Module 4 - Optimizing Canada’s Social Security System—Health Care

Question 1

Describe how national health care responsibilities are divided among the various Canadian legislative jurisdictions.

Answer 1

The structure of the Canadian public health system results from the constitutional assignment of jurisdiction over most aspects of health care to the provincial order of government. The system is referred to as a “national” health insurance system in that all provincial/territorial hospital and medical insurance plans are linked through adherence to national principles set at the federal level through the Canada Health Act (CHA). These insurance plans are designed and delivered by the provinces and territories, with the exceptions of health care for certain groups where responsibility lies with the federal government. The overall system is jointly funded by the federal and provincial/territorial governments.

Question 2

Compare the federal government’s role in health care with the provincial/territorial governments’ role.

Answer 2

The federal government’s role in health care involves:

(a) Setting and administering national principles or standards for the health care system through CHA
(b) Assisting in the financing of provincial/territorial health care services through fiscal transfers known as the Canada Health Transfer (CHT)
(c) Ensuring that the requirements of CHA are met
(d) Delivering primary and supplementary services to certain groups of people. These groups include First Nations people living on reserves, Inuit, serving members of the Canadian Forces, eligible veterans, inmates in federal penitentiaries and some groups of refugee claimants.
(e) Protecting and regulating health (e.g., regulation of pharmaceuticals, food and medical devices), consumer safety, disease surveillance and prevention, and support for health promotion and health research.

The federal government also provides certain health-related tax measures, including tax credits for medical expenses, disability, caregivers and infirm dependents; tax rebates to public institutions for health services; and deductions for private health insurance premiums for the self-employed.

The provinces and territories administer and deliver most of Canada’s health care services. They each establish their own hospital and medical plans, making decisions about how much money they will spend on their health care plan, where their hospitals will be located, how many physicians they will need, etc. In order to receive the full CHT from the federal government, their health insurance plans are expected to meet national principles set out under CHA. Each jurisdiction establishes its own method of financing the portion of overall costs not covered by federal funding.

Question 3

The provincial government’s role in health care involves:

Answer 3

(a) Determining benefits eligible for coverage
(b) Planning and paying for hospital and physician care in hospitals and public health facilities and negotiating fee schedules for health professionals
(c) Registering those eligible for benefits (e.g., through a health insurance card)
(d) Registering diagnostic facilities
(e) Enrolling health care practitioners
(f) Processing and paying practitioners’ bills for services rendered
(g) Auditing benefit claims for payment and auditing patterns of practice or billings submitted, etc.

Question 4

Outline the functions of the Canada Health Act Division (CHAD).

Answer 4

CHAD is part of Health Canada and is responsible for administering CHA by:

(a) Monitoring and analyzing provincial/territorial health care insurance plans for compliance with the criteria, conditions, and extra billing and user charge provisions of CHA
(b) Asking the provinces and territories to investigate and provide information and clarification when possible compliance issues arise and, when necessary, recommending corrective action to them, in order to ensure the criteria and conditions of CHA are met
(c) Conducting issue analysis and policy research to provide policy advice
(d) Informing the minister of possible noncompliance and recommending appropriate action to resolve issues
(e) Disseminating information on CHA
(f) Responding to information requests relating to CHA received by telephone, mail and the Internet from the public, members of Parliament, government departments, stakeholder organizations and the media
(g) Developing and maintaining formal and informal relationships with health officials in provincial/territorial governments to share information
(h) Collaborating with the provinces and territories to encourage compliance with CHA
(i) Collaborating with provincial/territorial health department representatives through the Interprovincial Health Insurance Agreements Coordinating Committee
(j) Working with Health Canada Legal Services and the Department of Justice on litigation issues that implicate CHA
(k) Producing the Canada Health Act Annual Report on the administration and operation of the Act.

Question 5

Identify the first steps that an individual must take in order to access public health care services in Canada.

Answer 5

Registration with the applicable jurisdiction is the first step for an individual to take. Registration and possession of a valid health insurance card are required in order to access insured services. New residents are advised to apply for coverage as soon as possible upon arrival in any given province or territory. It is the parents’ responsibility to register a newborn or adopted child.

Question 6

Describe the general approach taken by provincial/territorial jurisdictions for determining when coverage under their public health plan becomes effective.

Answer 6

Effective dates of coverage for registered individuals vary by jurisdiction. Generally:

(a) Newborn children are entitled to coverage upon birth.
(b) Insured residents moving from one province or territory to another are generally entitled to coverage as of the first day of the third month following the month of arrival. (In a couple of provinces, it is the first day of the third month following residency.) For example, a person who moved from Prince Edward Island to British Columbia on September 15 would be entitled to coverage in Prince Edward Island for September, October and November. On December 1, that person would be entitled to coverage in British Columbia.
(c) Persons arriving from outside Canada to reestablish residence in Canada are entitled to coverage as of the day of arrival (provided they are Canadian citizens or hold permanent resident status).
(d) For new Canadians or immigrants, the waiting period is not greater than three months (as required by CHA), and it begins the day of arrival and/or day of legal entitlement.
(e) Discharged members of the Canadian Forces and released inmates of federal penitentiaries are entitled to coverage as of the day of discharge or release.

Question 7

Define “primary health care services,” and identify the providers of such services.

Answer 7

Services provided at the first point of contact within the health care system are known as “primary health care services,” and they form the foundation of the health care system. Generally, primary health care serves the dual functions of:

(a) Providing a first point of contact for patients
(b) Coordinating patient health care services to ensure continuity of care and ease of movement across the health care system when more specialized services are needed (e.g., to specialists or hospitals).

When Canadians need health care, they generally contact a primary health care professional—a family doctor, nurse, nurse practitioner, pharmacist, etc., often working in a team of health care professionals. Primary health care services may include prevention and treatment of common diseases and injuries, which includes basic emergency services, referrals to and coordination with other levels of care such as hospital and specialist care, primary mental health care, palliative and end-of-life care, health promotion, healthy child development, primary maternity care and rehabilitation services.

A number of other health care professionals are involved in primary health care—for example, dentists, nurses, pharmacists and other allied health care personnel.

Question 8

Identify secondary health care services available in Canada.

Answer 8

Secondary health care services include specialized care at a hospital or services provided in the home or community (generally for short-term care) or in long-term care facilities (generally for long-term and chronic care). Needs are assessed and services are coordinated to provide continuity of care and comprehensive care. Care is provided by a range of formal, informal (often family) and volunteer caregivers. Referrals for secondary health services can be made by doctors, hospitals, community agencies, families and patients themselves.

Short-term secondary services can include specialized nursing care, homemaker services and adult day care, and they are often provided to individuals who are partially or totally incapacitated. Long-term secondary health care services include services for chronic care provided in a long-term facility.

Question 9

Describe services that are considered supplementary health care services in Canada.

Answer 9

Supplementary health care services include prescription drugs outside of the hospital, dental care, vision care, medical equipment and appliances (prostheses, wheelchairs, etc.), and the services of other health professionals outside of the hospital, such as physiotherapists.

Question 10

Briefly describe the five program criteria applicable only to insured health services that provincial/territorial health care insurance plans must meet to be eligible for the full federal CHT cash contribution.

Answer 10

(1) Public administration

(2) Comprehensiveness: The comprehensiveness criterion requires that provincial/ territorial health care insurance plans cover all insured health services provided by hospitals, physicians or dentists (i.e., surgical-dental services that require a hospital setting).

(3) Universality

(4) Portability: Residents moving from one province or territory to another must continue to be covered for insured health care services by the home jurisdiction during any waiting period imposed by the new province or territory of residence.

(5) Accessibility: The intent of the accessibility criterion is to ensure that insured residents in a province or territory have reasonable access to insured hospital, medical and surgical-dental services on uniform terms and conditions, unprecluded or unimpeded, either directly or indirectly, by charges (e.g., user charges or extra billing) or other means (e.g., discrimination on the basis of age, health status or financial circumstances).

Question 11

Outline two additional requirements of CHA as it relates to payments by provincial/ territorial health care insurance plans to providers of insured services.

Answer 11

Provincial/territorial health care insurance plans must provide:

(a) Reasonable compensation to physicians and dentists for all the insured health care services they provide
(b) Payment to hospitals to cover the cost of insured health care services.

Question 12

Define “insured persons” and “excluded persons” under CHA.

Answer 12

“Insured persons” under CHA are eligible residents of a province or territory. A resident of a province or territory is a person lawfully entitled to be or to remain in Canada who makes his or her home and is ordinarily present in the province or territory, but the term does not include a tourist, a transient or a visitor to the province or territory.

Each province and territory is responsible for determining its own minimum residence requirements with regard to an individual’s eligibility for benefits under its health insurance plan. The CHA gives no guidance on such residence requirements beyond limiting waiting periods to establish eligibility for and for entitlement to insured services to three months. Most provinces and territories also require residents to be physically present 183 days annually and provide evidence of their intent to return to the province.

Certain residents are “excluded persons”—serving members of the Canadian Forces or inmates of a federal penitentiary.

Question 13

Describe the process used to implement the portability provisions of CHA.

Answer 13

The within-Canada portability provisions of CHA are implemented through a series of bilateral reciprocal billing agreements between provinces and territories for hospital and physician services. All provinces and territories participate in reciprocal hospital agreements and all, with the exception of Quebec, participate in reciprocal physician agreements. This generally means that a patient’s health card will be accepted, in lieu of payment, when the patient receives hospital or physician services in another province or territory. The province or territory providing the service will directly bill the patient’s home province. If insured persons are temporarily absent in another province or territory, the portability criterion requires that insured services be paid at the host province’s rate. In Quebec, the cost for physician services received in another province or territory is reimbursed at the amount actually paid or the rate that would have been paid by the Régie de l’assurance maladie du Québec, whichever is less.

Question 14

Identify the effective date of health care coverage for insured health services under CHA for an individual moving from one province or territory to another and for an individual returning from outside Canada to reestablish residence in Canada.

Answer 14

Insured residents moving from one province or territory to another are generally entitled to coverage as of the first day of the third month following the month of arrival. Persons arriving from outside Canada to reestablish residence in Canada are generally entitled to coverage as of the day of arrival (provided they are Canadian citizens or hold permanent resident status).

Question 15

Describe how the costs of supplementary insured health care services are reimbursed by provincial/territorial health care insurance plans if the services are received outside an individual’s province or territory of residence.

Answer 15

Provincial/territorial reciprocal agreements do not apply to all services provided under the provincial/territorial health plans. For most supplementary health care services, there is no coverage if the service is rendered outside the province or territory of residence, or coverage is limited to the amounts payable in the home province or territory.

Question 16

Define “extra billing” and “user charges” under CHA, and outline the mandatory penalty provisions should these practices occur for insured health care services.

Answer 16

“Extra billing” is the billing for an insured health care service rendered to an insured person by a medical practitioner or a surgical-dentist providing insured health services in a hospital setting for an amount in addition to any amount paid or to be paid for that service by the provincial/ territorial health care insurance plan. For example, if a physician were to charge patients any amount for an office visit that is insured by the provincial/territorial health insurance plan, the amount charged constitutes extra billing.

“User charges” are any charges for an insured health service other than extra billing that are permitted by a provincial/territorial health care insurance plan and are not payable by the plan. For example, if patients were charged a facility fee for receiving an insured service at a hospital or clinic, that fee is considered a user charge.

Under CHA, provinces and territories that allow extra billing and user charges are subject to mandatory dollar-for-dollar deductions from the federal transfer payments under CHT.

Question 17

Outline the circumstances under which provinces and territories are permitted to charge a user fee for insured hospital services.

Answer 17

Provinces and territories are allowed to charge a user fee if hospitalization is for chronic care (in the opinion of the attending physician), and the patient is more or less permanently resident in the health care facility.

Question 18

Define “chronic care,” and identify the types of services provided in a chronic care facility.

Answer 18

In the context of CHA, “chronic care” is care required by a person who is chronically ill or has a functional disability (physical or mental), whose acute phase of illness is over, whose vital processes may or may not be stable, and who requires a range of services and medical management that can only be provided by a hospital. A chronic care facility is a facility providing ongoing, long-term, inpatient medical services. Chronic care facilities do not include nursing homes.

Question 19

Describe how the CHA defines “insured hospital services,” “insured physician services,” “insured surgical-dental services” and “extended health care services.”

Answer 19

Insured hospital services
are defined under CHA as medically necessary inpatient and outpatient services.

Insured physician services are defined under CHA as medically required services rendered by medical practitioners. Medically required physician services are generally determined by provincial/territorial health care insurance plans in conjunction with the medical profession.

Insured surgical-dental services are defined under CHA as services provided by a dentist in a hospital, where a hospital setting is required to properly perform the procedure.

Extended health care services are defined under CHA as certain aspects of long-term residential care (e.g., nursing home intermediate care and adult residential care services) and the health aspects of home care and ambulatory care services.

Question 20

Outline the types of practitioners who can provide insured physician services under CHA and the services that they provide that are considered by CHA to be “insured services.”

Answer 20

Persons who can provide insured physician services include:

(a) General practitioners, who are persons who engage in the general practice of medicine
(b) Physicians who are not specialists within the meaning of the clause
(c) Specialists, who are physicians and are recognized as specialists by the appropriate licensing body of the jurisdiction in which they practice.

Insured physician services under CHA are medically necessary services (i.e., necessary to diagnose, treat, rehabilitate or otherwise alter a disease pattern) covered by provincial/territorial health care insurance plans and rendered by a medical practitioner. Categories of insured physician services generally include:

(a) Diagnosis and treatment of illnesses and injuries
(b) Surgical services
(c) Maternity services
(d) Anesthesia services
(e) X-ray, laboratory and other diagnostic procedures.

Question 21

Describe the categories of insured surgical-dental services identified by CHA.

Answer 21

CHA defines “surgical-dental services” as any service performed by a dentist in a hospital, where a hospital is required to properly perform the procedure. Categories of insured services generally include:

(a) Oral and maxillary facial surgery
(b) Routine extraction services provided for cardiac patients, transplant patients, immune-compromised patients and radiation patients, when these patients are undergoing active treatment in a hospital setting and the attendant medical procedure requires the removal of teeth
(c) All precancerous or cancerous dental surgical biopsies.

Question 22

Identify the types of health care programs and services that fall outside the scope of CHA.

Answer 22

Noninsured health services are not considered medically necessary and are not insured under provincial/territorial health insurance legislation. They include:

(a) Noninsured hospital services for which patients may be charged, including preferred hospital accommodation unless prescribed by a physician or when standard ward level accommodation is unavailable, private duty nursing services, and the provision of telephones and televisions
(b) Noninsured physician services for which patients may be charged, including telephone advice; the provision of medical certificates required for work, school, insurance purposes and fitness clubs; testimony in court; and cosmetic services.

In addition, all provincial/territorial jurisdictions have discretion to provide a range of health care services that fall outside the scope of CHA. These supplementary health care services are provided under terms and conditions set by each jurisdiction and vary considerably across jurisdictions. They include prescription drugs, eye examinations, dental care, aids to independent living and paramedical services.

Question 23

Describe Health Canada’s approach to resolving possible CHA compliance issues with provinces/territories.

Answer 23

Part of the federal government’s responsibilities in the health care system is to ensure that the provincial/territorial health care insurance plans comply with the criteria, conditions and provisions of CHA and are eligible to receive the full amount of the CHT cash contribution.

Health Canada’s approach to resolving possible compliance issues emphasizes transparency, consultation and dialogue with provincial/territorial health ministry officials. In most instances, issues are successfully resolved through consultation and discussion based on a thorough examination of the facts. Deductions have only been applied when all options to resolve the issue have been exhausted.

Question 24

Describe the penalty provisions of the CHA for noncompliance.

Answer 24

There are both mandatory and discretionary penalties for noncompliance under the CHA.

Provinces and territories that allow extra billing and user charges are subject to mandatory dollar-for-dollar deductions from the federal transfer payments. If it has been determined that a province or territory has allowed, for example $100,000 in extra billing by physicians, the federal cash contribution to that province or territory is reduced by that same amount CHT. Under the Reimbursement Policy, a province or territory subject to a mandatory transfer deduction, may be provided a reimbursement if it eliminates the patient charges that led to the deductions within a specified timeframe.

Noncompliance with one of the five criteria or two conditions of CHA is subject to a discretionary penalty. The amount of any deduction from federal transfer payments under CHT is based on the magnitude of the noncompliance. CHA sets out a consultation process that must be undertaken with the province or territory before discretionary penalties can be levied.

Question 25

Describe the primary sources of clarification of the terms of CHA that have been issued by the federal government. (4)

Answer 25

There have been four clarifications issued by the federal government that relate to its position on CHA. They are:

(1) The Epp letter. This was a 1985 letter from then–federal Minister of Health and Welfare Jake Epp. His letter provided the federal government’s interpretation of CHA criteria, conditions and regulatory provisions. These clarifications have been used by the federal government in assessing and interpreting compliance with CHA. The Epp letter remains an important reference for interpreting CHA.
(2) The Marleau letter. This focused on the federal policy on private clinics. In 1994, a series of federal/provincial/territorial meetings that dealt with private clinics took place. The growth of private clinics providing medically necessary services funded partially by the public system and partially by patients was at issue, as was its impact on Canada’s universal, publicly funded health care system. At a 1994 federal/provincial/territorial meeting of health ministers, all ministers present, with the exception of Alberta, agreed to “take whatever steps required to regulate the development of private clinics in Canada.” In 1995, Diane Marleau, the federal minister of health at the time, wrote to all provincial/territorial ministers of health to announce the new Federal Policy on Private Clinics. The minister’s letter provided the federal interpretation of CHA as it relates to the issue of facility fees charged directly to patients receiving medically necessary services at private clinics. The letter stated that the definition of “hospital” contained in CHA includes any public facility that provides acute, rehabilitative or chronic care. Thus, when a provincial/territorial health care insurance plan pays the physician fee for a medically necessary service delivered at a private clinic, it must also pay the facility fee or face a deduction in federal transfer payments.
(3) A letter issued in 2002 by the federal minister of health to the provincial/ territorial counterparts, which outlined a Canada Health Act Dispute Avoidance and Resolution process. The process was agreed to by all provinces and territories, except Quebec. The process includes the dispute avoidance activities of government-to-government information exchange, discussions and clarification of issues as they arise, active participation of governments in ad hoc federal/provincial/territorial committees on CHA-related issues, and CHA advance assessments, upon request. Where dispute avoidance activities prove unsuccessful, dispute resolution activities may be initiated, beginning with government-to-government fact finding and negotiations. If these are unsuccessful, either minister of health involved may refer the issues to a third-party panel to undertake fact finding and provide advice and recommendations. The federal minister of health has the final authority to interpret and enforce CHA. In deciding whether to invoke the noncompliance provisions of CHA, the minister takes the panel’s report into consideration.
(4) The Petitpas Taylor Letter. In 2018, the former federal Minister of Health, Ginette Petitpas Taylor, formalized three additional positions on the CHA. The Diagnostic Services Policy confirmed the longstanding federal position that medically necessary services, including diagnostic services, are insured regardless of the venue where the services are delivered. The Reimbursement Policy gave the Minister of Health discretion to reimburse transfer deductions if a jurisdiction eliminated the patient charges that led to the deductions within a specified time frame. Finally, Strengthened Canada Health Act Reporting facilitated compliance monitoring and administration and funding transparency.

Question 26

Describe how the provincial/territorial jurisdictions determine the health care services to cover under their respective health care plans.

Answer 26

The provinces and territories each establish their own hospital and medical plans, making decisions about how much money they will spend on their health care plans, where their hospitals will be located, how many physicians they will need, etc.

CHA does not define “medically necessary services” but does require that if a service is medically necessary, the full cost of the service must be covered by the public health care insurance plan. The provinces and territories, in consultation with the respective physician colleges or groups, determine which services are medically necessary for health insurance purposes.

If a service is not considered to be medically required, the province or territory does not need to cover it through its health care insurance plan. As a result, compliance with CHA requirements means that all provincial/territorial health care insurance plans share certain common features and basic standards of insured health care coverage (with slight differences).

Question 27

Identify the general categories of insured hospital services provided under provincial/territorial health plans.

Answer 27

All provinces and territories cover treatment provided in acute care facilities for the entire period of time during which such services are medically required. Acute care includes health services provided to individuals suffering from serious and sudden health conditions that require ongoing professional nursing care and observation. Categories of insured hospital services under CHA generally include:

(a) Accommodation and meals at the standard or public ward rate and preferred accommodation if medically required
(b) Necessary nursing services
(c) Laboratory, radiological (x-ray) and other diagnostic procedures
(d) Drugs when administered in a hospital
(e) Use of operating room, case room and anesthetic facilities
(f) Use of radiotherapy and physiotherapy facilities
(g) Medical and surgical equipment and supplies
(h) Outpatient services. (An outpatient is a patient admitted to a hospital, clinic or other health care facility for treatment that does not require an overnight stay.)

Question 28

Describe how long-term secondary health services are provided in the public health care system.

Answer 28

All provinces and territories provide and pay for certain secondary services such as home and continuing care services, but many secondary services are not covered by CHA. Regulation and the range of covered services vary across jurisdictions.

Long-term secondary health care services are, for the most part, paid for by provincial/territorial governments, but the costs of room and board are the responsibility of the individual receiving care. (Sometimes costs of room and board are subsidized by provincial/territorial governments.)

Question 29

Describe the services defined as “extended health care services” under the CHA.

Answer 29

a) CHA defines “extended health care services” to include:

• Certain aspects of long-term residential care, including nursing home intermediate care services, accommodation and care, respite care, day programs, night care, palliative care and in some instances convalescent care
• Adult residential care services.

b) Health aspects of:

• Home care services, which provide professional nursing care to people of all ages in their own homes. They can also provide nonprofessional assistance with personal care and housekeeping provided by home support workers.
• Ambulatory care services, which can include services provided in hospital emergency rooms and day/night care in hospital facilities and health centres.

Question 30

Outline the extent to which long-term care services are funded through the public health care system.

Answer 30

There is little consistency across Canada in what facilities are called (e.g., nursing home, personal care facility, residential continuing care facility, etc.), the level or type of care offered and how it is measured and how facilities are governed or who owns them.

The provincial/territorial health care insurance plans cover the majority of nursing home costs for those who are without means by providing “ward” rates in a shared room. In all provinces and territories, most clients/residents pay a portion of the cost of nursing home care. Clients/residents pay for semiprivate and private accommodation in most institutions. The provincial/territorial health care insurance plans also cover health aspects of home care (provided in an LTC context), at least to the level of public health nursing. Beyond these, the range of services and level of coverage and cost of these services vary considerably by province and territory. Services are generally based on an assessment of need (provinces and territories have their own assessment tools).

Question 31

Describe the general extent of supplementary health care services provided by provincial/territorial health care insurance plans.

Answer 31

Where prescription drugs are covered, there is considerable variation among provincial/territorial plans in terms of who is covered for what drugs and what user fees apply. Provincial/territorial health care insurance plans subsidize the costs for some residents, particularly low-income individuals and seniors.

Plans vary between those that cover a wider range of prescription drugs for a targeted group of people (e.g., seniors and low-income individuals) and those that provide benefits for a larger range of people but have a narrower range of drugs and higher copayments and deductibles in order to limit utilization.

Most provinces and territories cover eye examinations for seniors and/or children.

Most provinces and territories provide limited, nonhospitalized dental care coverage for children. The maximum eligible age varies in each jurisdiction. The emphasis is on basic services.

Some provinces cover a portion of the cost of some aids to independent living such as hearing aids, wheelchairs and medical appliances.

Some provinces and territories cover physiotherapy services outside of a hospital in an approved facility, provided certain conditions are met. Some provinces provide chiropractor services.

Question 32

Outline how hospitals and physicians are reimbursed by the provincial/territorial health care plan for insured services.

Answer 32

Hospital operating costs are paid out of an annual budget that has been negotiated between the hospital and the provincial/territorial ministry of health or regional authority.

Doctors in private practice are generally paid through fee-for-service (FFS) schedules negotiated between each provincial/territorial government and the medical associations in its respective jurisdiction. Those in other practice settings, such as clinics, community health centres and group practices, are more likely to be paid through an alternative payment method such as salaries or a blended system, for example, FFS plus incentives.

Question 33

Describe the method of reimbursement for insured services provided by provincial/territorial health care insurance plans to medical providers who are “participating” practitioners.

Answer 33

For “participating” practitioners, the public health care administrator reimburses the health care provider directly at the rate defined by the jurisdiction’s fee schedule. This is regardless of whether the practitioner’s services have been provided inside, or outside, of a hospital. If the jurisdiction imposes specific dollar limits on the amount that the public plan will reimburse, the insured person is responsible for paying any charges over that limit to the practitioner or health care facility.

Question 34

Describe the method of reimbursement for insured services provided by provincial/ territorial health care insurance plans to medical providers who are “opted-out” practitioners and the information such practitioners must provide to receive that reimbursement.

Answer 34

For “opted-out” practitioners, the health care provider bills their patient directly at the rate set by the particular jurisdiction, and the patient then seeks reimbursement from the public health care administrator. In order for the patient to receive reimbursement from the public plan, that individual must obtain sufficient billing information from the practitioner to satisfy the public plan administrator.

Question 35

Describe what makes medical providers “nonparticipating” practitioners and how they are paid for the health care services they provide.

Answer 35

When the health care provider does not participate in the public plan, and as a result bills the patient directly at a fee level established by the provider, the practitioner is considered a “nonparticipating” practitioner. The practitioner must advise patients in advance that they do not participate in the public health care plan, and neither the practitioner nor the patient is eligible for any payments from the jurisdiction’s public health care plan.

Question 36

Describe how publicly funded health care is financed and why it is referred to as a “single payer” system.

Answer 36

Publicly funded health care is financed with general revenue raised through federal and provincial/territorial taxation such as personal and corporate taxes, sales taxes and other revenue. Approximately 72% of financing for health care comes from the public sector. Some provinces charge health care premiums, but nonpayment of a premium does not limit access to medically necessary services.

The Canadian public health care system is described as a “single payer” system. Canadians do not pay directly for services provided under public health plans, nor are they required to fill out forms at the time of receiving those services. When Canadians need medical care, in most instances, they go to the physician or clinic of their choice and present the health insurance card issued to all eligible residents of a province or territory. There are no deductibles, copayments or dollar limits on coverage for insured services.

Question 37

Distinguish between the financing of primary, secondary and supplementary health care services.

Answer 37

Most but not all primary health care services are financed through public health care plans. Not all services provided by dentists, nurses, pharmacists and other allied health care personnel are covered by these plans.

All provinces and territories provide and pay for certain secondary services, such as home and continuing care services, but many secondary services are not covered by CHA. Regulation and the range of covered services vary across jurisdictions.

Supplementary health care services are not generally covered under the publicly funded health care system. Persons who need these services pay for them in some manner—perhaps through private health insurance plans (often employer-sponsored health insurance programs) or directly through out-of-pocket payments. The provinces and territories provide coverage for some of the supplementary services noted above to certain groups of people (i.e., seniors, children and low-income residents). The level of coverage varies considerably across Canada.