner/Nurse Practitioner contracts that support collaborative practice teams in designated areas.

There are also a number of physicians who receive a portion of their remuneration through alternative funding. These alternative funding mechanisms include Sessional, Psychiatry, Remote Practice, Facility On-Call and Emergency Room funding. In total, over 60 percent of physicians in Nova Scotia receive all or a portion of their remuneration through alternative funding mechanisms.

In 2007-2008 total payments to physicians for insured services in Nova Scotia were $555,659,788. The Department paid an additional $7,606,977 for insured physician services provided to Nova Scotia residents outside the province, but within Canada.

Payment rates for dental services in the province are negotiated between the Department of Health and the Nova Scotia Dental Association and follow a process similar to physician negotiations. Dentists are paid on a fee-for-service basis. The current agreement, which was reached in April 2004, expired on March 31, 2008.

5.5 Payments to Hospitals

The Department of Health establishes budget targets for health care services. It does this by receiving business plans from the nine (9) District Health Authorities (DHAs), the IWK Health Centre and other non-DHA organizations. Approved provincial estimates form the basis on which payments are made to these organizations for service delivery.

The Health Authorities Act was given Royal Assent on June 8, 2000. The Act instituted the nine DHAs and the IWK that replaced the former regional health boards. This change came into effect in January 2001, under the District Health Authorities General Regulations. The implementation of community health boards under the Community Health Boards Member Selection Regulations was effective as of April 2001. The DHAs/IWK are responsible (section 20 of the Act) for overseeing the delivery of health services in their districts and are fully accountable for explaining their decisions on the community health plans through their business plan submissions to the Department of Health.

Section 10 of the Health Services and Insurance Act and sections 9 through 13 of the Hospital Insurance Regulations define the terms for payments by the Minister of Health to hospitals for insured hospital services.

In 2007-2008, there were 2,891 hospital beds in Nova Scotia (3.0 beds per 1,000 population). Department of Health direct expenditures for insured hospital services operating costs were increased to $1.3 Billion.

6.0 Recognition Given to Federal Transfers

In Nova Scotia, the Health Services and Insurance Act acknowledges the federal contribution regarding the cost of insured hospital services and insured health services provided to provincial residents. The residents of Nova Scotia are aware of ongoing federal contributions to Nova Scotia health care through the Canada Health Transfer (CHT) as well as other federal funds through press releases and media coverage.

The Government of Nova Scotia also recognized the federal contribution under the CHT in various published documents including the following documents released in 2007-2008:

• Public Accounts 2007-2008; and
  
  
• Budget Estimates 2007-2008.

7.0 Extended Health Care Services

The Nova Scotia Department of Health's Continuing Care branch offers home care and long-term care services. These services promote independence, fairness, equity, and choice for people with care needs. The Department of Health provides a Single Entry Access to its continuing care services. Nova Scotians can connect with Continuing Care through a single toll-free number.

In 2006, the Department of Health released a broad based, multi-year Continuing Care strategy that will see the addition of long-term care beds and the expansion and enhancement of community and home based services over the ensuing five to ten years.

7.1 Nursing Home Intermediate Care and Adult Residential Care Services

The Department of Health provides residentially based long-term care services in the following facility types:

• Nursing Homes & Homes for the Aged which provide a range of personal care and/or skilled nursing care to individuals who require ongoing access to professional nursing services;
  
  
• Residential Care Facilities which provide accommodation, personal care and/or supervisory care to four or more individuals in a residential setting; and
  
  
• Community Based Options which provide accommodation, personal care and/or supervisory care skills for three or less residents.
  
  

Residents who live in nursing homes, residential care facilities, and community-based options under the Department of Health's mandate have the costs of their health care services covered by the provincial government. Residents pay the accommodation cost portion of the long-term care services they receive. There is a daily Standard Accommodation Charge for each long-term care facility type. Subject to an income test, some residents may have accommodation costs subsidized through a reduction in the Standard Accommodation Charge. For more information please see:
www.gov.ns.ca/health/ccs/ltc.htm

7.2 Home Care Services

Broad-based, provincially funded home care services are available to Nova Scotians of all ages and help individuals to reach and maintain their maximum level of health and to support independent living in the community. Both chronic care services over the longer term and short-term acute services are provided through home care. Home care services can be provided to people who are chronically ill, convalescent, palliative, disabled or to individuals with an acute illness. The services available to individuals through home care include professional nursing care, assistance with personal care, nutritional care, aid with home making activities, home oxygen services and respite care. The program also provides referrals to and linkages with other services such as adult day programs, community based equipment loan programs, volunteer services, meals on wheels and community rehabilitation services. The Department of Health also offers a Self-managed Care service component to assist physically disabled Nova Scotians to increase control over their lives. The Self-managed Care program provides funds to eligible individuals so that they may directly employ caregivers to meet their home support and personal care needs.

In addition to the services outlined above, the following services and programs are provided to Nova Scotians outside the requirements of the Canada Health Act.

Nova Scotia Seniors' Pharmacare Program -- This provincial drug insurance plan helps seniors manage their prescription drug costs. Eligible persons include all residents aged 65 years or older and who do not have prescription drug coverage through Veterans Affairs Canada, First Nations and Inuit Health, or a private drug plan. The program provides access to prescription drugs, and diabetic and ostomy supplies listed as benefits in the Nova Scotia Formulary. Persons using this program are responsible for co-payments of 33 percent of prescription cost with an annual maximum of $382. General information regarding Pharmacare can be found at:
http://www.nspharmacare.ca
Nova Scotia Pharmacare

Special Funding for Drugs for Specific Disease States -- The Province provides special funding for drug therapies for a few specific disease states including cystic fibrosis, diabetes insipidus, cancer and growth hormone deficiency. There are no user charges for this coverage. General information regarding Drug Programs and Funding can be found at:
http://www.nspharmacare.ca
Nova Scotia Pharmacare

Nova Scotia Family Pharmacare Program -- This provincial drug insurance plan began in March 2008 and is designed to provide prescription drug coverage to Nova Scotians who are at risk of having unmet drug needs because they are un-insured or underinsured. The program is available to all residents of Nova Scotia, however people cannot receive benefits from the Family Pharmacare and Senior's Pharmacare or Diabetes Assistance or Community Services Income Assistance Pharmacare at the same time. There are no premiums to join Family Pharmacare, and the program's co-payment and deductible have yearly maximums that are set depending on a family's annual income. General information regarding Pharmacare can be found at: www.nspharmacare.ca
Nova Scotia Pharmacare

Diabetes Assistance Program -- In 2005-2006, $2.5 million was allocated to design and start this program. This program helps cover the cost of most diabetes medications and supplies and is available to Nova Scotians under 65 years of age who have no other drug coverage. General information on this program is available at:
http://www.nspharmacare.ca
Nova Scotia Pharmacare

Emergency Health Services -- Pre-hospital and Out of Hospital Emergency Care -- Emergency Health Services Nova Scotia (EHS) is responsible for the continual development, implementation, monitoring and evaluation of pre-hospital and out of hospital emergency health services in Nova Scotia. EHS integrates various pre-hospital and out of hospital services and programs into one system to meet the needs of Nova Scotians. These services include: EHS ground ambulance system, EHS LifeFlight (the provincial air medical transport system), the EHS Medical Communications Centre, Medical Oversight (Management and Direction), the EHS NS Trauma Program, EHS Atlantic Health Training and Simulation Centre and the EHS Medical First Response program. This integrated province-wide system has been rated in the top 10 percent of systems in North America. Nova Scotia residents are typically levied a user charge of $130.60, to be transported to hospital by ambulance (regardless of distance). There is no charge to the patient for transport from hospital to hospital.

Children's Oral Health Program (COHP) -- This program has two components: 1) the Insured Services Treatment component provides diagnostic, preventative and restorative services; and 2) the Public Health Services component provides prevention-oriented activities through the application of public health initiatives. Children are eligible for services up to the end of the month in which they turn 10 years of age.

Special Dental Plans -- This covers all dental services required, including prosthetics and orthodontics required by persons diagnosed as having a cleft palate cranofacial disorder; and-in-hospital and office delivered dental services provided to those diagnosed as being severely mentally challenged. Maxillofacial Prosthodontic services are also included within this group of services.

Diagnostic, preventive and restorative procedures to residents of the Nova Scotia School for the Blind are provided by the Paediatric Dentistry Program of the IWK Health Centre.

Beneficiaries covered are: patients registered with the Cleft Palate Cranofacial Clinic at the IWK Health Centre; registered students at the School for the Blind and patients with a signed statement to the effect that they are severely mentally challenged and require hospitalization for dental treatment; and those residents requiring the services of a maxillofacial prosthodontist.

Mental Health Services -- The IWK Heath Centre and the DHAs provide mental health services to Nova Scotians of all ages. A continuum of services is available across five core program areas: promotion, prevention and advocacy, outpatient and outreach services, community mental health supports, inpatient services and specialty services. These specialty services include: eating disorders, forensic mental health, seniors mental health, early psychosis, concurrent mental health and substance abuse disorders and neuro-developmental disorders for children and youth. Specialty services are located in the more heavily populated areas of the province and are accessible through all DHAs. This continuum of services is publicly funded.

Nova Scotia Addiction Services -- In Nova Scotia, the provision of Addiction Services is regionalized. Addiction services are provided through nine DHAs and the IWK Health Centre. These organizations are responsible for coordinating prevention and treatment services related to drugs, alcohol and gambling. In some cases, service delivery is provided via a shared service arrangement between two or three DHAs. The provincial Department of Health and the Department of Health Promotion and Protection are jointly responsible for setting provincial directions in substance abuse prevention and treatment, establishing and monitoring provincial standards for addiction services, monitoring the quality of prevention and treatment services across the system, supporting a provincial client data base, and maintaining a provincial alcohol and other drug use monitoring and surveillance system. The Departments work to ensure that there is provincial coordination around addiction prevention and treatment issues and support knowledge development and exchange opportunities throughout the province.

Programs and services are offered on out-patient, day or residential basis.

Specific services include:

• Prevention and community education;
• Community Based Services, including:
• Adolescent Services;
• Driving While Impaired and Ignition Interlock;
• Nicotine Treatment;
• Problem Gambling Services;
• Women's Services; Withdrawal Management;
• Structured Treatment Program; and
• Methadone Maintenance Treatment.

Client's needs are viewed holistically and services are tailored to meet individual needs. Treatment plans are based on a comprehensive assessment and may include a combination of individual, family and group therapy. Addiction services staff work in partnership with many other community services to ensure that clients are able to access the ranges of services necessary for recovery.

Optometric Benefit -- This benefit provides insurance for visual analysis carried out by optometrists. Vision analysis is defined as: "... an examination that includes the determination of: 1) the refractive status of the eye; 2) the presence of any observed abnormality in the visual system, and all necessary tests and prescriptions connected with such determination." Coverage is limited to one routine vision analysis every two years for those under 10 years of age and those 65 and over. Those between 10 and 65 are not covered for routine analyses, but are covered where medical need is indicated.

Prosthetic Services -- All insured residents of the province are eligible for financial assistance in acquiring and replacing standard arm and leg prostheses prescribed by a qualified physician and repairs on such prostheses as required. Patients are responsible for all costs over and above stated coverage.

Interpreter Service Program -- This program guarantees equal access to government services, offered to the general public, to eligible deaf and hard of hearing residents of Nova Scotia.

Speech and Language Pathology Program -- The service options of this program include: 1) one-to-one therapy; 2) small-group therapy; and 3) consultations (e.g. classroom, day-cares, developmental preschools, and residential facilities for individuals with special needs). The Nova Scotia Hearing and Speech Centres provide specialized services such as dysphagia (swallowing) programs and pervasive developmental delay programs at limited locations in the province. There are no user charges. Eligible persons include children from birth to school age and individuals when they leave school through their adult lifespan. Provincial school boards service children in the public school system.

Registered Persons

Insured Hospital Services Within Own Province or Territory

Insured Hospital Services Provided to Residents in Another Province or Territory

Insured Hospital Services Provided Outside Canada

Insured Physician Services Within Own Province or Territory

Insured Physician Services Provided to Residents in Another Province or Territory

Insured Physician Services Provided Outside Canada

Insured Surgical-Dental Services Within Own Province or Territory

New Brunswick

Introduction

New Brunswick remains committed to the five fundamental principles of the Canada Health Act (CHA), a commitment which is evident both in the day to day functioning of the various elements of New Brunswick's health system, and in new initiatives announced or implemented in 2007-2008.

As an example, New Brunswick's commitment to accessibility has long included the provision of health services to individuals in either French or English, reflecting the province's standing as Canada's only officially bilingual province. While maintaining this commitment, the 2007-2008 fiscal year also saw New Brunswick assuring access to French language services in the Acadian Peninsula, through continuing to implement recommendations made following the previous year's Dialogue Santé consultations.

Significant investments and improvements were made in 2007-2008 across the range of health services. The governance structure of New Brunswick's ambulance services was overhauled, to ensure equity and accessibility. Investment proceeded in a variety of e-health initiatives, improving both the quality and accessibility of services. Both comprehensiveness and accessibility improved with enhancements to palliative care -- both in home health care and institutional settings, and with significant investments in regional chemotherapy delivery.

Some of the most important work of 2007-2008, however, was preparatory -- and was not revealed until the fiscal year had changed over. April 2008 saw the introduction of a new Provincial Health Plan. Some of the plan's pillars (e.g. Enhancing Access) explicitly mirror the CHA principles. Others (e.g. Enhancing Efficiency, Harnessing Innovation, and Making Quality Count) implicitly speak to other CHA principles (e.g. comprehensiveness). The transformed governance structure expresses New Brunswick's ongoing commitment to health care's public administration, while exploring options to improve efficiency, quality, and accessibility.

As these initiatives and others become fully implemented, their workings and refinement will continue within the context of the CHA principles, and New Brunswick's obligations to its citizens.

1.0 Public Administration

1.1 Health Care Insurance Plan and Public Authority

In New Brunswick, the health care insurance plan is known as the Medical Services Plan. The public authority responsible for operating and administering the plan is the Minister of Health ("Minister"), whose authority rests under the Medical Services Payment Act and its Regulations.

The Medical Services Payment Act and Regulations specify eligibility criteria, the rights of the beneficiary and the responsibilities of the provincial authority, including the establishment of a medical service plan, the insured and the uninsured services. The legislation also stipulates the type of agreements the provincial authority may enter into with provinces and territories and with the New Brunswick Medical Society. As well, it specifies the rights of a medical practitioner; how the amounts to be paid for entitled services will be determined; how assessment of accounts for entitled services may be made; and confidentiality and privacy issues as they relate to the administration of the Medical Services Payment Act.

1.2 Reporting Relationship

The Medicare Services Branch and the Medicare Operations Branch of the Department of Health (the "Department") are mandated to administer the Medical Services Plan. The Minister reports to the Legislative Assembly through the Department's annual report and through regular legislative processes.

The Regional Health Authorities Act establishes the Regional Health Authorities ("RHA(s)") and sets forth the powers, duties and responsibilities of same. The Minister is responsible for the administration of the Act, provides direction to the RHAs and may delegate additional powers, duties or functions to an RHA.

1.3 Audit of Accounts

Three groups have a mandate to audit the Medical Services Plan.

1. The Office of the Auditor General: In accordance with the Auditor General Act, the Office of the Auditor General conducts the external audit of the accounts of the Province of New Brunswick, which includes the financial records of the Department . For 2007-2008, all financial transactions of the Department were subject to audit. These procedures are completed on a routine basis each year. Following the audit, the Auditor General issues a management letter or report to identify errors and control weaknesses. The Auditor General also conducts management reviews on programs as he or she sees fit and follows up on prior years' audits. For 2007-2008, the Auditor General also reported on the state of program evaluation in the Department and followed up on prior recommendations regarding psychiatric hospitals and units, and the Prescription Drug Program.
2. The Office of the Comptroller: The Comptroller is the chief internal auditor for the Province of New Brunswick and provides accounting, audit and consulting services in accordance with responsibilities and authority set out in the Financial Administration Act. The Comptroller's internal audit objectives cover Appropriations Audits, Information Systems Audits, Statutory Audits and Value-For-Money Audits. The audit work performed by the Office varies, depending on the nature of the entity audited and the audit objectives. During 2007-2008, the Office of the Comptroller performed routine audits of new computer systems and specific payments made by the Department.
3. Department of Health Internal Audit Branch: The Department's Internal Audit Branch was established to independently review and evaluate departmental activities as a service to all levels of management. This group is responsible for providing departmental management with information about the adequacy and the effectiveness of its system of internal controls and adherence to legislation and stated policy. The Branch also performs program audits to report on the efficiency, effectiveness and economy of programs in meeting departmental objectives. During 2007-08, the Branch reported on Continuing Medical Education (CME) payments, Information Technology (IT) outsourcing, and examined Medicare card usage.

2.0 Comprehensiveness

2.1 Insured Hospital Services

Legislation providing for insured hospital services includes the Hospital Services Act, section 9 of Regulation 84-167 and the Hospital Act.

During fiscal 2007-08, there were eight Regional Health Authorities (RHAs), established under the authority of the Regional Health Authorities Act. Each RHA includes a regional hospital facility and a number of smaller facilities, all of which provide insured services for both in- and out-patients. Each RHA has health facilities and health centres without designated beds that provide a range of services to entitled persons.

Under Regulation 84-167 of the Hospital Services Act, New Brunswick residents are entitled to the following in-patient and out-patient insured hospital services.

In-patient services include:

• accommodation and meals at the standard ward level;
• necessary nursing service;
• laboratory, radiological and other diagnostic procedures, together with the necessary interpretations for maintaining health, preventing disease and helping diagnose and treat any injury, illness or disability;
• drugs, biological and related preparations;
• use of operating room, case room and anesthetic facilities, including necessary equipment and supplies, and routine surgical supplies;
• use of radiotherapy facilities, where available;
• use of physiotherapy facilities, where available; and
• services rendered by persons who receive remuneration therefore from the RHA.

Out-patient services in a hospital facility operated by an approved RHA are as follows:

• laboratory and diagnostic procedures, together with the necessary interpretations when referred by a medical practitioner or nurse practitioner, when approved facilities are available;
• laboratory and diagnostic procedures, together with the necessary interpretations, where approved facilities are available, when performed for the purpose of a mammography screening service that has been approved by the Minister of Health;
• the hospital component of available outpatient services when prescribed by a medical practitioner or nurse practitioner and provided in an out-patient facility of an approved RHA, for maintaining health, preventing disease and helping diagnose and treat any injury, illness or disability, excluding the following services:
  • the provision of any proprietary medicines;
  • the provision of medications for the patient to take home;
  • diagnostic services performed to satisfy the requirements of third parties, such as employers and insurance companies;
  • visits solely for the administration of drugs, vaccines, sera or biological products; and
  • any out-patient service that is an entitled service under the Medical Services Payment Act.

The process for adding a hospital service to the list of insured services involves the Department receiving a proposal from a Regional Health Authority or other stakeholder, who is then screened for eligibility against the criteria for insured hospital services described under the Hospital Services Act and its Regulations.

2.2 Insured Physician Services

The enabling legislation providing for insured physician services is the Medical Services Payment Act and corresponding Regulations.

No changes pertaining to physician services were introduced to this Act and regulations during fiscal 2007-2008.

The New Brunswick Medical Services Plan covers physicians who provide medically required services. The conditions that a physician must meet to participate in the New Brunswick Medical Services Plan are:

• maintain current licensure with the New Brunswick College of Physicians and Surgeons;
• maintain membership in the New Brunswick Medical Society;
• hold privileges in a RHA; and
• signing of the Participating Physicians Agreement.

The number of physicians with an active status as of March 31, 2008, was 1,453.

Physicians in New Brunswick have the option to opt out totally or for selected services. Totally opted-out practitioners are not paid directly by Medicare for the services they render and must bill patients directly in all cases. Patients are not entitled to reimbursement from Medicare for services rendered by totally opted-out physicians.

The selective opting-out provision may not be invoked in the case of an emergency or for continuation of care commenced on an opted-in basis. Opted-in physicians wishing to opt out for a service must first obtain the patient's agreement to be treated on an opted-out basis, after which they may bill the patient directly for the service. In these instances , the following procedures must be adhered to.

The physician must advise the patient in advance and:

• the charges must not exceed the Medicare tariff. The practitioner must complete the specified Medicare claim forms and indicate the exact total amount charged to the patient. The beneficiary seeks reimbursement by certifying on the claim form that the services have been received and forwarding the claim form to Medicare.
• if the charges will be in excess of the Medicare tariff, the practitioner must inform the beneficiary before rendering the service that:
  • they are opting out and charging fees above the Medicare tariff;
  • in accepting service under these conditions, the beneficiary waives all rights to Medicare reimbursement; and
  • the patient is entitled to seek services from another practitioner who participates in the Medical Services Plan.
• the physician must obtain a signed waiver from the patient on the specified form and forward such form to Medicare.

As of March 31, 2008, no physicians rendering health care services had elected to completely opt out of the New Brunswick Medical Services Plan.

The range of entitled services under Medicare includes the medical portion of all services rendered by medical practitioners that are medically required. It also includes certain surgical-dental procedures when performed by a physician or a dental surgeon in a hospital facility. The range of non-entitled services is set out under Schedule 2, Regulation 84-20 and the Medical Services Payment Act.

An individual, a physician or the Department may request the addition of a new service. All requests are considered by the New Service Items Committee, which is jointly managed by the New Brunswick Medical Society and the Department. The decision to add a new service is usually based on conformity to "medically necessary" and whether the service is considered generally acceptable practice (not experimental) within New Brunswick and Canada. Considerations under the term "medically necessary" include services required for maintaining health, preventing disease and/or diagnosing or treating an injury, illness or disability. No public consultation process is used.

During fiscal 2007-2008, the following physician services were added:

• Intra tympanic injection of medication
• Meniscal Allograph Transplantation
• Insertion of Pessary
• CT Angiography of Coronary Arteries
• Repair of Femoral False Aneurysm

2.3 Insured Surgical-Dental Services

Schedule 4 of Regulation 84-20 under the Medical Services Payment Act, identifies the insured surgical-dental services that can be provided by a qualified dental practitioner in a hospital, providing the condition of the patient requires services to be rendered in a hospital. In addition, a general dental practitioner may be paid to assist another dentist for medically required services under some conditions.

In addition to Schedule 4 of Regulation 84-20, Oral Maxillofacial Surgeons (OMS) have added access to approximately 300 service codes in the Physician Manual and can admit and discharge patients in addition to performing physical examinations. The array of services include, those performed in an outpatient setting.

The conditions that an OMS and a dental practitioner must meet to participate in the medical plan are:

• maintaining current registration with the New Brunswick Dental Society and;
• completing the Participating Physician's Agreement (included in the New Brunswick Medicare Dental registration form).

As of March 31, 2008, there were 87 OMSs and dentists registered with the Plan.

OMSs and Dentists have the same opting out provision as physicians (see section 2.2) and must follow the same guidelines. The Department has no data for the number of non-enrolled dental practitioners in New Brunswick.

2.4 Uninsured Hospital, Physician and Surgical-Dental Services

Uninsured hospital services include the following: patent medicines; take-home drugs; third-party requests for diagnostic services; visits to administer drugs, vaccines, sera or biological products; televisions and telephones; preferred accommodation at the patient's request; and hospital services directly related to services listed under Schedule 2 of the Regulation under the Medical Services Payment Act.

Services are not insured if provided to those entitled under other statutes.

The services listed in Schedule 2 of New Brunswick Regulation 84-20 under the Medical Services Payment Act are specifically excluded from the range of entitled medical services under Medicare, namely:

• elective surgery or other services for cosmetic purposes;
• correction of inverted nipple;
• breast augmentation;
• otoplasty for persons over the age of 18;
• removal of minor skin lesions, except where the lesions are, or are suspected to be, pre-cancerous;
• abortion, unless the abortion is performed by a specialist in the field of obstetrics and gynaecology in a hospital facility approved by the jurisdiction in which the hospital facility is located and two medical practitioners certify in writing that the abortion was medically required;
• surgical assistance for cataract surgery unless such assistance is required because of risk of procedural failure, other than the risk inherent in removing the cataract itself, due to the existence of an illness or other complication;
• medicines, drugs, materials, surgical supplies or prosthetic devices;
• vaccines, serums, drugs and biological products listed in sections 1006 and 108 of New Brunswick Regulation 88-200 under the Health Act;
• advice or prescription renewal by telephone which is not specifically provided for in the Schedule of Fees;
• examinations of medical records or certificates at the request of a third party, or other services required by hospital regulations or medical by-laws;
• dental service provided by a medical practitioner or an OMS;
• services that are generally accepted within New Brunswick as experimental or that are provided as applied research;
• services that are provided in conjunction with, or in relation to, the services referred to above;
• testimony in a court or before any other tribunal;
• immunization, examinations or certificates for travel, employment, emigration, insurance purposes, or at the request of any third party;
• services provided by medical practitioners or OMS to members of their immediate family;
• psychoanalysis;
• electrocardiogram (ECG) where not performed by a specialist in internal medicine or paediatrics;
• laboratory procedures not intended as part of an examination or consultation fee;
• refractions;
• services provided within the province by medical practitioners, OMS or dental practitioners for which the fee exceeds the amount payable under this Regulation;
• the fitting and supplying of eyeglasses or contact lenses;
• transsexual surgery;
• radiology services provided in the province by a private radiology clinic;
• acupuncture;
• complete medical examinations when performed for a periodic check-up and not for medically necessary purposes;
• circumcision of the newborn;
• reversal of vasectomies;
• second and subsequent injections for impotence;
• reversal of tubal ligations;
• intrauterine inseminations;
• bariatric surgery unless the person (i) has a body mass index of 40 or greater, (ii) has obesity-related co-morbid conditions, and (iii) has, under the supervision of a medical practitioner, commenced and failed an exercise and diet program to reduce the person's weight to a more acceptable level; and
• venipuncture for the purpose of taking blood when preformed as a stand-alone procedure in a facility that is not an approved hospital facility.

Dental services not specifically listed in Schedule 4 of the Dental Schedule are not covered by the Plan. Those listed in Schedule 2 are considered the only non-insured medical services.

There are no specific policies or guidelines, other than the Act and Regulations, to ensure that charges for uninsured medical goods and services (i.e., enhanced medical goods and services such as intraocular lenses, fibreglass casts, etc.), provided in conjunction with an insured health service, do not compromise reasonable access to insured services. Intraocular lenses are now provided by the hospitals.

The decision to de-insure physician or surgical-dental services is based on the conformity of the service to the definition of "medically necessary," a review of medical service plans across the country and the previous use of the particular service. Once a decision to de-insure is reached, the Medical Services Payment Act dictates that the government may not make any changes to the Regulation until the advice and recommendations of the New Brunswick Medical Society are received or until the period within which the Society was requested by the Minister to furnish advice and make recommendations has expired. Subsequent to receiving their input and resolution of any issues, a regulatory change is completed. Physicians are informed in writing following notification of approval. The public is usually informed through a media release. No public consultation process is used.

In 2007-2008 the code for "mileage for house calls to patients on home dialysis, per kilometre in excess of 5 km, one way" was removed from the insured service list

3.0 Universality

3.1 Eligibility

Sections 3 and 4 of the Medical Services Payment Act and its Regulation 84-20, define eligibility for the health care insurance plan in New Brunswick.

Residents are required to complete a Medicare application and to provide proof of Canadian citizenship, Native status or valid Canadian immigration document. A resident is defined as a person lawfully entitled to be, or to remain, in Canada, who makes his or her home and is ordinarily present in New Brunswick, but does not include a tourist, transient, or visitor to the province.

All persons entering or returning to New Brunswick (excluding children adopted from outside Canada) have a waiting period before becoming eligible for Medicare coverage. Coverage commences on the first day of the third month following the month of arrival.

Residents who are ineligible for Medicare coverage include:

• regular members of the Canadian Armed Forces;
• members of the Royal Canadian Mounted Police (RCMP);
• inmates of federal prisons;
• persons moving to New Brunswick as temporary residents;
• a family member who moves from another province to New Brunswick before other family members move;
• persons who have entered New Brunswick from another province to further their education and who are eligible to receive coverage under the medical services plan of that province; and
• non-Canadians who are issued certain types of Canadian authorization permits (e.g., a Student Authorization).

Provisions to become eligible for Medicare coverage include:

• non-Canadians who are issued an immigration permit that would not normally entitle them to coverage are eligible if legally married to, or in a common-law relationship with, an eligible New Brunswick resident.

Provisions when status changes include:

• persons who have been discharged or released from the Canadian Armed Forces, the RCMP or a federal penitentiary. Provided they are residing in New Brunswick at the time, these persons are eligible for coverage on the date of their release. They must complete an application, provide the official date of release and provide proof of citizenship.

3.2 Registration Requirements

A beneficiary who wishes to become eligible to receive entitled services shall register, together with any dependants under the age of 19, on a form provided by Medicare for this purpose, or be registered by a person acting on his or her behalf.

Upon approval of the application, the beneficiary and dependants are registered and a Medicare card with an expiry date is issued to the beneficiary and each dependent.

A Notice of Expiry form providing all family information currently existing on the Medicare files is issued to the beneficiary two or three months before the expiry date of the Medicare card or cards. A beneficiary who wishes to remain eligible to receive entitled services is required to confirm the information on the Notice of Expiry, to make any changes as appropriate and return the form to Medicare. Upon receiving the completed form, the file is updated and new card(s) are issued bearing a revised expiry date.

Currently in New Brunswick, only those individuals deemed eligible are registered.

All family members (the beneficiary, spouse and dependents under the age of 19) are required to register as a family unit. Residents who are cohabiting, but not legally married, are eligible to register as a family unit if they so request.

Residents may opt out of Medicare coverage if they choose. They are asked to provide written confirmation of their intention. This information is added to their files and benefits are terminated.

3.3 Other Categories of Individual

Non-Canadians who may be issued an immigration permit that would not normally entitle them to Medicare coverage are eligible, provided that they are legally married to, or living in a common-law relationship with, an eligible New Brunswick resident and still possess a valid immigration permit. At the time of renewal, they are required to provide an updated immigration document.

4.0 Portability

4.1 Minimum Waiting Period

A person is eligible for New Brunswick Medicare coverage on the first day of the third month following the month permanent residence has been established in New Brunswick. The three month waiting period is legislated under New Brunswick's Medical Services Payment Act and no exemptions can be made.

4.2 Coverage During Temporary Absences in Canada

The legislation that defines portability of health insurance during temporary absences in Canada is the Medical Services Payment Act, Regulation 84-20, sections 3(4) and 3(5).

Students in full-time attendance at a university or other approved educational institution who leave New Brunswick to further their education in another province are granted coverage for a 12-month period that is renewable provided they comply with the following:

• provide proof of enrolment;
• contact Medicare once every 12-month period to retain their eligibility;
• do not establish residence outside New Brunswick; and
• do not receive health coverage in another province.

Residents temporarily employed in another province or territory, are granted coverage for up to 12 months provided the following terms are adhered to:

• residents do not establish residence in another province;
• residents do not receive coverage in another province; and
• residents plan on returning to New Brunswick.

If absent longer than 12 months, residents should apply for coverage in the province or territory where they are employed and should be entitled to receive coverage on the first day of the thirteenth month.

New Brunswick has formal agreements with all Canadian provinces and territories for reciprocal billing of insured hospital services. In addition, New Brunswick has reciprocal agreements with all provinces except Quebec for the provision of insured physicians' services. Services provided by Quebec physicians to New Brunswick residents are paid at Quebec rates, if the service delivered is insured in New Brunswick. The majority of such claims are received directly from Quebec physicians. Any paid claims submitted by the patient are reimbursed to the patient, according to New Brunswick regulations.

There were 213,710 physician services provided to New Brunswick residents in other provinces and territories during 2007-2008 . The total amount paid for these services was $11,998,933.

4.3 Coverage During Temporary Absences Outside Canada

The legislation that defines portability of health insurance during temporary absences outside Canada is the Medical Services Payment Act, Regulation 84-20, sections 3(4) and 3(5).

Eligibility for "temporarily absent" New Brunswick residents is determined in accordance with the Medical Services Payment Act and Regulations and the Inter-Provincial Agreement on Eligibility and Portability.

Residents temporarily employed outside the country are granted coverage for up to 12 months, regardless if it is known beforehand that they will be absent beyond the 12-month period, provided they do not establish residence outside Canada.

Any absence over 182 days, whether it is for work purposes or vacation, would require the Director's approval. This approval can only be up to 12 months in duration and will only be granted once every three years. Families of workers temporarily employed outside Canada will continue to be covered, provided that they reside in New Brunswick.

New Brunswick residents who exceed the 12 month extension have to reapply for New Brunswick Medicare upon their return to New Brunswick, and be subject to the legislated three month waiting period. However, a "grace period" of up to 14 days could be extended to those New Brunswick residents who have been "temporarily absent" slightly beyond the 12 month absence. In some cases this would alleviate having to reapply as a returning resident with the legislated three month waiting period.

Exception for Temporary Workers: Mobile Workers are residents whose employment requires them to travel outside the province (e.g., pilots, truck drivers, etc.). Certain guidelines must be met to receive Mobile Worker designation. These are as follows:

• applications must be submitted in writing;
• documentation is required as proof of Mobile Worker status (e.g., letter from employer confirming that frequent travel is required outside New Brunswick; letter from New Brunswick resident confirming that their permanent residence is New Brunswick and how often they return to New Brunswick; copy of resident's New Brunswick drivers license; if working outside Canada, copy of resident's Immigration document that allows them to work outside the country);
• the worker's permanent residence must remain in New Brunswick; and
• the worker must return to New Brunswick during their off-time.

Mobile Worker status is assigned for a maximum of two years, after which the New Brunswick resident must reapply and resubmit documentation to confirm continuing Mobile Worker status.

Contract Workers

Any New Brunswick resident accepting a contract out-of-country must supply the following information and documentation:

• letter of request from the New Brunswick resident with their signature, detailing their absence including Medicare number, New Brunswick address, date of departure, destination and forwarding address, reason for absence and date of return; and
• copy of contractual agreement between employee and employer which defines a start date and end date of employment.

"Contract Worker" status is assigned for up to a maximum of two years. Any further requests for contract worker status must be forwarded to the Director of Medicare Services for approval on an individual basis.

Students

Those in full-time attendance at a university or other approved educational institution, who leave New Brunswick to further their education in another country, will be granted coverage for a 12-month period that is renewable, provided that they do the following:

• provide proof of enrolment;
• contact Medicare, once every 12-month period to retain their eligibility;
• do not establish permanent residence outside New Brunswick; and
• do not receive health coverage elsewhere.

4.4 Prior Approval Requirement

Medicare will cover out-of-country services that are not available in Canada on a prior approval basis only. Residents may opt to seek non-emergency out-of-country services; however, those who receive such services will assume responsibility for the total cost.

New Brunswick residents may be eligible for reimbursement if they receive elective medical services outside the country, provided they fulfill the following requirements:

• the required service, or equivalent or alternate service, must be unavailable in Canada;
• it must be rendered in a hospital listed in the current edition of the American Hospital Association Guide to the Health Care Field (guide to United States hospitals, health care systems, networks, alliances, health organizations, agencies and providers);
• the service must be rendered by a medical doctor; and
• the service must be an accepted method of treatment recognized by the medical community and be regarded as scientifically proven in Canada. Experimental procedures are not covered.

If the above requirements are met, it is mandatory to request prior approval from Medicare in order to receive coverage. A physician, patient or family member may request prior approval to receive these services outside the country, accompanied by supporting documentation from a Canadian specialist or specialists.

The following are considered exemptions under the out-of-country coverage policy:

• haemodialysis: patients will be required to obtain prior approval and Medicare will reimburse the resident at a rate equivalent to the inter-provincial rate of $220 per session; and
• allergy testing for environmental sensitivity: all tests outside the country will be paid at a maximum rate of $50 per day, an amount equivalent to an out-patient visit.

Prior approval is also required to refer patients to psychiatric hospitals and addiction centres outside the province because they are excluded from the Interprovincial Reciprocal Billing Agreement. A request for prior approval must be received by Medicare from the Addiction Services or Mental Health branches of the Department of Health.

5.0 Accessibility

5.1 Access to Insured Health Services

New Brunswick charges no user fees for insured health services as defined by the Canada Health Act. Therefore, all residents of New Brunswick have equal access to these services.

5.2 Access to Insured Hospital Services

The following measures were taken in 2007-2008 to improve access to hospital services:

• A provincial surgical patient registry was implemented. This ensures that there is an accurate and standardized list of patients who are waiting for surgery in New Brunswick. Utilizing this wait time information has resulted in ongoing improvements to surgical wait times resulting in more timely access to surgery.
• Each of the 16 facilities that perform surgery is implementing recommended changes to its processes and resources which is resulting in improving efficiencies and increasing capacity, thereby improving timely access to surgery.
• Electrophysiology services are now being offered at the New Brunswick Heart Centre. New Brunswickers previously had to travel out-of-province to obtain these services.
• An additional fixed Magnetic Resonance Imaging unit (MRI) is now in operation at the Dr. Everett Chalmers Regional Hospital in Fredericton. There are now 6 MRI units (2 mobile and 4 fixed) in the province.
• Cardiac rehabilitation services have been enhanced throughout the province. Existing programs were enhanced and new programs were implemented in areas where this service was previously unavailable.
• Six nurse practitioners were added in order to improve access to primary care services.
• Three new oncology clinics were established in the northern rural part of the province.  Patients can now receive their treatment closer to home.
• Radiation therapy treatment capacity was increased in Moncton in order to address a growing patient load.
• The maximum number of annual PET examinations was increased from 300 to 600.
• A new 70 bed hospital began operating in Waterville, New Brunswick during fiscal 2007-08. Following the opening of this new facility, 2 facilities were closed (total of 52 beds). This increased the maximum bed capacity by 18.

5.3 Access to Insured Physician and Surgical-Dental Services

As of March 31, 2008, there were 708 general practitioners, 745 specialists, and 87 OMSs and dentists registered with the plan.

In fiscal 2007-2008, the Department continued to work on its recruitment and retention strategy, aimed at attracting newly licensed family practitioners and specialists. This strategy includes a contingency fund to allow the Department to more effectively respond to potential recruitment opportunities, including the provision of location grants for $25,000 and $50,000 for family practitioners and $40,000 for specialists willing to practice in under-serviced areas of the province.The recruitment and retention strategy also provides for increased government involvement in post-graduate training of family physicians, the maintenance of 350 weeks in summer rural preceptorship training for medical students, and moving physician remuneration toward relative parity with other Atlantic provinces.

5.4 Physician Compensation

Payments to physicians and dentists are governed under the Medical Services Payment Act, Regulations 84-20, 93-143 and 96-113.

Fiscal 2007-2008 marked the third and final year of an agreement with fee-for-service physicians that provides for a 13 percent increase in fees over a three-year period (2005-2006 to 2007-2008 for 4.0%, 4.5% and 4.5% respectively).

There is no formal negotiation process for dental practitioners in New Brunswick.

The methods used to compensate physicians for providing insured health services in New Brunswick are fee-for-service, salary and sessional or alternate payment mechanisms that may also include a blended system.

5.5 Payments to Hospitals

The legislative authorities governing payments to hospital facilities in New Brunswick are the Hospital Act, which governs the administration of hospitals, and the Hospital Services Act, which governs the financing of hospitals. The Regional Health Authorities Act provides for the delivery and administration of health services in defined geographic areas within the province.

There were no changes during the 2007-2008 fiscal affecting the hospital payment process.

The Department uses two components to distribute available funding to New Brunswick's RHAs.

The main component is a "Current Service Level" (CSL) base. This component addresses five main patient-care delivered services as follows:

• tertiary services (cardiac, dialysis, oncology);
• psychiatric services (psychiatric units and facilities);
• dedicated programs (e.g., addictions services);
• community-based services (Extra-Mural Program; health service centres); and
• general patient care.

Added to this are non-patient care support services (e.g., general administration, laundry, food services, energy).

The current budget process may extend over more than one fiscal year and includes several steps. By March of each year, RHAs are to provide the Department with their utilization data and revenue projections for the following fiscal year, as well as their actual utilization data and revenue figures for the first nine months of the current fiscal year. This information, along with the audited financial statements from the previous two fiscal years, is used to evaluate the expected funding level for each RHA.

Budget amendments are provided during the year to allow for adjustments to applicable programs and services on either recurring or non-recurring bases. The "year-end settlement process" reconciles the total annual approved budget for each RHA to its audited financial statements and reconciles budgeted revenues and expenses to actual revenues and expenses.

Any requests of funding for new programs are submitted to the branch responsible for the new program. An evaluation of the request is performed by Department of Health officials in collaboration with the Regional Health Authority staff.

6.0 Recognition Given to Federal Transfers

New Brunswick routinely recognizes the federal role regarding its contributions under the Canada Health Transfer (CHT) in public documentation presented through legislative and administrative processes. These include the following:

• the Budget Papers presented by the Minister of Finance on March 18, 2008 ;
• the 2006-2007 Public Accounts presented by the Minister of Finance on September 28, 2007;
• the 2007-2008 Public Accounts presented by the Minister of Finance on September 26, 2008; and
• the Main Estimates presented by the Minister of Finance on March 18, 2008.

New Brunswick does not produce promotional documentation on its insured medical and hospital benefits.

7.0 Extended Health Care Services

7.1 Nursing Home Intermediate Care and Adult Residential Care Services

The New Brunswick Long-Term Care program, a non-insured service, was transferred to the Department of Family and Community Services on April 1, 2000. Nursing home care, also a non-insured service, is offered through the Nursing Home Services program of the Department of Family and Community Services, now called the Department of Social Development (since December 2007). Other adult residential care services and facilities are available through a variety of agencies and funding sources within the province.

Nursing homes are private, not-for-profit organizations. In order to be admitted to a nursing home, clients go through an evaluation process, based on specific health condition criteria.

Adult Residential Facilities are, for the most part, private and not-for-profit organizations. The number of available beds fluctuates as private entrepreneur's open and close residential facilities. Clients are admitted after going through the same evaluation process used for nursing home admissions. Public housing units are available for low-income elderly persons. Admission criteria are based on age and the applicant's financial situation. The Victorian Order of Nurses offers support services to some units.

7.2 Home Care Services

The New Brunswick Extra-Mural Program provides comprehensive home healthcare services throughout the province. Services include acute, palliative, chronic care, rehabilitation services provided in community settings (an individual's home, a nursing home or public school) and a home oxygen program. Since 1996, this program has been delivered by New Brunswick's RHAs according to provincial policies and standards.

Service providers include registered nurses, licensed practical nurses, social workers, dieticians, respiratory therapists, physiotherapists, occupational therapists, speech language pathologists and pharmacists, where funded.

A demonstration project is now providing screening, assessment and appropriate community intervention to prevent unnecessary hospital admissions when it is possible for seniors to be living at home safely supported and secure. These services, although not covered by the Canada Health Act, are considered insured services under the provincial Hospital Services Plan.

7.3 Ambulatory Health Care Services

Ambulatory health care services were delivered by New Brunswick's RHAs according to provincial policies and standards, and included services provided in hospital emergency rooms, day or night care in hospitals and in clinics if it is available in hospitals, health centres and Community Health Centres. This is considered an insured service under the provincial Hospital Services Plan.

Registered Persons

Insured Hospital Services Within Own Province or Territory

Insured Hospital Services Provided to Residents in Another Province or Territory

Insured Hospital Services Provided Outside Canada

Insured Physician Services Within Own Province or Territory

Insured Physician Services Provided to Residents in Another Province or Territory

Insured Physician Services Provided Outside Canada

Insured Surgical-Dental Services Within Own Province or Territory

Quebec

1.0 Public Administration

1.1 Health Care Insurance Plan and Public Authority

Quebec's hospital insurance plan, the Régime d'assurance hospitalisation du Québec, is administered by the ministère de la Santé et des Services sociaux (MSSS) [Quebec Department of Health and Social Services].

Quebec's health insurance plan, the Régime d'assurance maladie du Québec, is administered by the Régie de l'assurance maladie du Québec (RAMQ) [Quebec Health Insurance Board], a public body established by the provincial government and reporting to the Minister of Health and Social Services.

1.2 Reporting Relationship

The Public Administration Act (R.S.Q., c. A-6.01) sets out the government criteria for preparing reports on the planning and performance of public authorities, including the ministère de la Santé et des Services sociaux and the Régie de l'assurance maladie du Québec.

1.3 Audit of Accounts

Both plans (the Quebec hospital insurance plan and the Quebec health insurance plan) are operated on a non-profit basis. All books and accounts are audited by the Auditor General of the province.

2.0 Comprehensiveness

2.1 Insured Hospital Services

Insured in-patient services include: standard ward accommodation and meals; necessary nursing services; routine surgical supplies; diagnostic services; use of operating rooms, delivery rooms and anesthetic facilities; medications, prosthetic and orthotic devices that can be integrated with the human body; biologicals and related preparations; use of radiotherapy, radiology and physiotherapy facilities; and services rendered by hospital staff.

Out-patient services include: clinical services for psychiatric care; electroshock, insulin and behaviour therapies; emergency care; minor surgery (day surgery); radiotherapy; diagnostic services; physiotherapy; occupational therapy; inhalation therapy, audiology, speech therapy and orthoptic services; and other services or examinations required under Quebec legislation.

Other services covered by insurance are: mechanical, hormonal or chemical contraception services; surgical sterilization services (including tubal ligation or vasectomy); reanastomosis of the fallopian tubes or vas deferens; and ablation of a tooth or root when the health status of the person makes hospital services necessary.

The MSSS administers an ambulance transportation program that is free-of-charge to persons aged 65 or older.

In addition to basic insured health services, the Régie also covers the following, with some limitations, for certain inhabitants of Quebec, as defined by the Health Insurance Act, and for employment assistance recipients: optometric services; dental care for children and employment assistance recipients, and acrylic dental prostheses for employment assistance recipients; prostheses, orthopedic appliances, locomotion and postural aids, and other equipment that helps with a physical disability; external breast prostheses; ocular prostheses; hearing aids, assistive listening devices and visual aids for people with a visual or auditory disability; and permanent ostomy appliances.

Since January 1, 1997, in terms of drug insurance, the Régie covers, over and above its regular clientele (employment assistance recipients and persons 65 years of age or older), individuals who otherwise would not have access to a private drug insurance plan. Currently (2007), the drug insurance plan covers 3.29 million insured persons.

2.2 Insured Physician Services

The services insured under this plan include medical and surgical services that are provided by physicians and are required from a medical standpoint.

2.3 Insured Surgical-Dental Services

Services insured under this plan include oral surgery performed in a hospital centre or university institution determined by regulation, by dental surgeons and specialists in oral and maxillo-facial surgery.

2.4 Uninsured Hospital, Physician and Surgical-Dental Services

Uninsured hospital services include: plastic surgery; in vitro fertilization; a private or semi-private room at the patient's request; televisions; telephones; drugs and biologics ordered after discharge from hospital; and services for which the patient is covered under the Act Respecting Industrial Accidents and Occupational Diseases or other federal or provincial legislation.

The following services are not insured: any examination or service not related to a process of cure or prevention of illness; psychoanalysis of any kind, unless such service is rendered in an institution authorized for this purpose by the Minister of Health and Social Services; any service rendered solely for aesthetic purposes; any refractive surgery, except in cases where there is documented failure in astigmatism of more than 3.00 diopters or for anisometropia of more than 5.00 diopters, measured at the cornea, when corrective lenses or corneal lenses are worn; any consultation by telecommunication or by correspondence; any service rendered by a professional to his or her spouse or children; any examination, expert appraisal, testimony, certificate or other formality required for legal purposes or by a person other than one who has received an insured service, except in certain cases; any visit made for the sole purpose of obtaining the renewal of a prescription; any examinations, vaccinations, immunizations or injections, where the service is provided to a group or for certain purposes; any service rendered by a professional on the basis of an agreement or a contract with an employer, an association or an organization; any adjustment of eye glasses or contact lenses; any surgical ablation of a tooth or tooth fragment performed by a physician, except where the service is provided in a hospital in certain cases; all acupuncture procedures; injection of sclerosing substances and the examination done at that time; mammography used for screening purposes, unless this service is delivered on a doctor's orders in a place designated by the Minister, in either case, to a recipient who is 35 years of age or older, on condition that such an examination has not been performed on the recipient in the previous year; thermography, tomodensitometry, magnetic resonance imaging and use of radionuclides in vivo in humans, unless these services are rendered in a hospital centre; ultrasonography, unless this service is rendered in a hospital centre or, for obstetrical purposes, in a local community service centre (CLSC) recognized for that purpose; any radiological or anesthetic service provided by a physician if required with a view to providing an uninsured service, with the exception of a dental service provided in a hospital centre or, in the case of a radiology service, if required by a person other than a physician or dentist; any sex-reassignment surgical service, unless it is provided on the recommendation of a physician specializing in psychiatry and is provided in a hospital centre recognized for this purpose; and any services that are not associated with a pathology and that are rendered by a physician to a patient between 18 and 65 years of age, unless that individual is the holder of a claim card, for colour blindness or a refraction problem, in order to provide or renew a prescription for eyeglasses or contact lenses.

3.0 Universality

3.1 Eligibility

Registration with the hospital insurance plan is not required. Registration with the Régie de l'assurance maladie du Québec or proof of residence is sufficient to establish eligibility. All persons who reside or stay in Quebec must be registered with the Régie de l'assurance maladie du Québec to be eligible for coverage under the health insurance plan.

3.2 Registration Requirements

Registration with the hospital insurance plan is not required. Registration with the Régie or proof of residence is sufficient to establish eligibility.

3.3 Other Categories of Individual

Services received by regular members of the Canadian Forces, members of the Royal Canadian Mounted Police (RCMP) and inmates of federal penitentiaries are not covered by the Plan. There are no health premium charges.

Certain categories of residents, notably permanent residents under the Immigration Act and persons returning to live in Canada, become eligible under the Plan following a waiting period of up to three months. Persons receiving last resort financial assistance are eligible upon registration. Members of the Canadian Forces and RCMP who have not acquired the status of inhabitant of Quebec become eligible the day they arrive, and inmates of federal penitentiaries become eligible the day they are released. Immediate coverage is provided for certain seasonal workers, repatriated Canadians, persons from outside Canada who are living in Quebec under an official bursary or internship program of the ministère de l'Éducation [Quebec Department of Education], and refugees. Persons from outside Canada who have work permits and are living in Quebec for the purpose of holding an office or employment for a period of more than six months become eligible for the plan following a waiting period.

4.0 Portability

4.1 Minimum Waiting Period

Persons settling in Quebec after moving from another province of Canada are entitled to coverage under the Quebec Health Insurance Plan when they cease to be entitled to benefits from their province of origin, provided they register with the Régie.

4.2 Coverage During Temporary Absences Outside Quebec (in Canada)

If living outside Quebec in another province or territory for 183 days or more, students and fulltime unpaid trainees may retain their status as residents of Quebec. In the first case, they retain it for four calendar years at most, and in the second, for two consecutive calendar years at most.

This is also the case for persons living in another province or territory who are temporarily employed or working on contract there. Their resident status can be maintained for no more than two consecutive calendar years.

Persons directly employed or working on contract outside Quebec in another province or territory, for a company or corporate body having its headquarters or a place of business in Quebec, or employed by the federal government and posted outside Quebec, also retain their status as an inhabitant of the province, provided their families remain in Quebec or they retain a dwelling there.

Status as an inhabitant of the province is also maintained by persons who remain outside the province for 183 days or more, but less than 12 months within a calendar year, provided such absence occurs only once every seven years and provided they notify the Régie of the absence.

The costs of medical services received in another province or territory of Canada are reimbursed at the amount actually paid or the rate that would have been paid by the Régie for such services in Quebec, whichever is less. However, Quebec has negotiated a permanent arrangement with Ontario to pay Ottawa doctors at the Ontario fee rate for emergency care and when the specialized services provided are not offered in the Outaouais region. This agreement became effective November 1, 1989. A similar agreement was signed in December 1991 between the Centre de santé Témiscaming (Témiscaming health centre) and North Bay.

Costs of hospital services with which a recipient is provided in another province or territory of Canada are paid in accordance with the terms and conditions of the interprovincial agreement on reciprocal billing regarding hospital insurance agreed on by the provinces and territories of Canada. In-patient costs are paid at standard ward rates approved by the host province or territory, and out-patient costs or the costs of expensive procedures are paid at approved interprovincial rates. However, since November 1, 1995, the Government of Quebec reimburses a maximum of $450 per day of hospitalization when an Outaouais inhabitant is hospitalized in an Ottawa hospital for non-urgent care or services available in the Outaouais.

Insured persons who leave Quebec to settle in another province or territory of Canada are covered for up to three months after leaving the province.

4.3 Coverage During Temporary Absences Outside Quebec (outside Canada)

Students, unpaid trainees, Quebec government officials posted abroad and employees of non-profit organizations working in international aid or cooperation programs recognized by the Minister of Health and Social Services must contact the Régie to ascertain their eligibility. If the Régie recognizes them as having special status, they receive full reimbursement of hospital costs in case of emergency or sudden illness, and 75 percent reimbursement in other cases.

Persons directly employed or working on contract outside Canada, for a company or corporate body having its headquarters or a place of business in Quebec, or employed by the federal government and posted outside Quebec, also retain their status as inhabitant of the province, provided their families remain in Quebec or they retain a dwelling there.

As of September 1, 1996, hospital services provided outside Canada in case of emergency or sudden illness are reimbursed by the Régie, usually in Canadian funds, to a maximum of CAN$100 per day if the patient was hospitalized (including in the case of day surgery) or to a maximum of CAN$50 per day for out-patient services.

However, hemodialysis treatments are covered to a maximum of CAN$220 per treatment. In such cases, the Régie provides reimbursement for the associated professional services. The services must be dispensed in a hospital or hospital centre recognized and accredited by the appropriate authorities. No reimbursements are made for nursing homes, spas or similar establishments.

Costs for insured services provided by physicians, dentists, oral surgeons and optometrists are reimbursed at the rate that would have been paid by the Régie to a health professional recognized in Quebec, up to the amount of the expenses actually incurred. The cost of all services insured in the province is reimbursed at the Quebec rate, usually in Canadian funds, when they are incurred abroad.

An insured person who moves permanently from Quebec to another country ceases to be a recipient as of the day of departure.

4.4 Prior Approval Requirement

Insured persons requiring medical services in hospitals abroad, in cases where those services are not available in Quebec or elsewhere in Canada, are reimbursed 100 percent if prior consent has been given for medical and hospital services that meet certain conditions. Consent is not given by the Plan's officials if the medical service in question is available in Quebec or elsewhere in Canada.

5.0 Accessibility

5.1 Access to Insured Health Services

Everyone has the right to receive adequate health care services without any kind of discrimination.

There is no extra-billing by Quebec physicians.

5.2 Access to Insured Hospital Services

On March 31, 2008, Quebec had 117 institutions operating as hospital centres for a clientele suffering from acute illnesses. There were 20,400 beds for persons requiring care for acute physical or psychiatric ailments allotted to these institutions. From April 1, 2007 to March 31, 2008, Quebec hospital institutions had nearly 716,191 admissions for short stays (including births) and 307,246 registrations for day surgeries. These hospitalizations accounted for 5,124,049 patient days.

Restructuring of the health network: In November 2003, Quebec announced the implementation of local service networks covering all of Quebec. At the heart of each local network is a new local authority, the Centre de santé et de services sociaux (CSSS) [the health and social services centre]. These centres are the result of the merger of the public institutions whose mission it was to provide CLSC (local community service centre) services, CHSLD (residential and long-term care) services, and, in most cases, neighbourhood hospital services. The CSSSs also provide the people in their territory with access to other medical services, general and specialized hospital services, and social services. To do so, they will have to enter into service agreements with other health sector organizations. The linking of services within a territory forms the local services network. Thus, the aim of integrated local health and social services networks is to make all the stakeholders in a given territory collectively responsible for the health and well-being of the people in that territory.

5.3 Access to Insured Physician and Surgical-Dental Services

Primary care: In 2003-2004, family medicine groups (FMGs) were established. These groups work closely with the CSSSs and other network resources to provide services such as health assessment, case management and follow-up, diagnosis, treatment of acute and chronic problems, and disease prevention. Their services are available 24 hours a day, seven days a week. In April 2008, there were 160 accredited FMGs in Quebec.

The Conseil médical du Québec has established a committee to develop the concept of the physician/ population ratio because interprovincial comparisons suggest that Quebec has an adequate number of physicians.

5.4 Physician Compensation

Physicians are remunerated in accordance with the negotiated fee schedule. Physicians who have withdrawn from the health insurance plan are paid directly by the patient according to the fee schedule after the patient has collected from the Régie. Nonparticipating physicians are paid directly by their patients according to the amount charged.

Provision is made in law for reasonable compensation for all insured health services rendered by health professionals. The Minister may enter into an agreement with the organizations representing any class of health professional. This agreement may prescribe a different rate of compensation for medical services in a territory where the number of professionals is considered insufficient. The Minister may also provide for a different rate of compensation for general practitioners and medical specialists during the first years of practice, depending on the territory or the activity involved. These provisions are preceded by consultation with the organizations representing the professional groups.

While the majority of physicians practise within the provincial plan, Quebec allows two other options: professionals who have withdrawn from the plan and practise outside the plan, but agree to remuneration according to the provincial fee schedule; and nonparticipating professionals who practice outside the plan, with no reimbursement from the Régie going to either them or their patients.

In 2007-2008, the Régie paid an amount estimated at $3,654,700 to doctors in the province, while the amount for medical services outside the province reached an estimated $9.7 million.

5.5 Payments to Hospitals

The Minister of Health and Social Services funds hospitals through payments directly related to the cost of insured services provided.

The payments made in 2006-2007 to institutions operating as hospital centres for insured health services provided to inhabitants of Quebec were more than $8.2 billion. Payments to hospital centres outside Quebec were approximately $118.9 million.

7.0 Extended Health Care Services

Intermediate care, adult residential care and home care services are available. Admission is coordinated locally or regionally and based on a single assessment tool. The CSSSs receive individuals, evaluate their care requirements, and either arrange for provision of services such as day care centre programs or home care, or refer them to the appropriate agencies.

The MSSS offers some home care services, including nursing care and assistance, homemaker services and medical supervision.

Quebec insures long-term care establishments and long-term care units in acute-care hospitals focus on maintaining their clients' autonomy and functional abilities by providing them with a variety of programs and services, including health care services.

Ontario

Introduction

Ontario has one of the largest and most complex publicly funded health care systems in the world. Administered by the province's Ministry of Health and Long-Term Care (MOHLTC), Ontario's health care system was supported by over $37.9 billion (including capital) in spending for 2007-2008.

The Ministry provides services to the public through such programs as health insurance, drug benefits, assistive devices, forensic mental health and supportive housing, long-term care, home care, community and public health, and health promotion and disease prevention. It also regulates hospitals and nursing homes, operates medical laboratories and coordinates emergency health services.

Fourteen Local Health Integration Networks (LHINs) have been established by the Ministry to plan, integrate and fund health services in their local area for the health service providers. While the LHINs are responsible for managing the local health care system, the Ministry is responsible for establishing overall strategic direction and provincial priorities for the health system.

1.0 Public Administration

1.1 Health Care Insurance Plan and Public Authority

The Ontario Health Insurance Plan (OHIP) is administered on a non-profit basis by Ministry of Health and Long-Term Care (MOHLTC). OHIP was established under the Health Insurance Act, Revised Statutes of Ontario, 1990, c. H-6, to provide insurance in respect of the cost of insured services provided in hospitals and health facilities, and by physicians and other health care practitioners.

1.2 Reporting Relationship

The Health Insurance Act stipulates that the Minister of Health and Long-Term Care is responsible for the administration and operation of OHIP, and is Ontario's public authority for the purposes of the Canada Health Act.

1.3 Audit of Accounts

MOHLTC is audited annually by the Office of the Auditor General of Ontario. The Auditor General's 2007 Annual Report was released on December 11, 2007.

MOHLTC's accounts and transactions are published annually in the Public Accounts of Ontario. The 2007-2008 Public Accounts of Ontario were released on August 25, 2008.

1.4 Designated Agency

Local Health Integration Networks (LHINs) were established under the Local Health System Integration Act, 2006 to improve Ontarians' health through better access to high-quality health services, coordinated health care, and effective and efficient management of the health system at the local level. On April 1, 2007, the LHINs assumed full responsibilities for funding, planning, and integrating health care services at the local level.

LHINs are not-for-profit Crown Agencies that plan, integrate and fund local health services that are delivered by hospitals, Community Care Access Centres, long-term care homes, community health centres, community support services, and mental health agencies. The Act requires each LHIN to prepare an Annual Report for the Minister who is required to table the reports before the Legislative Assembly.

For fiscal 2007-08, the MOHLTC entered into an accountability agreement with each LHIN that includes performance goals and objectives for the networks as well as the allocations for health service providers. The Act also provides the LHINs with the authority to fund health service providers and to enter into service accountability agreements with these providers.

The Local Health System Integration Act reaffirms the principles of the French Languages Services Act to ensure equitable access to services in French for French-speaking Ontarians.

2.0 Comprehensiveness

2.1 Insured Hospital Services

Insured in-patient and out-patient hospital services in Ontario are prescribed under the Health Insurance Act, and Regulation 552 under that Act.

Insured in-patient hospital services include medically required: use of operating rooms, obstetrical delivery rooms and anaesthetic facilities; necessary nursing services; laboratory, radiological and other diagnostic procedures; drugs, biologicals and related preparations; and, accommodation and meals at the standard ward level.

Insured out-patient services include medically required: laboratory, radiological and other diagnostic procedures; use of radiotherapy, occupational therapy, physiotherapy and speech therapy facilities, where available; use of diet counselling services; use of the operating room, anaesthetic facilities, surgical supplies, necessary nursing service, and supplying of drugs, biologicals, and related preparations (subject to some exceptions), including vaccines, anti-cancer drugs, biologicals and related preparations (subject to some exceptions); provision of equipment, supplies and medication to haemophiliac patients for use at home; and the following drugs for take-home use: cyclosporine to transplant patients; zidovudine, didanosine, zalcitabine and pentamidine to patients with HIV infection; biosynthetic human growth hormone to patients with endogenous growth hormone deficiency; drugs for treating cystic fibrosis and thalassemia; erythropoieitins to patients with anaemia of end-stage renal disease; alglucerase to patients with Gaucher disease; clozapine to patients with treatment-resistant schizophrenia; verteporfin to treat patients with predominantly classic subfoveal choroidal neovascularisation secondary to either age-related macular degeneration, presumed ocular histoplasmosis syndrome or pathologic myopia.

In 2007-2008, there were 150 public hospital corporations (excluding specialty mental health hospitals, private hospitals, federal hospitals and long-term care homes) staffed and in operation in Ontario. This includes 132 acute care hospital corporations, 14 chronic care hospitals, and four general and special rehabilitation units. Though they provide a mix of services, hospitals are categorized by major activity. For example, many acute care hospitals offer chronic care services. A number of designated chronic care facilities also offer rehabilitation.

When insured physician services are provided in licensed health facilities outside hospitals and where the total cost paid for these insured services is not included in the physician fees paid under the Health Insurance Act, MOHLTC provides funding through the payment of facility fees under the Independent Health Facilities Act. Facility fees cover the cost of the premises, equipment, supplies, and personnel used to render an insured service. Under the Independent Health Facilities Act, patient charges for facility fees are prohibited.

Facility fees are charged to the provincial government only by facilities that are licensed under the Independent Health Facilities Act. Examples of facilities that are licensed under this Act include: surgical/treatment facilities (e.g., those providing abortions, cataract surgery, dialysis and non-cosmetic plastic surgery) and diagnostic facilities (e.g., those providing x-ray, ultrasound, nuclear medicine, sleep studies and pulmonary function studies). New facilities are ordinarily established through a Request for Proposals process based on an assessment of need for the service.

2.2 Insured Physician Services

Insured physician services are prescribed under the Health Insurance Act and regulations under that Act.

Under subsection 37.1(1) of Regulation 552 of the Health Insurance Act, a service provided by a physician in Ontario is an insured service if it is medically necessary; contained in the Schedule of Benefits for Physician Services; and rendered in such circumstances or under such conditions as outlined in the Schedule of Benefits. Physicians provide medical, surgical and diagnostic services, including primary health care services. Services are provided in a variety of settings, including: private physician offices, community health centres, hospitals, mental health facilities, licensed independent health facilities, and long-term care homes.

In general terms, insured physician services include: diagnosis and treatment of medical disabilities and conditions; medical examinations and tests; surgical procedures; maternity care; anaesthesia; radiology and laboratory services in approved facilities; and, immunizations, injections and tests.

The Schedule of Benefits is regularly reviewed and revised to reflect current medical practice and new technologies. New services may be added, existing services revised or obsolete services removed through regulatory amendment. This process involves consultation with the Ontario Medical Association.

During 2007-2008, physicians could submit claims for all insured services rendered to insured persons directly to the Ontario Health Insurance Plan (OHIP) office, in accordance with section 15 of the Health Insurance Act, or a limited number could bill the insured person, as specified in section 15 of the Act (see also Part II of the Commitment to the Future of Medicare Act). Physicians who do not bill OHIP directly are commonly referred to as having "opted-out". When a physician has opted out, the physician bills the patient (not exceeding the amount payable for the service under the Schedule of Benefits), and the patient is then entitled to reimbursement by OHIP. However, the number of physicians who may opt out was fixed (on a "grandparented" basis) following proclamation of the Commitment to the Future of Medicare Act on September 23, 2004.

Physicians must be registered to practice medicine in Ontario by the College of Physicians and Surgeons of Ontario.

There were approximately 23,900 physicians who submitted claims to OHIP in 2007-2008. This figure includes physicians submitting both fee-for-service claims and physicians included in an alternative payment plan who submitted tracking or shadow-billed claims.

2.3 Insured Surgical-Dental Services

Certain surgical-dental services are prescribed as insured services in section 16 of Regulation 552 in the Health Insurance Act and the Dental Schedule of Benefits. The Health Insurance Act authorizes OHIP to cover a limited number of procedures when the insured services are medically necessary and are performed in a public hospital graded under the Public Hospitals Act as Group A, B, C or D by a dental surgeon who has been appointed to the dental staff of the public hospital.

Approximately 315 dentists and dental/oral surgeons provided insured surgical-dental services in Ontario in 2007-2008.

2.4 Uninsured Hospital, Physician and Surgical-Dental Services

Services prescribed by and rendered in accordance with the Health Insurance Act and regulations under that Act are insured.

Uninsured hospital services include: additional charges for preferred accommodation unless prescribed by a physician, oral-maxillofacial surgeon or midwife; telephones and televisions; charges for private-duty nursing; provision of medications for patients to take home from hospital, with certain exceptions; and in-province, out-patient hospital visits solely for administering drugs, subject to certain exceptions.

Section 24 of Regulation 552 details those physician services that are specifically prescribed as uninsured.

Uninsured physician services include: services that are not medically necessary; toll charges for long-distance telephone calls; the preparation or provision of a drug, antigen, antiserum or other substance, unless the drug, antigen or antiserum is used to facilitate a procedure; advice given by telephone at the request of the insured person or the person's representative; an interview or case conference (in limited circumstances); the preparation and transfer of records at the insured person's request; a service that is received wholly or partly for producing or completing a document or transmitting information to a "third party" in prescribed circumstances; the production or completion of a document or transmitting information to any person other than the insured person in prescribed circumstances; provision of a prescription when no concomitant insured service is rendered; acupuncture procedures; psychological testing; research and survey programs; and experimental treatment .

3.0 Universality

3.1 Eligibility

To be considered a resident of Ontario for the purpose of obtaining Ontario health insurance coverage, a person must:

• Hold Canadian citizenship or an immigration status as prescribed in Regulation 552 of the Health Insurance Act;
• Be ordinarily resident in Ontario, which includes:
  • Making his or her permanent and principal home in Ontario;
  • Subject to some limited exceptions, being physically present in Ontario for at least 153 days in any 12-month period; and
  • For most new and returning residents, be physically present in Ontario for 153 of the first 183 days following the date residency is established in Ontario (i.e., a person cannot be away from the province for more than 30 days in the first six months of residency).

With certain exceptions in which there is an exemption from the waiting period, residents of Ontario, as defined in Regulation 552 of the Health Insurance Act, are eligible for Ontario health insurance coverage subject to a three-month waiting period. Assessment of whether or not an individual is subject to the three-month waiting period occurs at the time of their application for health insurance coverage. Examples of those who are exempt from the three-month waiting period include newborn babies born in Ontario and insured residents from another province or territory who move to Ontario and immediately become residents of approved charitable homes, municipal homes for the aged or nursing homes in Ontario.

The Fairness for Military Families Act (Employment Standards and Health Insurance), 2007, was passed on December 3, 2007, and amended the Health Insurance Act, exempting eligible military family members (spouses and dependent children of active members of the Canadian Forces) from the waiting period for Ontario health insurance coverage upon establishing residency in Ontario.

Individuals who are not eligible for OHIP coverage are those who do not meet the definition of a resident, including those who do not hold an immigration status that is set out in Regulation 552, such as tourists, transients, and visitors to the province. Other individuals such as federal penitentiary inmates, Canadian Forces members and ranked Royal Canadian Mounted Police personnel do not require Ontario health insurance coverage as their health services are covered under a federal health care plan.

Persons who were previously ineligible for Ontario health insurance coverage but whose status and/ or residency situation has changed (e.g., change in immigration status) may be eligible, upon application, subject to the requirements of Regulation 552.

When it is determined that a person is not eligible or is no longer eligible for OHIP coverage, a request may be made to MOHLTC to review the decision. Anyone may request that MOHLTC review the denial of their OHIP eligibility by making a request in writing to the General Manager of OHIP.

3.2 Registration Requirements

Every resident of Ontario (or their legally authorized substitute decision maker), who seeks Ontario health insurance coverage, is required to apply to obtain coverage.

A health card is issued to eligible residents upon application provided they meet the eligibility requirements as set out under Regulation 552. Eligible persons should apply for coverage upon establishing their permanent and principal home in the province.

As of April 21, 2008, MOHLTC, in partnership with the Ministry of Government Services, transferred the delivery of health card registration services to Service Ontario. Service Ontario now manages the province-wide network for health card registration services. MOHLTC continues to be responsible for the policy and programs related to health insurance, including the policy and program management of health card registration.

Registration is done through local Service Ontario Health Card Services -- OHIP offices. Applicants for Ontario health insurance coverage must complete and sign a Registration for Ontario Health Insurance Coverage form and provide original documents to prove their Canadian citizenship or eligible immigration status, their residency in Ontario and their identity. Eligible applicants over the age of 15.5 are generally required to have their photographs and signatures captured for their photo health cards.

Each photo health card has a renewal/expiry date in the bottom right-hand corner of the card. Renewal notices are sent to registrants several weeks before the card's renewal date.

MOHLTC is the sole payer for OHIP insured physician, hospital, and dental surgical services. An eligible Ontario resident may not register with or obtain any benefits from another insurance plan for the cost of any insured service that is covered by OHIP (with the exception of during a waiting period).

Approximately 12.7 million Ontario residents were registered with OHIP and held valid and active health cards as of April 1, 2008.

3.3 Other Categories of Individual

MOHLTC provides health insurance coverage to residents of Ontario other than Canadian citizens and Permanent Residents/Landed Immigrants. These residents are required to provide acceptable documentation to support their eligible immigration status, their residency in Ontario, and their identity in the same manner as Canadian citizen or Permanent Resident/Landed Immigrant applicants.

The individuals listed below, who ordinarily reside in Ontario, may be eligible for Ontario health insurance coverage in accordance with Regulation 552 and prevailing MOHLTC policy. Clients applying for coverage under any of these categories should contact their local Service Ontario Health Card Services -- OHIP office for further details.

Applicants for Permanent Residence/Applicants for Landing: These are persons who have submitted an application for Permanent Resident/Landed Immigrant status to Citizenship and Immigration Canada (CIC) and have passed CIC's medical requirements.

Convention Refugees and Protected Persons: These are persons who are determined to be Convention Refugees or Protected Persons under the terms of the Immigration and Refugee Protection Act. Members of this group are exempt from the three-month waiting period.

Holders of Temporary Resident Permits/Minister's Permits: A Temporary Resident Permit/Minister's Permit is issued to an individual by Citi-zenship and Immigration Canada when there are compelling reasons to admit an individual into Canada who would otherwise be inadmissible under the federal Immigration and Refugee Protection Act. Each Temporary Resident Permit/Minister's Permit has a case type, or numerical designation, on the permit that indicates the circumstances allowing the individual entry into Canada. Individuals who hold a permit with a case type of 86, 87, 88, 89 or 80 (if for adoption) are eligible for Ontario health insurance coverage. Individuals who hold a permit with a case type of 80 (except adoption), 81, 84, 85, 90, 91, 92, 93, 94, 95 and 96 are not eligible for Ontario health insurance coverage.

Clergy, Foreign Workers and their Accompanying Family Members: An eligible foreign clergy is a person who is sponsored by a religious organization or denomination and has finalized an agreement to minister full-time to a religious congregation in Ontario for a period of at least six consecutive months.

A foreign worker is a person who has a finalized contract of employment or an agreement of employment with a Canadian employer located in Ontario, and has been issued a Work Permit/Employment Authorization by CIC that names the Canadian employer, states the person's prospective occupation, and has been issued for a period of at least six months.

Spouses, same sex partners and/or dependant children (under 22 years of age; or 22 years of age or older, if dependent due to a mental or physical disability) of an eligible foreign member of the clergy or an eligible foreign worker are also eligible for Ontario health insurance coverage if the member of the clergy or the foreign worker is to be employed in Ontario for at least three consecutive years and if the family member will be ordinarily a resident of Ontario.

Live-in Caregivers: Eligible Live-in Caregivers are persons who hold a valid Work Permit/ Employment Authorization under the Live-in Caregivers in Canada Program (LCP) or the former Foreign Domestic Movement (FDM) administered by CIC, and ordinarily reside in Ontario. The Work Permit/Employment Authorization for LCP or FDM workers does not have to list the three specific employment conditions required by all other foreign workers.

Migrant Farm Workers: Migrant farm workers are persons who have been issued a Work Permit/ Employment Authorization under the Caribbean, Commonwealth and Mexican Seasonal Agriculture Workers Program administered by CIC. Due to the special nature of their employment, migrant farm workers are exempt from the three-month waiting period and are not required to be ordinarily resident in Ontario (may be resident for less than the required five month period and not have a permanent and principal home in Ontario) and still qualify for OHIP.

3.4 Premiums

There are no premiums payable as a condition of obtaining Ontario health insurance coverage. The Ontario Health Premium is collected through the provincial income tax system and is not connected to OHIP registration or eligibility in any way. Responsibility for the administration of the Ontario Health Premium lies with the Ontario Ministry of Finance.

4.0 Portability

4.1 Minimum Waiting Period

In accordance with subsection 3(3) of Regulation 552 under the Health Insurance Act, individuals who move to Ontario are typically entitled to Ontario Health Insurance Plan (OHIP) coverage, three months after establishing residency in the province, unless listed as an exception in section 3(4).

In accordance with the Interprovincial Agreement on Eligibility and Portability, persons moving permanently to Ontario from another Canadian province or territory will typically be eligible for OHIP coverage on the first day of the third month following the date residency is established.

4.2 Coverage During Temporary Absences in Canada

Insured out-of-province services are prescribed under sections 28, 29 to 32 of Regulation 552 of the Health Insurance Act.

Ontario adheres to the terms of the Interprovincial Agreement on Eligibility and Portability; therefore, insured residents who are temporarily outside of Ontario can use their Ontario health cards to obtain insured physician and hospital services.

An insured person who leaves Ontario temporarily to travel within Canada, without establishing residency in another province or territory, may continue to be covered by OHIP for a period of up to 12 months.

An insured person who seeks or accepts employment in another province or territory may continue to be covered by OHIP for a period of up to 12 months. If the individual plans to remain outside Ontario beyond the 12-month maximum, he or she should apply for coverage in the province or territory where that person has been working or seeking work.

Insured students who are temporarily absent from Ontario, but remain within Canada, may be eligible for continuous health insurance coverage for the duration of their full-time studies, provided they do not establish permanent residency elsewhere during this period. To ensure that they maintain continuous OHIP eligibility, a student should provide MOHLTC with documentation from their educational institution confirming registration as a full-time student. Family members (spouses and dependent children) of students who are studying in another province or territory are also eligible for continuous OHIP eligibility while accompanying students for the duration of their studies.

In accordance with MOHLTC policy, most insured residents who want to travel, work or study outside Ontario, but within Canada, and maintain OHIP coverage, must have resided in Ontario for at least 153 days in the last 12-month period immediately prior to departure from Ontario.

Ontario participates in the Hospital Reciprocal Billing agreements with all other provinces and territories for insured hospital in- and out-patient services. Payment is at the in-patient rate of the plan in the province or territory where hospitalization occurs. Ontario pays the standard out-patient charges authorized by the Interprovincial Health Insurance Agreements Coordinating Committee.

Ontario also participates in the Physicians' Reciprocal Billing agreements with all other provinces and territories, except Québec (which has not signed a reciprocal agreement with any other province or territory), for insured physician services. Ontario residents who may be required to pay for physician services received in Québec can submit their receipts to MOHLTC for payment as an insured service at Ontario rates.

4.3 Coverage During Temporary Absences Outside Canada

Health insurance coverage for insured Ontario residents during extended absences outside Canada is governed by sections 28.1 through 29 (inclusive) and section 31 of Regulation 552 of the Health Insurance Act.

In accordance with sections 1.1(3), 1.1(4), 1.1(5) and 1.1(6) of Regulation 552 of the Health Insurance Act, MOHLTC may provide insured Ontario residents with continuous Ontario health insurance coverage during absences outside Canada of longer than 212 days (seven months) in a 12-month period.

The Ministry requests that residents apply to MOHLTC for this coverage before their departure and provide documents explaining the reason for their absence outside Canada. In accordance with the regulations and MOHLTC policy, most applicants must also have been ordinarily resident in Ontario for at least 153 days in each of the two consecutive 12-month periods before their expected date of departure.

The length of time that MOHLTC will provide a person with continuous Ontario health insurance coverage during an extended absence outside Canada varies depending on the reason for the absence. Please refer to the information below for further details: Certain family members may also qualify for continuous Ontario health insurance coverage while accompanying the primary applicant on an extended absence outside Canada and should contact their local OHIP office for details.

Reason	OHIP Coverage
Study	Duration of a full-time accredited academic program (unlimited)
Work	Five-year terms
Missionary Work	Duration of missionary activities (unlimited)
Vacation/Other	Up to two years in a lifetime

Out-of-country services are covered under sections 28.1 to 28.6 inclusive, and sections 29 and 31 of Regulation 552 of the Health Insurance Act.

Effective September 1, 1995, out-of-country emergency hospital costs are reimbursed at Ontario fixed per diem rates of:

• a maximum $400 (CAD) for in-patient services;
• a maximum $50 (CAD) for out-patient services (except dialysis); and
• the actual cost incurred by the patient per dialysis treatment.

During 2007-2008, emergency medically necessary out-of-country physician services were reimbursed at the Ontario rates detailed in regulation under the Health Insurance Act or the amount billed, whichever is less. Charges for medically necessary emergency or out-of-country in-patient and out-patient services are reimbursed only when rendered in a licensed or approved hospital or a licensed health facility. Medically necessary out-of-country laboratory services when done on an emergency basis by a physician are reimbursed in accordance with the formula set out in section 29(1)(b) of the Regulation or the amount billed, whichever is less, and when done on an emergency basis by a laboratory, in accordance with the formula set out in section 31 of the Regulation. 2007-08 figures reflecting Ontario's payments for out-of-country emergency in-patient and out-patient insured hospital and medical services are not available.

4.4 Prior Approval Requirement

As set out in section 28.4 of Regulation 552 of the Health Insurance Act, approval from MOHLTC is required for payment for non-emergency health services provided outside of Canada prior to the medical services being rendered. Where medically accepted treatment is not available in Ontario, or in those instances where the patient faces a delay in accessing treatment in Ontario that would threaten the patient's life or cause medically-significant irreversible tissue damage, the patient may be entitled to full funding for out-of-country health services.

Under section 28.5 of Regulation 552 of the Health Insurance Act, laboratory tests performed outside Canada are paid for, with prior approval from MOHLTC, if the following conditions are met:

• the kind of service or test is not performed in Ontario;
• the service or test is generally accepted in Ontario as appropriate for a person in the same circumstances as the insured person;
• the service or test is not experimental; and
• the service or test is not performed for research purposes.

In 2007-2008, Ontario's total payments for prior-approved treatment outside Canada were $101.4 million.

There is no formal prior-approval process required for services provided to Ontario residents outside the province, but within Canada, if the insured service is covered under the Hospital Reciprocal Billing System. All uninsured or approved for clinical usage (experimental) devices and drugs are the costs of the patient or must have prior approval from their home province. As detailed above in section 4.2, the Interprovincial Agreement on Eligibility and Portability ensures that Ontario residents who are temporarily travelling, working or studying in another province continue to be eligible for Ontario health coverage.

5.0 Accessibility

5.1 Access to Insured Health Services

All insured hospital, physician and surgical-dental services are available to Ontario residents on uniform terms and conditions.

All insured persons are entitled to all insured physician, surgical-dental and hospital services, as defined in the Health Insurance Act and Regulations.

Access to insured services is protected under Part II of the Commitment to the Future of Medicare Act (CFMA), "Health Services Accessibility". This Act prohibits any person or any entity from charging more or accepting payment or other benefit for more than the amount payable by the Ontario Health Insurance Plan (OHIP). In addition, the CFMA prohibits physicians, practitioners and hospitals from refusing to provide an insured service if an insured person chooses not to pay for an uninsured service. The Act further prohibits any person or entity from paying, conferring or receiving a payment or other benefit in exchange for preferred access to an insured service.

The Ministry of Health and Long-Term Care (MOHLTC) investigates all possible contraventions of Part II of the CFMA that come to its attention. For situations in which it is found that a patient has made an unauthorized payment, the Ministry ensures that the amount is repaid to that patient.

MOHLTC implemented Health Number/Card Validation to aid health care providers and patients with access to health services and claim payment. Providers may subscribe for validation privileges to verify their patient eligibility and health number/ version code status (card status). If patients require access to health services and do not have a health card in their possession, the provider may obtain the necessary information by submitting to MOHLTC a Health Number Release Form signed by the patient. An accelerated process for obtaining health numbers for patients who are unable to provide a health number and require emergency treatment is available to emergency room facilities through the Health Number Look Up service.

5.2 Access to Insured Hospital Services

Public hospitals in Ontario are not permitted to refuse the admission of a patient if by refusal of admission the patient's life would be endangered.

In 2007-2008, there were 150 public hospital corporations staffed and in operation in Ontario, which included chronic, general and special rehabilitation units. There were 6,947,381 acute patient days, 1,929,221 chronic patient days and 775,379 rehabilitation patient days delivered by public hospitals.

Acute care priority services are designated highly specialized hospital-based services that deal with life-threatening conditions. These services are often high-cost and are rapidly growing, which has made access a concern. Generally, these services are managed provincially, on a time-limited basis.

Acute care priority services include:

• selected cardiovascular services;
• selected cancer services;
• chronic kidney disease;
• critical care services; and
• organ and tissue donation and organ transplantation.

5.3 Access to Insured Physician and Dental-Surgical Services

In 2007-2008, MOHLTC conducted the below initiatives to improve access to physician services:

Underserviced Area Program (UAP): UAP is one of a number of initiatives/supports that MOHLTC provides to help communities across the province access needed health care services. UAP provides a variety of integrated initiatives aimed at attracting and retaining health care providers. To be eligible for the UAP's recruitment and retention support, a community must be designated as underserviced. UAP works closely with underserviced communities to identify their need for health human resources. It provides financial incentives and practice supports, and enables community access to primary care services in smaller, rural areas unable to support full-time family physicians by providing funding to operate 21 nursing stations, as well as access to physician services by funding locums and outreach clinics in northern communities experiencing physician shortages. Currently, there are 139 communities in Ontario designated as underserviced for general/family practitioners and 14 northern Ontario communities designated as under-serviced for medical specialists.

Northern Physician Retention Initiative (NPRI): NPRI provides eligible family practitioners and specialists who maintain practices in northern Ontario for at least four years with a retention incentive as well as access to funding for continuing medical education.

Northern Health Travel Grant Program (NHTG): NHTG helps defray transportation-related costs for residents of northern Ontario who must travel long distances to access insured hospital and specialist medical services that are not locally available, and also promotes using specialist services located in northern Ontario, which encourages more specialists to practice and remain in the north.

Primary Health Care: During 2007-2008, Ontario continued to align its new and existing primary care delivery models to help improve and expand access to primary health care for all Ontarians by continuing to include elements such as after-hours access to telephone triage, health information, and on-call physicians (as required) through the Telephone Health Advisory Service (THAS), increased after-hours coverage and preventive care initiatives that enhance health promotion, disease prevention, and chronic disease management. As of March 31, 2008, there were approximately 8.2 million patients rostered to 6,918 physicians in the various models, which include the Comprehensive Care Model (CCM), Family Health Groups (FHGs), Family Health Networks (FHNs), Family Health Organizations (FHOs), Rural and Northern Physician Group Agreement (RNPGA), and Community Health Centres (CHCs). There are negotiated agreements in place to address other special needs populations such as: the homeless, remote First Nations communities, palliative care patients, and maternity centre patients. Another model is currently being developed to recognize and compensate physicians for the uniqueness of practicing within speciality areas such as HIV, oncology, palliative care and care of the elderly. As part of transforming its health care system, Ontario has reached its goal of creating 150 Family Health Teams (FHTs), which are in various stages of development and implementation. When fully operational it is expected that these 150 teams will improve access to primary care for more than 2.5 million Ontarians in 112 communities.

5.4 Physician Compensation

Physicians are paid for the services they provide through a number of mechanisms. Some physician payments are provided through fee-for-service arrangements. Remuneration is based on the Schedule of Benefits under the Health Insurance Act. Other physician payment models include Alternate Payment Plans and new funding arrangements for physicians in Academic Health Science Centres.

General practitioners paid solely on a fee-for-service basis represent 36 per cent of Ontario's registered general practitioners. The remaining family physicians in Ontario receive funding through one of the primary care initiatives such as Family Health Organizations, Family Health Networks, Family Health Groups, Comprehensive Care Models, and Blended Salary Model -- Family Health Team. Family Health Teams build upon existing primary care physician funded models by providing funding for inter-disciplinary health care professionals, who work as integral members of the team. Physicians participating in Family Health Teams are funded by one of three compensation options that include: Blended Capitation (such as FHN or FHO), Complement Based Models (RNPGA or other specialized model agreements) and Blended Salary Model (for community-sponsored FHTs).

MOHLTC negotiates payment rates, incentives and other changes to the Schedule of Benefits for Physician Services with the Ontario Medical Association. A new Physician Services' Agreement with the Ontario Medical Association was negotiated for a four-year term, from April 2004 to March 2008. The Agreement provided for an across-the-board fee increase of 2 per cent for specialists and 2.5 per cent for general practitioners/family physicians, effective April 1, 2004. Further increases in specific fee codes were implemented on various dates from October 1, 2005, through to June 1, 2008.

The Agreement eliminated payment thresholds, effective April 1, 2005. This Agreement expands access to care in rural communities by introducing new funding to support hospital-based specialists in the north; enhances care for seniors by introducing new on-call fees in long-term care homes, home care and palliative care; supports hospital care by expanding hospital on-call coverage and in-hospital care fees for specialists and by introducing new fees for family doctors caring for their own patients in emergency departments; supports health promotion and disease prevention by introducing special fees for managing specific chronic diseases; promotes access to primary health care services by introducing special fees for enrolling unattached patients or patients without family physicians; invests in initiatives to recruit physicians to Ontario; and, makes quality of life improvements for physicians such as expanding pregnancy and parental leave benefits.

Under the Agreement, the parties began meeting in April 2007, to undertake a performance review of the degree to which the objectives under the Agreement have been met.

A new agreement has been negotiated and is currently in the implementation stage.

With respect to insured surgical-dental services, MOHLTC negotiates changes to the Schedule of Benefits for Dental Services with the Ontario Dental Association. In 2002-2003, MOHLTC and the Ontario Dental Association agreed on a new multi-year funding agreement for dental services, which became effective on April 1, 2003, and expired on March 31, 2007. The terms of the agreement continue until a new contract is negotiated by the parties.

5.5 Payments to Hospitals

The Ontario budget system is a prospective reimbursement system that reflects the effects of workload increases, costs related to provincial priority services, wait time strategies, and cost increases in respect of above-average growth in the volume of service in specific geographic locations. Payments are made to hospitals on a semi-monthly basis.

On April 1, 2007, LHINs assumed funding authority for hospitals in Ontario. The LHINs negotiate the Hospital Service Accountability Agreements (HSAAs) with the hospitals and are the lead for the Hospital Annual Planning Process (HAPP).Payments to hospitals are based on historical global allocations and multi-year incremental increases that incorporate population growth and anticipated service demands within the available provincial budget.

Each year, public hospitals submit Hospital Annual Planning Submissions (HAPS) to the LHINs that are the result of broad consultations within the facilities (e.g., all levels of staff, unions, physicians and board) and within the community and region. HAPS are based on a multi-year budget and provide a corresponding multi-year planning forecast. The data submitted in the HAPS are used to populate schedules for service volumes and performance targets that form the contractual basis for the HSAA

In an HSAA between the LHIN and the hospital, hospital performance is measured through five key performance indicators: total margin, current ratio, percentage of full-time nurses, relative risk of readmission and chronic care patient quality indicators. A review of the targets in each of the schedules and a discussion of corresponding corridors for performance indicators in the HSAA is conducted between the LHIN and the hospital.

The Interprovincial Hospitals' Reciprocal Billing agreements are a convenient administrative arrangement in which provincial/territorial governments reimburse hospitals in their jurisdictions for insured services provided to patients from other provinces/territories.

MOHLTC reviews chronic care co-payment regulations and rates annually, accounting for changes in the Consumer Price Index, Old Age Security each year, and determines whether revisions to the regulations and rates are appropriate.

6.0 Recognition Given to Federal Transfers

The Government of Ontario publicly acknowledged the federal contributions provided through the Canada Health Transfer in its 2007-2008 publications.

7.0 Extended Health Care Services

7.1 Nursing Home Intermediate Care and Adult Residential Care Services

Long-Term Care (LTC) homes provide care and personal support services and accommodation for people who are no longer able to live independently. Nursing care is available on-site 24-hours a day. Residents may also require on-site supervision, personal care and monitoring to ensure their safety and well-being. The home-like environment is intended to foster the best possible quality of life. MOHLTC, via the LHINs, currently funds all LTC homes licensed or approved under three different Acts: the Homes for the Aged and Rest Homes Act, the Nursing Homes Act, and the Charitable Institutions Act. MOHLTC retains responsibility for compliance, inspections and enforcement under the various Acts.

The new Long-Term Care Homes Act, 2007, received Royal Assent on June 4, 2007 replaces the three existing pieces of legislation and provide a legislative framework to enable improved management, of and quality of services to, a growing and rapidly changing sector. Regulations to support the implementation of the new Act are under development. The new Act would also enable better planning for the needs of the population requiring appropriate residential services provided in a LTC home.

As of July 31, 2008, there were 622 LTC homes with 75,972 beds in operation, of which 268 were not-for-profit facilities (including municipal, charitable and not-for-profit nursing homes) and 354 were for-profit nursing homes.

Long-Term Care homes offer higher levels of nursing and personal care support services than those offered by either retirement homes or supportive housing. Residents in LTC homes must qualify for placement in the homes. Placement is solely coordinated by Community Care Access Centres (CCACs).

MOHLTC regulates the Long-Term Care home sector through its Compliance Management Program which is designed to safeguard residents' rights, safety, security, quality of care and quality of life. Through the Compliance Management Program, MOHLTC monitors and inspects LTC homes for compliance with legislation, regulation, standards and criteria, service agreements and, where necessary, uses enforcement measures to achieve compliance.

On August 1, 2005, new regulations were introduced to ensure that at least one registered nurse is on site and on duty in all LTC homes 24 hours a day, seven days a week. Effective January 1, 2006, all LTC homes were required to implement two new standards: Skin Care and Wound Management, and Continence Care. As of April 1, 2006, Ministry inspectors began monitoring compliance with the new standards. [this paragraph merges 2]

The Ministry's public Reports on Long-Term Care Homes website provides information on all LTC homes in Ontario, including reports on home profiles, the outcomes of compliance inspections and verified complaint inspections for a 12-month period.

The Ministry engaged Ms. Shirlee Sharkey in August 2007 to provide independent advice regarding staffing and care standards for LTC homes in Ontario. Ms. Sharkey completed her review and submitted her final report, People Caring for People: Impacting the Quality of Life and Care of Residents of Long-Term Care Homes. Ms. Sharkey's report, released publicly on June 17, 2008, includes 11 recommendations relating to strengthening staff capacity and accountability for better outcomes in the LTC homes sector.

The Minister publicly supported in principle the recommendations provided by Ms. Sharkey. In addition, the Ministry announced:

• Ms. Sharkey has agreed to chair an Implementation Team to facilitate implementation of recommendations from her staffing and care report as well as provide advice on key resident care areas which require regulations under the Long-Term Care Homes Act, 2007; and
• The Ontario Health Quality Council (OHQC) has been tasked to measure and publicly report quality of care and resident satisfaction in long-term care homes.

7.2 Home Care Services

Ontario home and community care programs provide a range of services that support people living in their homes or other community care settings. These services are available through Community Care Access Centres (CCACs) and Community Service agencies.

CCACs provide simplified access for eligible Ontario residents, of all ages, to home and community care; make arrangements for the provision of home care services to people in their homes, schools and communities; and determine eligibility, manage the waiting lists, and authorize admission to publicly-funded LTC homes. There is no charge for services provided by CCACs.

The CCAC is responsible for the following:

• providing or purchasing a range of community services on behalf of eligible clients. Services include: nursing, personal care/homemaking, physiotherapy, occupational therapy, speech-language pathology, social work, dietetics, medical supplies and dressings, hospital and sickroom equipment, assistance in obtaining a drug card and laboratory and diagnostic services, and transportation to medical appointments and hospitals;
• assessing an individual's requirements and determining their eligibility for professional and personal support health services, homemaking, and personal support services provided in people's homes and in the community. CCACs assess and determine eligibility for professional health services for children/youth in public and private schools and receiving home schooling, and for personal support services for children/youth in private schools or receiving home schooling;
• developing plans of service;
• re-assessing the individual's needs and revising the service plan when the individual's needs have changed;
• providing information and referral services for the public to home and community care related services; and
• managing the Requests for Proposal process for purchased client services.

Legislation most relevant to CCACs includes: the Long-Term Care Act, 1994; Health Insurance Act; Community Care Access Corporations Act, 2001; Nursing Homes Act; Charitable Institutions Act; Homes for the Aged and Rest Homes Act; Local Health System Integration Act, 2006; and French Language Services Act. Each CCAC must also be familiar with all other relevant laws, including, but not limited to, the Health Care Consent Act, 1996; Substitute Decisions Act, 1992; Personal Health Information Protection Act, 2004; and the Ministry of Health Appeal and Review Boards Act, 1998.

Community service agencies provide support services that include: respite, volunteer hospice services, Alzheimer services, homemaking, attendant care, adult day services, caregiver support, meal services, home maintenance and repair, friendly visiting, security checks and reassurance, social and recreational services, volunteer transportation, palliative care consultation and education, and services for persons with physical disabilities such as attendant outreach, direct funding and special services for the blind and hearing impaired. Some of these community services are also provided to clients through assisted living services in supportive housing and there are services specifically for clients with acquired brain injury. Community services are legislated under the Long-Term Care Act, 1994 and are delivered by community-based, not-for-profit agencies that rely heavily on volunteers, and are funded by MOHLTC.

The provincial End-of-Life Care Strategy helps replace hospitalizations, where appropriate, with home care services made possible through advances in treatment practices and collaborative planning between all health care sectors. The objectives of the strategy are to shift care of the dying from the acute setting to an appropriate alternate setting based on individual preference; to enhance/ develop a client-centred and interdisciplinary end-of-life care service capacity; and to improve access to, and coordination/consistency of comprehensive end-of-life care services. End-of-life care services are provided in home or the community by CCACs, Community Support Service agencies and residential hospices.

7.3 Ambulatory Health Care Services

Community Health Centres are transfer payment agencies governed by incorporated non-profit community boards of directors that include members of the community served by the centre. The name "Community Health Centre" reflects the fact that the agency is established by the community and provides programs and services in response to needs identified in that community. Community Health Centres deliver services through inter-disciplinary teams including physicians, nurse practitioners, nurses, counsellors, dieticians, therapists, community health workers and health promoters. Services include comprehensive primary care as well as group and community programs, such as diabetes education, parent/child programs, community kitchens, and youth outreach services. Community Health Centres work within a population health framework that places an equal emphasis on providing comprehensive primary care, preventing illness, and health promotion.

Community Health Centres identify the priority populations that they will serve -- traditionally people have experienced barriers to access based on culture, language, literacy, age, geographic isolation, socio-economic status, disability, mental health status and homelessness. Community Health Centres also develop partnerships with other service providers to improve access to care, promote effective service integration and build community capacity to address the social determinants of health in their communities.

Service is provided through 54 Community Health Centres operating from more than 80 full-service sites across Ontario. Of these, 27 are in large urban centres, 14 are in smaller urban centres, and 13 are in either northern or rural communities. There is no legislation specific to Community Health Centres.

Historically, Community Health Centres have been developed based on expressions of interest from sponsoring groups. This has resulted in an uneven distribution and some significant gaps in coverage across the province. Between 2004 and 2008, the government is expanding the network of Community Health Centres by adding 22 new centres and 27 satellite centres. This expansion will be targeted to communities with at-risk populations facing barriers to access. Once implemented, it is expected that many of the most critical gaps in coverage will be addressed.

Registered Persons

Insured Hospital Services Within Own Province or Territory

Insured Hospital Services Provided to Residents in Another Province or Territory

Insured Hospital Services Provided Outside Canada

Insured Physician Services Within Own Province or Territory

Insured Physician Services Provided to Residents in Another Province or Territory

Insured Physician Services Provided Outside Canada

Insured Surgical-Dental Services Within Own Province or Territory