What You Need to Know About Your Insured Health Benefits

ometimes, a patient needs medical treatment or care that cannot be provided in Manitoba.  Manitoba Health may cover some of the costs of this care, based on a specific approval process.

You may be eligible for help with costs related to getting medical care in another province or country when:

• an appropriate physician recommends that you need a necessary, specific medical service (i.e., care or treatment); and
• that treatment is not available in Manitoba.

What is an "appropriate physician"?

An appropriate physician means a Manitoba specialist.  A specialist is a doctor who focuses on a certain area of medicine (for example, a physician who specializes in treating heart disease or cancer).  "Appropriate" means that the specialist’s field of expertise is related to the patient’s disorder (for example, an obstetrician, or pregnancy specialist, cannot make a neurological, or nerve disorder referral).

Specialists can diagnose and assess very specific illnesses and conditions.  They are also likely to know where the treatment and expertise that a patient requires is available.

What is the approval process?

Your family doctor may decide it is necessary to refer you to a specialist.  The specialist will assess your condition or illness, and may prescribe treatment.

If the prescribed treatment is not available in Manitoba:

• the specialist must write a letter to Manitoba Health, and provide certain information about your case;
• Manitoba Health will review the letter from the specialist, and seek an opinion from a medical consultant if necessary;
• after reviewing your case, Manitoba Health will write back to the specialist to approve or deny coverage for out-of-province treatment.  You will also receive a copy of this letter.

In emergencies (e.g., life-threatening cases, such as an organ transplant), this process can be handled very quickly.

Does it matter where my doctor refers me?

Yes.  Manitoba Health will pay for care or treatment in the United States only if all Canadian medical resources have been exhausted.  In some cases, documentation (i.e., proof) that you have seen other Canadian specialists may be required before your request for referral outside the country will be considered.

What costs are covered if I am approved for treatment outside Manitoba?

In Canada:

• Doctor bills – The Manitoba government has made arrangements with all other Canadian provinces and territories (except Quebec) to send bills for medical care directly to Manitoba Health for payment.  In most cases, you do not have to pay any out-of-pocket expenses for approved medical services provided in Canada.
• Hospital bills – Similar arrangements apply to hospital care.  If you are admitted to a hospital anywhere in Canada, Manitoba Health will pay the standard ward rate on your behalf.

In the United States:

If you are referred for medical care outside Canada, and your referral is approved, you may have to pay some of the costs for your medical and hospital services.

For medical and hospital services provided in the U.S., Manitoba Health will cover:

• doctor bills, at the same rate a Manitoba doctor would receive for similar services; and
  
  
• hospital bills, up to 75 per cent of insured hospital services.

If your costs for medical and hospital services exceed these coverage limits, it is your responsibility to pay the difference, unless you qualify for special assistance based on financial hardship.  This is because costs for such services in the U.S. are generally much higher than costs for the same services in Canada.

What about travel costs?

If your out-of-province referral is approved, you may be reimbursed for reasonable transportation costs.  Accommodations, meals, taxis, ambulance and other expenses are not covered.

Also see:  Travel Subsidy for Out-of-Province Medical Referrals.

What if I need an escort?

Travel costs for an escort may also be reimbursed if the escort is required for your well-being and safety during travel.  If an escort is required, your specialist must notify Manitoba Health by including that information in his or her initial letter of request.

How do the bills get paid?

• Doctor and hospital bills – In most cases, the original doctor bills and hospital bills will be sent directly to Manitoba Health for processing.
  
  
• Transportation costs – You must send your original receipts for transportation costs, or a letter requesting mileage reimbursement, to the Out-of-Province Claims Section at Manitoba Health.

If you have already paid a doctor or hospital bill, you must include in your request for reimbursement the original receipt showing the amount you paid.  If you do not include a receipt, Manitoba Health will pay the doctor or hospital directly.