O. Reg. 83/11: GENERAL

 

ontario regulation 83/11

made under the

health insurance act

Made: March 23, 2011
Filed: March 25, 2011
Published on e-Laws: March 29, 2011
Printed in The Ontario Gazette: April 9, 2011

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

(General)

1. The definition of “schedule of benefits” in subsection 1 (1) of Regulation 552 of the Revised Regulations of Ontario, 1990 is amended by adding the following paragraph:

16. Amendments dated April 1, 2011;

2. Subsection 27 (3) of the Regulation is amended by striking out “For the purposes of section 28.4” in the portion before clause (a) and substituting “For the purposes of section 28.4, except paragraph 3 of subsection 28.4 (7)”.

3. (1) Section 28.4 of the Regulation is amended by adding the following subsection:

(3.1) Despite anything in this section, this section does not apply to a service that is a therapeutic laboratory service or a diagnostic laboratory test, unless the therapeutic laboratory service or diagnostic laboratory test is necessary for the purpose of rendering a service that is insured under this section and that is not a therapeutic laboratory service or diagnostic laboratory test.

(2) Paragraph 2 of subsection 28.4 (7) of the Regulation is revoked and the following substituted:

2. The application mentioned in paragraph 1 includes written confirmation that the conditions set out in clauses (2) (a) and (b) and one of the conditions set out in clause (2) (c) are satisfied, from,

i. a physician who is a specialist, as defined in the schedule of benefits, in the type of service for which approval of payment is sought,

ii. a general practitioner, if the type of service for which approval of payment is sought is within the general practitioner’s scope of practice, or

iii. in emergency circumstances, a physician who practises medicine in Ontario or an emergency patient referral service.

3. In circumstances that are not emergency circumstances, a service that is identical or equivalent to the service for which payment is sought is not covered by a preferred provider arrangement entered into,

i. between the Minister and the operator of a hospital outside Ontario but within Canada under subsection 27 (1),

ii. between the Minister and the operator of a health facility outside Ontario but within Canada under subsection 27 (2), or

iii. between the Minister and a physician or practitioner outside Ontario but within Canada under subsection 27 (4).

(3) Subsection 28.4 (7) of the Regulation is amended by adding the following paragraph:

4. For a service that consists primarily of the administration of a drug, including the provision of the drug that is administered, there is a recommendation from the executive officer appointed under the Ontario Drug Benefit Act for payment for the drug for a person in the same medical circumstances as the insured person.

(4) Section 28.4 of the Regulation is amended by adding the following subsections:

(7.1) For the purposes of subclause (2) (c) (i), if there is a physician in Ontario who has provided written confirmation that he or she is available to provide the service that is the subject of an application under subsection (7) and the service is within the physician’s scope of practice, the service is deemed to be identical or equivalent to the service that is the subject of the application.

(7.2) For the purposes of paragraph 3 of subsection (7), if there is a physician in Canada who has provided written confirmation that he or she is available to provide the service that is the subject of an application under subsection (7) and the service is within the physician’s scope of practice, the service is deemed to be identical or equivalent to the service that is the subject of the application.

(5) Subsection 28.4 (9) of the Regulation is amended by striking out “April 1, 2009” in the portion before clause (a) and substituting “April 1, 2011”.

(6) Clause 28.4 (9) (b) of the Regulation is revoked and the following substituted:

(b) if the applications are in respect of the continuation or extension of the same service for which approval was granted before that date, as long as,

(i) the service is for the same insured person,

(ii) the service is for the same medical condition, and

(iii) the insured person has been outside of Canada receiving the service at a hospital or health facility on a continuous basis without having returned to Ontario since before April 1, 2011.

4. (1) Subsection 28.5 (4) of the Regulation is revoked and the following substituted:

(4) An amount is payable for an insured service prescribed by subsection (1) if the following conditions are met:

1. An application for approval of payment is submitted to the General Manager on behalf of the insured person by a physician who practises medicine in Ontario.

2. The application mentioned in paragraph 1 includes written confirmation from the physician who submits the application that, in his or her opinion, the conditions in subsection (1) are satisfied.

3. Written approval of payment of the amount for the service is granted by the General Manager before the service is rendered and the service is rendered within the time limit set out in the written approval.

4. The service is a test as defined in section 5 of the Laboratory and Specimen Collection Centre Licensing Act.

(4.1) In addition to the written confirmation required under paragraph 2 of subsection (4), an application for approval of payment for a laboratory service or test that is a genetic service or test must include written confirmation from an Ontario physician who has the designation of a Fellow with the Canadian College of Medical Geneticists that, in his or her opinion, the conditions in subsection (1) are satisfied.

(2) Section 28.5 of the Regulation is amended by adding the following subsection:

(6) This section, as it read immediately before April 1, 2011, continues to apply to an application for approval of payment for a service if the application was mailed, faxed or otherwise delivered to the General Manager before that date.

Commencement

5. (1) Subject to subsection (2), this Regulation comes into force on April 1, 2011.

(2) Subsection 3 (3) comes into force on October 1, 2011.