Health Insurance Act
Loi sur l’assurance-santé
R.R.O. 1990, REGULATION 552
GENERAL
Historical version for the period June 3, 2008 to June 17, 2008.
Disclaimer: This consolidation is not an official copy of the law because it is affected by one or more retroactive provisions which have not been incorporated into it. For information about the retroactive provisions, see O. Reg. 421/09, subsection 3 (2).
Last amendment: O.Reg. 168/08.
This Regulation is made in English only.
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CONTENTS
SectionsDefinitions / 1-1.1
Health Card / 2-2.3
Applications / 3
Information with Respect to Eligibility / 3.1
Miscellaneous / 4-6
Insured Hospital Services in Canada / 7-11
Extended Care Services / 12-14
Insured Ambulance Services / 15
Specified Health Care Services / 16-23
Exclusions / 24-27
Hospital Services / 28
Out of Country Services / 28.1-28.6
Health Services / 29-33
Designated Hospitals and Health Facilities / 34-35
Information to be Furnished by Designated Hospitals / 36-37
Physician Services / 37.1-37.7
Billing and Payment for Insured Services / 38-38.6
Subrogation (Procedural) / 39
Table 2
Table 4
Table 5
Table 6
Schedule 1
Schedule 2 / Federal hospitals
Schedule 4 / Hospitals for psychiatric illnesses and for alcoholism and drug addiction
Schedule 6 / Rehabilitation and crippled children’s centres
Schedule 7 / Ambulance service operators
Schedule 8 / Public health laboratories approved as related health facilities
Schedule 12
Schedule 16 / Schedule of benefits for out of province services nuclear medicine — in vivo
Schedule 17 / Medications for the treatment of cystic fibrosis
Schedule 18 / Medications for the treatment of thalassemia
Schedule 22 / Laboratory tests authorized by registered nurse in the extended class
Schedule 23 / Optometry services
Definitions
1.(1)In this Regulation,
“benefit period” means the period of time during which an insured person is entitled to insured services;
“dental surgeon” means a person entitled to practise dentistry in the place where dental services are rendered by the surgeon;
“extended class nursing staff” means those registered nurses in the extended class in a hospital,
(a) who are employed by the hospital and are authorized to diagnose, prescribe for or treat out-patients in the hospital, and
(b) who are not employed by the hospital and to whom the governing body or authority of the hospital has granted privileges to diagnose, prescribe for or treat out-patients in the hospital;
“hospital” means any hospital that is designated under this Regulation to participate in the Plan;
“in-patient” means a person admitted to and assigned a bed in a hospital in-patient area;
“midwife” means a member of the College of Midwives of Ontario;
“nursing home” means a nursing home operated or maintained under the authority of a licence issued under the Nursing Homes Act;
“oral and maxillofacial surgeon” means,
(a) with respect to dental services rendered in Ontario, a dental surgeon who holds a specialty certificate of registration from the Royal College of Dental Surgeons of Ontario authorizing the surgeon to practise oral and maxillofacial surgery in Ontario,
(b) with respect to dental services rendered elsewhere in Canada, a person who holds a designation from a professional regulatory body in the Canadian province or territory outside of Ontario where the services are rendered that, in the opinion of the General Manager, is equivalent to the designation referred to in clause (a), or
(c) with respect to dental services rendered outside Canada, a person who is authorized to practise oral and maxillofacial surgery in the jurisdiction outside Canada where the services are rendered and holds, in the opinion of the General Manager, a designation equivalent to the designation referred to in clause(a);
“out-patient” means a person who receives out-patient services and is not admitted to an in-patient area;
“physiotherapist” means a member of the College of Physiotherapists of Ontario;
“prescribed form” means the form prescribed by the General Manager for the purpose;
“registered nurse in the extended class” means a member of the College of Nurses of Ontario who is a registered nurse and who holds an extended certificate of registration under the Nursing Act, 1991;
“schedule of benefits” means the document published by the Ministry of Health and Long-Term Care titled “Schedule of Benefits — Physician Services under the Health Insurance Act (October 1, 2005)”, but does not include the “[Commentary…]” portions of the document, or its Appendices A, B, C and F, and includes the following amendments to the document:
1. Amendments dated April 1, 2006.
1.1 Amendments dated May 12, 2006.
2. Amendments dated July 1, 2006.
3. Amendments dated October 1, 2006.
4. Amendments dated October 2, 2006 (effective as of October 1, 2006).
4.0.1 Amendments dated October 1, 2006 (made in 2007).
4.1 Amendments dated December 1, 2006.
5. Amendments dated January 1, 2007.
6. Amendments dated April 1, 2007.
6.1 Amendments dated October 1, 2007.
7. Amendments dated January 1, 2008.
8. Amendments dated January 2, 2008 (effective as of January 1, 2008).
9. Amendments dated November 19, 2007 (effective as of February 1, 2008).
9.1 Amendments dated November 22, 2007 (effective as of February 1, 2008).
10. Amendments dated April 1, 2008.
11. Amendments dated April 15, 2008 (effective as of June 3, 2008);
“schedule of laboratory benefits” means the document published by the Ministry of Health and Long-Term Care titled “Schedule of Benefits for Laboratory Services”, dated April 1, 1999, together with the following documents, all of which can be accessed on the Ministry’s website www.health.gov.on.ca by clicking on the Health Care Providers link, the OHIP for Healthcare Professionals link and on the Ontario Health Insurance Schedule of Benefits and Fees link:
1. The Ministry of Health and Long-Term Care document titled “Addendum Dated April 1, 2001 to Schedule of Benefits for Laboratory Services”.
2. The Ministry of Health and Long-Term Care document titled “Addendum Dated April 1, 2004 to Schedule of Benefits for Laboratory Services”.
3. The Ministry of Health and Long-Term Care document titled “Addendum Dated August 16, 2004 to Schedule of Benefits for Laboratory Services”.
4. The Ministry of Health and Long-Term Care document titled “Addendum Dated March 1, 2006 to the Schedule of Benefits for Laboratory Services”.
5. The Ministry of Health and Long-Term Care document titled “Addendum Dated December 17, 2007 (Effective as of March 1, 2008) to the Schedule of Benefits for Laboratory Services”.
6. The Ministry of Health and Long-Term Care document titled “Addendum Dated January 14, 2008 (Effective April 1, 2008) to the Schedule of Benefits for Laboratory Services”;
“schedule of optometry benefits” means the document published by the Ministry of Health and Long-Term Care titled “Schedule of Benefits for Optometry Services” (December 1, 2006), but does not include the “[Commentary…]” portions of the document, or any appendix to the document;
“spouse” means a person,
(a) to whom the person is married, or
(b) with whom the person was living, in a conjugal relationship outside marriage, if the two persons,
(i) have cohabited for at least one year,
(ii) are together the parents of a child, or
(iii) have together entered into a cohabitation agreement under section 53 of the Family Law Act;
“standard ward accommodation” means,
(a) a bed in a hospital area designated by the hospital in accordance with Regulation 794 of the Revised Regulations of Ontario, 1990 under the Ministry of Health Act as a standard ward.
(b) Revoked: O.Reg. 375/93, s.1.
R.R.O. 1990, Reg. 552, s.1; O.Reg. 616/91, s.1(1); O.Reg. 214/93, s.1; O.Reg. 375/93, s.1; O.Reg. 794/93, s.1; O.Reg. 488/94, s.1; O.Reg. 114/96, s.1; O.Reg. 409/96, s.1(1); O.Reg. 410/96, s.1; O.Reg. 502/97, s.1(1); O.Reg. 44/98, s.1; O.Reg. 147/98, s.1; O.Reg. 375/98, s.1(1); O.Reg. 376/98, s.1; O.Reg. 378/98, s.1; O.Reg. 478/98, s.1; O.Reg. 178/99, s.1(1-5); O.Reg. 201/99, s.1; O.Reg. 482/99, s.1; O.Reg. 67/00, s.1; O.Reg. 322/00, s.1; O.Reg.368/00, s.1(1); O.Reg. 617/00, s.1; O.Reg. 66/01, s.1; O.Reg. 250/01, s.1(1); O.Reg. 272/01, s.1(1); O.Reg. 345/01, s.1; O.Reg. 415/01, s.1; O.Reg. 56/02, s.1(1); O.Reg. 169/02, s.1(1); O.Reg. 302/02, s.1(1); O.Reg. 361/02, s.1(1); O.Reg. 18/03, s.1; O.Reg. 50/03, s.1; O.Reg. 62/03, s.1; O.Reg. 203/03, s.1; O.Reg. 221/03, s.1; O.Reg. 265/03, s.1(1); O.Reg. 266/03, s.1; O.Reg. 350/03, s.1; O.Reg. 6/04, s.1; O.Reg. 238/04, s.1; O.Reg. 320/04, s.1 (1, 2); O.Reg. 352/04, s.1; O.Reg. 129/05, s.1; O.Reg. 328/05, s.1; O.Reg. 374/05, s.1; O.Reg. 502/05, s.1 (1); O.Reg. 96/06, s.1(1); O.Reg. 318/06, s.1; O.Reg. 418/06, s.1; O.Reg. 420/06, s.1; O.Reg. 501/06, s.1; O.Reg. 538/06, s.1; O.Reg. 557/06, s.1; O.Reg. 24/07, s.1; O.Reg. 98/07, s.1; O.Reg. 128/07, s.1; O.Reg. 189/07, s.1; O.Reg. 403/07, s. 1; O.Reg. 519/07, s.1; O.Reg. 587/07, s.1; O.Reg. 8/08, s.1; O.Reg. 26/08, s.1; O.Reg. 52/08, s.1; O.Reg. 168/08, s.1.
(2)A reference to the schedule of benefits or the schedule of optometry benefits in relation to a service is a reference to the relevant schedule in force at the time the service was rendered. O.Reg. 320/04, s.1 (3).
(3)For the purposes of the definition of “schedule of benefits” in subsection (1), the document mentioned in that definition does not include its Appendix H, or its table of contents, alphabetic index or numeric index. O.Reg. 96/06, s.1(2).
(4)Revoked: O.Reg. 265/03, s.1(2).
1.1(1)For the purposes of the Act,
“resident” means an individual,
(a) who is present in Ontario by virtue of an employment authorization issued under the Caribbean Commonwealth and Mexican Seasonal Agricultural Workers Programme administered by the federal Department of Citizenship and Immigration, or
(b) who is ordinarily resident in Ontario and who is one of the following:
1. A Canadian citizen, a landed immigrant under the Immigration Act (Canada) or a permanent resident under the Immigration and Refugee Protection Act (Canada).
2. A person who is registered as an Indian under the Indian Act (Canada).
3. A Convention refugee as defined in the Immigration Act (Canada).
4. A person who has submitted an application for landing under the Immigration Act (Canada), who has not yet been granted landing and who has been confirmed by the federal Department of Citizenship and Immigration as having satisfied the medical requirements for landing.
5. Revoked: O.Reg. 87/95, s.1.
6. A person who has finalized a contract of employment or an agreement of employment with a Canadian employer situated in Ontario and who, at the time the person makes his or her application to become an insured person, holds an employment authorization under the Immigration Act (Canada) which,
i. names the Canadian employer,
ii. states the person’s prospective occupation, and
iii. has been issued for a period of at least six months.
7. The spouse or dependent child under the age of 19 years of a person referred to in paragraph 6 if the Canadian employer provides the General Manager with written confirmation of the employer’s intention to employ the person referred to in paragraph 6 for a period of three continuous years.
8. A member of the clergy of any religious denomination who has finalized an agreement of employment to minister on a full-time basis to a religious congregation in Ontario for a period of not less than six consecutive months and whose duties will consist mainly of preaching doctrine, presiding at liturgical functions and spiritual counselling.
9. The spouse and the dependent children under the age of 19 years of a member of the clergy referred to in paragraph 8 if the religious congregation provides the General Manager with written confirmation that it intends to employ the member for a period of at least three consecutive years.
10. A person granted a minister’s permit under section 37 of the Immigration Act (Canada) which indicates on its face that the person is a member of an inadmissible class designated as case type 86, 87, 88 or 89 or, if the permit is issued for the purpose of an adoption by an insured person, as case type 80.
11. A person granted an employment authorization under the Live-in Care Givers in Canada Programme or the Foreign Domestic Movement administered by the federal Department of Citizenship and Immigration. O.Reg. 490/94, s.1; O.Reg. 87/95, s.1; O.Reg. 67/00, s.2(1, 2); O.Reg. 328/05, s.2 (1, 2); O.Reg. 362/06, s.1.
(2)For the purposes of subsection (1), a person is ordinarily resident in Ontario only if,
(a) in the case of an insured person or of a person who comes to Ontario from another province or territory in which that person was insured by the provincial or territorial health insurance authority, the person,
(i) makes his or her permanent and principal home in Ontario, and
(ii) subject to subsections (3), (4), (5) and (6), is present in Ontario for at least 153 days in any 12-month period; and
(b) in the case of a person who is applying to be an insured person for the first time or who is re-establishing his or her entitlement after having been uninsured for a period of time, other than a person who comes to Ontario from another province or territory in which that person was insured by the provincial or territorial health insurance authority, the person,
(i) intends to make his or her permanent and principal home in Ontario, and
(ii) is present in Ontario for at least 153 days immediately following the application. O.Reg. 490/94, s.1; O.Reg. 85/99, s.1(1,2).
(3)A person referred to in clause (2) (a) is exempt from the requirement of subclause (2) (a) (ii) if the person provides the General Manager with evidence that he or she meets one of the following criteria:
1. The person’s employment requires the person to travel frequently outside of Ontario.
2. The General Manager has approved, under section 28.4, payment for a treatment to be provided to the person outside Canada.
3. The person,
i. leaves Ontario for a reason mentioned in subsection (4),
ii. met the requirement of subclause (2) (a) (ii) for at least two consecutive 12-month periods immediately before leaving, and
iii. intends to return to make his or her permanent and principal home in Ontario.
4. The person,
i. is the spouse of, or a dependent child who is under 19 years of age of, a person who is exempt under paragraph 3,
ii. leaves Ontario to accompany the exempt person referred to in subparagraph i,
iii. met the requirement of subclause (2) (a) (ii) for at least two consecutive 12-month periods immediately before leaving, and