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Health Insurance Act

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

Consolidation Period: From December 3, 2007 to the e-Laws currency date.

Last amendment: 2007, c. 16, Sched. B.

SKIP TABLE OF CONTENTS

CONTENTS

Definitions

1.  In this Act,

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

“business day” means a day on which Canada Post ordinarily delivers lettermail; (“jour ouvrable”)

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

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

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

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

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

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

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

“joint committee” means the Joint Committee on the Schedule of Benefits established under subsection 5 (1); (“comité mixte”)

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

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

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

Note: On a day to be named by proclamation of the Lieutenant Governor, section 1 is amended by the Statutes of Ontario, 2007, chapter 10, Schedule G, subsection 1 (3) by adding the following definition:

“payment committee” means the Physician Services Payment Committee established under subsection 5.4 (1); (“comité de paiement”)

See: 2007, c. 10, Sched. G, ss. 1 (3), 36 (2).

“payment correction list” means the list of circumstances for which payments are subject to correction referred to in subsection 5 (7), as amended from time to time; (“liste de rectification au titre des paiements”)

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

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

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

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

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

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

“Review Board” means the Physician Payment Review Board established under subsection 5.1 (1); (“Commission de révision”)

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

Administration

Administration of Plan by Minister

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

Duties of Minister

(2)  The Minister may,

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

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

(c) limit the hospital and health care services outside Canada for which payment may be made under the Plan;

(d) establish one or more advisory committees to advise or assist in the operation of the Plan;

(e) authorize surveys and research programs and obtain statistics for purposes related to the Plan. R.S.O. 1990, c. H.6, s. 2 (2).

Collection of personal information

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

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

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

Agreements concerning personal information

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

Agreements concerning payment information

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

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

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

Limitation

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

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

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

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

Confidentiality

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

Physiotherapy clinics

(7)  In the case of physiotherapy clinics that have been prescribed as health facilities for the purposes of the definition of “health facility” in section 1, the Minister may,

(a) approve a change to the name, ownership or location of the clinic; or

(b) approve another clinic to be the replacement for that clinic,

and such a clinic shall be deemed to be prescribed as a health facility, but, for greater certainty, the Minister may not approve a change that increases the number of clinics that are prescribed. 2007, c. 10, Sched. C, s. 1.

List

(8)  The Minister shall keep and maintain a list of clinics approved under subsection (7) and ensure that the list is available to the public. 2007, c. 10, Sched. C, s. 1.

Ontario-Canada agreement

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

Idem

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

General Manager

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

Duties

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

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

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

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

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

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

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

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

Collection of personal information

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

Use of personal information

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

Disclosure

(3)  The Minister and the General Manager shall disclose personal information if all prescribed conditions have been met and if the disclosure is necessary for purposes related to the administration of this Act, the Commitment to the Future of Medicare Act, 2004 or the Independent Health Facilities Act or for such other purposes as may be prescribed. However, the Minister or the General Manager shall not disclose the information if, in his or her opinion, the disclosure is not necessary for those purposes. 1996, c. 1, Sched. H, s. 3; 2006, c. 19, Sched. L, s. 3 (4).

Obligation

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

(a) disclosure of the names or other identifying information is necessary for the purposes described in subsection (3), 2 (5) or 38 (4); or

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

Joint Committee

Joint Committee on the Schedule of Benefits

5.  (1)  The Minister shall establish a joint committee to perform the functions set out in subsection (3) and the committee shall be known in English as the Joint Committee on the Schedule of Benefits and in French as the Comité mixte de la liste des prestations. 2007, c. 10, Sched. G, s. 2 (1).

Members

(2)  The joint committee shall consist of the prescribed number of members appointed by the Minister,

(a) one-half of whom shall be appointed from among physicians nominated for the purpose by the Ontario Medical Association; and

(b) one-half of whom shall be other physicians. 2007, c. 10, Sched. G, s. 2 (1).

Functions

(3)  The joint committee will,

(a) provide an opinion on its interpretation of any of the provisions of the schedule of benefits,

(i) upon the written request of the General Manager, or

(ii) upon the written request of a physician if clause 18 (14) (c) applies, but shall provide such an opinion without considering any matters specific to the physician’s claim;

(b) where in the opinion of the joint committee it is appropriate to do so, make recommendations to the General Manager and the Ontario Medical Association on amendments to the schedule of benefits based on its opinions under clause (a);

(c) publish, maintain and amend the payment correction list; and

(d) perform such other duties as may be prescribed. 2007, c. 10, Sched. G, s. 2 (1).

Limitation

(4)  The joint committee has the power to act only in an advisory capacity under clause (3) (a) and shall not hold hearings. 2007, c. 10, Sched. G, s. 2 (1).

Response

(5)  The joint committee shall respond to a request under clause (3) (a) within 30 business days of receiving the request, or within any other time that may be prescribed. 2007, c. 10, Sched. G, s. 2 (1).

If can’t reach opinion

(6)  If the joint committee is unable to come to an opinion in response to a request under clause (3) (a), it shall issue a report to that effect. 2007, c. 10, Sched. G, s. 2 (1).

List

(7)  Immediately upon the coming into force of this subsection, there shall be published on the Internet at a website that is accessible to physicians a list of circumstances described in subsection 18 (2) for which payments are subject to correction. The list will initially be established by the Medical Services Payment Committee established by agreement between the Ontario Medical Association and the Crown in right of Ontario. 2007, c. 10, Sched. G, s. 2 (1).

Payment correction list

(8)  For greater clarity, a circumstance described in subsection 18 (2) may be listed or described on the payment correction list without specific reference to subsection 18 (2). 2007, c. 10, Sched. G, s. 2 (1).

Same

(9)  The joint committee shall publish, maintain and amend the payment correction list and cause its amended versions to be published as provided in subsection (7) or in such other manner as may be prescribed. 2007, c. 10, Sched. G, s. 2 (1).

Remuneration and expenses

(10)  Members of the joint committee may be paid such remuneration and receive such reimbursement for expenses as the Lieutenant Governor in Council may determine. 2007, c. 10, Sched. G, s. 2 (1).

Review Board established

5.1  (1)  There is established a board to be known in English as the Physician Payment Review Board and in French as Commission de révision des paiements effectués aux médecins. 2007, c. 10, Sched. G, s. 2 (1).

Duties

(2)  The Review Board shall perform such duties as are set out in this Act and Schedule 1. 2007, c. 10, Sched. G, s. 2 (1).

May only order authorized payments

(3)  For greater certainty, the Review Board may only order payments that are authorized under this Act. 2007, c. 10, Sched. G, s. 2 (1).

Application of SPPA

(4)  Subject to subsection 12 (5) of Schedule 1, the Statutory Powers Procedure Act applies to all proceedings of the Review Board. 2007, c. 10, Sched. G, s. 2 (1).

Composition

(5)  The Review Board shall be composed of no fewer than 26 and no more than 40 members who shall be appointed by the Lieutenant Governor in Council on the recommendation of the Minister, as follows:

1. No fewer than 20 and no more than 30 members who are physicians, one-half of whom are to be selected by the Minister for the Minister’s recommendation, and one-half of whom are to be selected by the Ontario Medical Association for the Minister’s recommendation. If there are not sufficient nominees put forward by that Association to permit the minimum number of 20 physicians to be appointed, the Minister may recommend sufficient physicians to meet or exceed the minimum requirement.

2. No fewer than six and not more than 10 members who are not physicians and who are selected from the public. 2007, c. 10, Sched. G, s. 2 (1).

Same

(6)  A physician shall not be appointed or reappointed as a member of the Review Board unless,

(a) he or she is actively engaged in rendering insured services to insured persons and submitting accounts for insured services to the Plan at the time of first appointment; and

(b) he or she has not been retired from rendering insured services to insured persons and submitting accounts for insured services to the Plan for more than three years in the case of a reappointment. 2007, c. 10, Sched. G, s. 2 (1).

Same

(7)  Both the Ontario Medical Association and the Minister shall make best efforts to ensure that physicians recommended for appointment to the Review Board represent a broad range of physician practices. 2007, c. 10, Sched. G, s. 2 (1).

Same

(8)  A person may not be appointed as a member of the Review Board if he or she is employed,

(a) under Part III of the Public Service of Ontario Act, 2006; or

(b) by any agency of the Crown. 2007, c. 10, Sched. G, s. 2 (4).

Chair and vice chairs

(9)  The Review Board shall elect one of its members as its chair and at least one but not more than three of its members as a vice chair. 2007, c. 10, Sched. G, s. 2 (1).

Remuneration and expenses

(10)  The members of the Review Board and persons appointed under subsection (11) shall be paid the remuneration and expenses the Lieutenant Governor in Council determines except that the remuneration for physician members shall not be less than $500 a day. 2007, c. 10, Sched. G, s. 2 (1).

Appointment of persons to assist

(11)  The Review Board may appoint from time to time one or more persons having technical or special knowledge of any matter before it to inquire into and report to the Review Board and to assist the Review Board in any capacity in respect of any matter before it. 2007, c. 10, Sched. G, s. 2 (1).

Not to sit on Review Board or review panel

(12)  A person appointed pursuant to subsection (11) shall not sit as a member of the Review Board or of any review panel appointed to conduct a hearing. 2007, c. 10, Sched. G, s. 2 (1).

Employees

(13)  Such employees as the Review Board considers necessary to carry out its duties may be appointed under the Part III of the Public Service of Ontario Act, 2006. 2007, c. 10, Sched. G, s. 2 (4).

Annual meeting

(14)  The Review Board shall meet annually to review its policies and procedures. 2007, c. 10, Sched. G, s. 2 (1).

Annual report

(15)  The Review Board shall report annually to the Minister. 2007, c. 10, Sched. G, s. 2 (1).

Tabling of report

(16)  The Minister shall submit the report to the Lieutenant Governor in Council and shall cause the report to be laid before the Assembly if it is in session or, if not, at the next session. 2007, c. 10, Sched. G, s. 2 (1).

Disclosure

5.2  (1)  A nominee or other potential appointee to the joint committee or the Review Board shall notify the Minister if he or she has been found guilty of fraud under the Criminal Code (Canada) or if he or she has been found guilty of an offence under the laws of Canada or a province or territory that is relevant to his or her suitability to sit as a member, unless the finding of guilt is for an offence for which he or she has received a pardon. 2007, c. 10, Sched. G, s. 2 (1).

Same

(2)  The requirement to disclose as set out in subsection (1) continues during the term of the person’s appointment or any subsequent reappointment. 2007, c. 10, Sched. G, s. 2 (1).

Disqualification

5.3  (1)  A person who has been found guilty of fraud under the Criminal Code (Canada) or has been found guilty of an offence under the laws of Canada or a province or territory that in the Minister’s opinion is relevant to the person’s suitability to sit as a member of the joint committee or the Review Board may not be appointed or reappointed as a member of the joint committee or the Review Board, unless the finding of guilt is for an offence for which the person has received a pardon. 2007, c. 10, Sched. G, s. 2 (1).

Same

(2)  A physician who has been the subject of a finding of professional misconduct, incompetence or incapacity whether in Ontario or in another jurisdiction may not be appointed or reappointed as a member of the joint committee or the Review Board. 2007, c. 10, Sched. G, s. 2 (1).

Time-limited disqualification

(3)  A physician who has been required to reimburse the Plan as a result of a decision of the Medical Review Committee, the Review Board or the Appeal Board may not be appointed or re-appointed as a member of the joint committee or the Review Board until 10 years have passed since he or she was last required to reimburse the Plan. 2007, c. 10, Sched. G, s. 2 (1).

Continuing qualifications

(4)  A person’s membership in the joint committee or the Review Board is automatically terminated,

(a) in the case of a physician, if he or she ceases to be a member of the College of Physicians and Surgeons of Ontario;

(b) in the case of any member, if he or she ceases to be qualified under subsection (1), (2) or (3); and

(c) in the case of any member, if he or she fails to provide information required under subsection (6) within the time specified by the Minister. 2007, c. 10, Sched. G, s. 2 (1).

Waiver

(5)  If the Minister believes that the circumstances justify it, the Minister may appoint a person who is otherwise disqualified under subsection (1), (2) or (3), or reappoint a person whose membership has been automatically terminated under subsection (4), unless the disqualification or termination is the result of a conviction for fraud under the Criminal Code (Canada) for which the person has not received a pardon. 2007, c. 10, Sched. G, s. 2 (1).

Information

(6)  Any person being considered for appointment or reappointment to the joint committee or the Review Board and any member of the joint committee or the Review Board shall, if requested to do so by the Minister, provide the Minister within the time specified in the request with any information relevant to determining the person’s eligibility to be appointed or reappointed or to remain a member, as a condition of being appointed or reappointed or continuing to be a member, as the case may be. 2007, c. 10, Sched. G, s. 2 (1).

Note: On a day to be named by proclamation of the Lieutenant Governor, the Act is amended by the Statutes of Ontario, 2007, chapter 10, Schedule G, section 3 by adding the following section:

Physician Services Payment Committee

5.4  (1)  The Minister shall establish a committee to perform the functions set out in subsection (5) and the committee shall be known in English as the Physician Services Payment Committee and in French as the Comité de paiement des services de médecin. 2007, c. 10, Sched. G, s. 3.

Members

(2)  The payment committee shall consist of the prescribed number of physicians, appointed by the Minister,

(a) one-half of whom shall be appointed from among physicians nominated for the purpose by the Ontario Medical Association; and

(b) one-half of whom shall be other physicians. 2007, c. 10, Sched. G, s. 3.

Qualifications, disclosure, etc.

(3)  Sections 5.2 and 5.3 apply with necessary modifications to the payment committee. 2007, c. 10, Sched. G, s. 3.

Chair

(4)  The Minister shall appoint a chair for the payment committee, who shall not be a member of the committee, and shall not have a vote in any proceedings of the payment committee. 2007, c. 10, Sched. G, s. 3.

Functions

(5)  The payment committee will have the responsibility for making recommendations to the Minister with respect to amendments to the schedule of benefits and other physician payment programs, and in particular shall,

(a) make timely and appropriate recommendations to amend the schedule of fees and other payment programs to reflect current medical practice and meet the needs of the health care system;

(b) conduct specialty specific or service specific reviews;

(c) on the request of the General Manager, provide its opinion on any proposed amendments to the schedule of benefits; and

(d) perform such other duties as may be prescribed. 2007, c. 10, Sched. G, s. 3.

Performing role of joint committee

(6)  The Lieutenant Governor in Council may make regulations assigning to the payment committee any or all of the role and functions of the joint committee, and where such a regulation has been made, every reference in this Act to anything that may be done by the joint committee with respect to its role or function shall be deemed to be a reference to the payment committee. 2007, c. 10, Sched. G, s. 3.

Remuneration and expenses

(7)  Members of the payment committee may be paid such remuneration and receive such reimbursement for expenses as the Lieutenant Governor in Council may determine. 2007, c. 10, Sched. G, s. 3.

See: 2007, c. 10, Sched. G, ss. 3, 36 (2).

Practitioner Review Committees

Practitioner review committees

6.  (1)  The Minister shall appoint the following practitioner review committees:

1. A chiropody review committee composed of the prescribed number of members who are not physicians or practitioners and the prescribed number of members from among the persons nominated by the College of Chiropodists of Ontario.

2. A chiropractic review committee composed of the prescribed number of members who are not physicians or practitioners and the prescribed number of members from among the persons nominated by the College of Chiropractors of Ontario.

3. A dentistry review committee composed of the prescribed number of members who are not physicians or practitioners and the prescribed number of members from among the persons nominated by The Royal College of Dental Surgeons of Ontario.

4. An optometry review committee composed of the prescribed number of members who are not physicians or practitioners and the prescribed number of members from among the persons nominated by the College of Optometrists of Ontario.

5. An osteopathy review committee composed of the prescribed number of members who are not physicians or practitioners and the prescribed number of members from among the persons nominated by the Board of Directors of Osteopathy appointed under the Drugless Practitioners Act. 1993, c. 32, s. 2 (3); 1998, c. 18, Sched. G, s. 54 (2, 3).

Same

(1.1)  The number of members of a practitioner review committee who are not physicians or practitioners shall be not more than two-thirds the number of members who are nominated by a professional governing body. 1993, c. 32, s. 2 (3).

Committee of board or college

(2)  Every practitioner review committee is a committee of the board or college that nominates persons appointed as members of the committee. R.S.O. 1990, c. H.6, s. 6 (2).

Quorum

(3)  Three members of a practitioner review committee, one of whom shall be a member who is not a physician or practitioner, constitute a quorum of the committee. However, one member who is a practitioner constitutes a quorum for the purposes of a review requested under subsection 18.1 (4) or 39.1 (3). 1996, c. 1, Sched. H, s. 5 (1).

Divisions

(3.1)  A practitioner review committee may sit in several divisions simultaneously, if a quorum of the committee is present in each division. 1996, c. 1, Sched. H, s. 5 (1).

Remuneration

(4)  The members of a practitioner review committee shall be paid such remuneration for their services, on an hourly basis, a daily basis or otherwise, as the Lieutenant Governor in Council determines. R.S.O. 1990, c. H.6, s. 6 (4).

Administration expenses

(5)  Every practitioner review committee shall be paid such amounts for the expenses of the committee and the engaging of assistance for the committee as may be approved by the Minister. R.S.O. 1990, c. H.6, s. 6 (5).

Ineligibility

(6)  A person may not be a member of a practitioner review committee if he or she is employed,

(a) under Part III of the Public Service of Ontario Act, 2006; or

(b) by any agency of the Crown. 2006, c. 35, Sched. C, s. 53.

Duties

(7)  Every practitioner review committee shall perform such duties as are assigned to it under the Act and shall make reports and recommendations respecting any matter referred to it by the Minister, the Appeal Board or the board or college of which it is a committee. 1996, c. 1, Sched. H, s. 5 (2).

Powers

(8)  Members of a practitioner review committee have the powers of an inspector appointed under subsection 40 (3). 1996, c. 1, Sched. H, s. 5 (2).

Medical Eligibility Committee

Medical Eligibility Committee

7.  (1)  The Minister may appoint in writing such number of physicians as he or she considers appropriate from time to time not to exceed fifteen, to form a committee to be known in English as the Medical Eligibility Committee and in French as comité d’admissibilité médicale.

Term of office

(2)  The Minister shall specify the term of office for each physician in his or her written appointment.

Quorum

(3)  Any three members constitute a quorum and are sufficient for the exercise of all functions of the Medical Eligibility Committee.

Divisions of Committee

(4)  The Medical Eligibility Committee may sit in several divisions simultaneously, if a quorum of the Committee is present in each division.

Decision of Committee

(5)  The decision of the majority of the members of the Medical Eligibility Committee present and constituting a quorum is the decision of the Committee.

Qualifications of members

(6)  No member of the Medical Eligibility Committee shall be employed in the service of Ontario or any agency of the Crown.

Committee chair

(7)  The Minister shall from time to time designate one of the physicians to be the chair of the Committee who shall assign the members to sit on the various divisions of the Committee and prescribe the duties to be performed by each division.

Remuneration

(8)  The members of the Medical Eligibility Committee shall be paid such remuneration for their services, on an hourly basis, a daily basis or otherwise, as the Lieutenant Governor in Council determines. R.S.O. 1990, c. H.6, s. 7 (1-8).

Duties

(9)  The Medical Eligibility Committee shall perform such duties as are assigned to it under the Act or by the Minister. 1996, c. 1, Sched. H, s. 6.

Report to Assembly

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

Report to Assembly

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

Ontario Health Insurance Plan

Ontario Health Insurance Plan continued

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

Right to insurance

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

Establishing entitlement

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

Military families

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

Change in information

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

Health card

11.1  (1)  A health card remains the property of the Minister at all times.

Taking possession of card

(2)  A prescribed person may take possession of a health card that is surrendered to him or her voluntarily.

Return to General Manager

(3)  On taking possession of a health card under subsection (2), the person shall return it to the General Manager as soon as possible.

Protection from liability

(4)  No proceeding for taking possession of a health card shall be commenced against a person who does so in accordance with subsection (2). 1993, c. 32, s. 2 (4).

Insured services

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

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

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

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

Exceptions

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

Restrictions

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

Same

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

Same

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

Entitlement to insured services

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

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

Choice of physician or practitioner

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

Other insurance prohibited

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

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

Note: On a day to be named by proclamation of the Lieutenant Governor, clause (a) is amended by the Statutes of Ontario, 2007, chapter 8, section 209 by striking out “nursing home services” and substituting “long-term care home services”. See: 2007, c. 8, ss. 209, 232 (2).

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

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

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

Resident not to benefit from prohibited insurance

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

Exceptions

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

Idem

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

Exception

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

Billing – physicians

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

Requirements where Plan billed

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

(a) payment shall be made,

(i) directly to the physician, or

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

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

Where s. 2 (2) applies

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

Billing – practitioners

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

Same – non-designated

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

Requirements where Plan billed

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

(a) payment shall be made,

(i) directly to the practitioner, or

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

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

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

Where s. 2 (2) applies

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

Interpretation

(5)  In this section,

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

Transitional

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

1. Sections 15 and 15.1 do not apply to him or her.

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

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

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

Same

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

Same

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

Interpretation

(3)  In this section,

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

Billing numbers

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

(a) submitted personally by the physician or practitioner;

(b) paid to the physician or practitioner personally;

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

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

Health facilities

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

Applies despite direction

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

Exception

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

Definition

(5)  In this section,

“billing number” means the unique identifying number issued by the General Manager to a physician, practitioner or health facility for the purpose of identifying the accounts or claims for insured services rendered by that physician, practitioner or health facility. 2004, c. 5, s. 36.

Direction to make payments to entity

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

(2)  Repealed: 2004, c. 5, s. 37.

Person or entity not entitled

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

Repayment to Plan

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

Interpretation

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

Keeping and inspection of records

(6)  Section 37.1 applies with necessary modifications to a person or entity to whom payment is made pursuant to a direction by a physician or practitioner and,

(a) in the case of a direction by a practitioner, subsections 40 (3) and (4) and sections 40.1 and 40.2 apply with necessary modifications to an inspection of the records required to be kept; and

(b) in the case of a direction by a physician, subsections 37 (5) to (7) apply with necessary modifications in respect of the records required to be kept. 2007, c. 10, Sched. G, s. 6.

Accounts for insured services

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

(2)  Repealed: 2004, c. 5, s. 38.

Time for submitting

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

Fees payable for insured services

17.1  (1)  A physician or practitioner who submits an account to the General Manager in accordance with this Act for insured services provided by the physician or practitioner is entitled to be paid the fee determined under this section. 2007, c. 10, Sched. G, s. 7.

Same

(2)  An insured person who submits an account to the General Manager in accordance with this Act for insured services provided by a physician or practitioner to the insured person is entitled to be paid the fee determined under this section. 2007, c. 10, Sched. G, s. 7.

Amount

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

Same

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

Adjustment of amount

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

1. The professional specialization of the physician or practitioner.

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

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

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

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

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

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

Threshold amount

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

Same

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

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

Fees payable, health facilities

17.2  (1)  Subject to section 28, a health facility that submits an account to the General Manager in accordance with the Act for insured services performed by the facility is entitled to be paid the fee determined under this section.

Same

(2)  Subsections 17.1 (3) and (4) apply, with necessary modifications, with respect to the basic fee payable for an insured service.

Adjustment of amount

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

Threshold amount

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

Payment of accounts

18.  (1)  The General Manager shall determine all issues relating to accounts for insured services in accordance with this Act and shall make the payments from the Plan that are authorized under this Act. 2007, c. 10, Sched. G, s. 8 (1).

Same

(2)  The General Manager may refuse to pay for a service provided by a physician, practitioner or health facility or may pay a reduced amount in the following circumstances:

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

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

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

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

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

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

7. In such other circumstances as may be prescribed. 1996, c. 1, Sched. H, s. 13.

Refusal to pay

(3)  The General Manager shall refuse to pay for an insured service if the account for the service is not prepared in the required form, does not meet the prescribed requirements or is not submitted to him or her within the prescribed time. However, the General Manager may pay for the service if there are extenuating circumstances. 2007, c. 10, Sched. G, s. 8 (2).

Refusal to pay

(4)  Despite subsection (2), the General Manager may refuse to pay a physician for a service or pay a reduced amount for the service only if a circumstance described in subsection (2) that is also set out or described in the payment correction list exists in respect of the claim or claims, or if permitted to do so by an order of the Review Board. 2007, c. 10, Sched. G, s. 8 (2).

Referral to Review Board for expedited hea