4 Members
5 Quorum and voting
6 Functions of OOCHSC
7 Screening of application
8 Review and decision of OOCHSC
9 Payment by Minister
10 Appeal of OOCHSC decision
11 Appeal Panel
12 Majority decision
13 Appeal Panel reviews application and OOCHSC decision
14 Expiry
Interpretation
1(1) In
this Regulation,
(a) “Appeal
Panel” means the Out‑of‑Country Health Services Appeal Panel
continued under section 11;
(b) “Chair”,
except in sections 11 and 12, means the chair of the Out-of-Country Health
Services Committee;
(c) “dependant”
means dependant as defined in the Alberta Health Care Insurance Regulation;
(d) “elective
services” means insured services and insured hospital services that are not
provided in an emergency or in other circumstances in which medical care is
required without delay;
(e) “insured
hospital services” means insured services as defined in Part 3 of the Hospitals
Act;
(f) “OOCHSC”
means the Out-of-Country Health Services Committee continued under section 3.
(2) For
the purposes of this Regulation, a service is available in Canada if a resident
could have obtained the service in Canada within the time period generally
accepted as reasonable by the medical or dental profession for any resident
with a similar condition.
Application
2(1) Subject
to subsection (2), a resident of Alberta may apply to the OOCHSC for approval
of the payment of expenses with respect to insured services or insured hospital
services received outside of Canada, where the resident or the resident’s
dependant has endeavoured to receive the services in Canada and the services are
not available in Canada.
(2) An
application may only be made under subsection (1) with respect to
(a) elective
services, if the application is made prior to receiving the services, or
(b) insured
services or insured hospital services that are not elective services, if the
application is made
(i) prior to receiving the services, or
(ii) not later than 365 days after the services were received.
(3) An
application under subsection (1) must
(a) be
in writing in a form established by the OOCHSC,
(b) contain
the information required under section 7(1)(c), and
(c) include
a letter in support of the application from
(i) an Alberta physician, if the services are insured medical
services referred to in the Medical Benefits Regulation or insured
hospital services, or
(ii) an Alberta dentist, if the insured services are oral and
maxillofacial surgery services referred to in the Oral and Maxillofacial
Surgery Benefits Regulation.
(4) An
application under subsection (1) may be made on behalf of a resident to the
OOCHSC
(a) by
a resident’s personal representative who is a resident of Alberta,
(b) by
a physician registered under the Medical Profession Act, or
(c) by
a dentist registered as a regulated member under Schedule 7 to the Health
Professions Act.
OOCHSC continued
3 The Out‑of‑Country Health
Services Committee established under the Alberta Health Care Insurance
Regulation (AR 216/81) is continued.
Members
4(1) The
OOCHSC consists of the following members appointed by the Minister:
(a) 4
physicians;
(b) an
employee of the Department of Health and Wellness.
(2) The
term of a member appointed under subsection (1)(a) shall not exceed 3 years,
and the member is eligible for reappointment.
(3) The
person referred to in subsection (1)(b) is the Chair.
(4) The
Minister may designate an employee of the Department of Health and Wellness as
an alternate for the member referred to in subsection (1)(b) to act as Chair in
the place of that member when that member is temporarily absent or unable to act.
(5) Members
of the OOCHSC who are not employees of the Department of Health and Wellness
are entitled to
(a) remuneration
in accordance with the Committee Remuneration Order at 2 times the rate
set out in Schedule 1, Part A of that Order, and
(b) travelling
and living expenses in accordance with Schedule 1, Part A of the Committee
Remuneration Order.
Quorum and voting
5(1) The
quorum for the purpose of meetings of the OOCHSC is 3 members, one of whom must
be the Chair.
(2) The
Chair is a non‑voting member of the OOCHSC.
(3) A
tie vote on a matter is deemed to be a vote against the matter.
(4) A
decision made by the majority of the members of the OOCHSC who are present at a
meeting is, if the members present constitute a quorum, deemed to be a decision
of the OOCHSC.
Functions of OOCHSC
6(1) The
OOCHSC shall review, evaluate and decide on all applications made under section
2 that are declared to be complete by the Chair under section 7.
(2) The
OOCHSC shall, on the request of the Minister,
(a) submit
reports to the Minister on its activities, and
(b) carry
out any other activities related to insured services and insured hospital
services that the Minister considers appropriate.
Screening of
application
7(1) When
an application under section 2 is received by the OOCHSC, the Chair shall
conduct an initial screening of the application to ensure that the application
(a) is
submitted by a person referred to in section 2,
(b) is
supported in writing by an Alberta physician or dentist unless there are
extenuating circumstances as determined by the Chair, and
(c) contains
information, including health information, that the Chair considers to be
sufficient for the proper review by the OOCHSC.
(2) In
carrying out the initial screening of an application under subsection (1), the
Chair, or the person designated by the Chair for that purpose, may conduct any
independent investigation that may be considered necessary in order to complete
the initial screening of an application.
(3) After
the Chair has concluded the initial screening of an application and is
satisfied that the application meets the requirements set out in subsection
(1), the Chair may declare the application complete and forward that
application to the OOCHSC for review.
Review and decision
of OOCHSC
8(1) Within
60 days from the date that the Chair has declared under section 7 that an
application is complete, the OOCHSC shall decide
(a) whether
the services referred to in the application are insured services or insured
hospital services,
(b) whether
to approve payment with respect to insured services and insured hospital
services received or to be received outside of Canada, and
(c) whether,
in respect of insured services and insured hospital services received or to be
received outside of Canada, to impose conditions on payment.
(2) In
making a decision under subsection (1), the OOCHSC may not approve payment for
(a) subsistence
and accommodation costs of the person receiving insured services or insured
hospital services outside of Canada or of anyone who accompanies that person,
(b) insured
services or insured hospital services provided outside Canada if the services
are available in Canada, and
(c) services
that the OOCHSC decides are experimental or applied research.
(3) The
OOCHSC may, if it considers it to be advisable or necessary, consult with
health specialists in respect of the matter under its consideration before it
renders its decision under subsection (1).
(4) Where
the OOCHSC consults with a health specialist under subsection (3), the Minister
may pay that health specialist an appropriate fee in respect of that
consultation.
(5) The
OOCHSC shall, within 10 days of making a decision under subsection (1),
excluding Saturdays, Sundays and holidays, send
(a) a
written copy of its decision with reasons to the Minister, to the applicant
and, if the applicant is a person referred to in section 2(4), to the resident
on whose behalf the application is made, and
(b) notice
of the right to appeal the decision to the applicant and, if the applicant is a
person referred to in section 2(4), to the resident on whose behalf the
application is made.
Payment by Minister
9 If the OOCHSC approves an application for
payment under section 8, the Minister shall pay for those services approved by
the OOCHSC.
Appeal of OOCHSC
decision
10 The resident or the person making the
application on the resident’s behalf under section 2 may appeal a decision of
the OOCHSC under section 8 to the Appeal Panel by submitting a notice of appeal
to the Appeal Panel within 60 days of receipt of the decision.
Appeal Panel
11(1) The
Out‑of‑Country Health Services Appeal Panel established under the Alberta
Health Care Insurance Regulation (AR 216/81) is continued.
(2) The
Appeal Panel consists of 6 members appointed by the Minister, of which 4 must
be physicians, one must be an ethicist and one must be a member of the general
public.
(3) The
term of the members referred to in subsection (2) shall not be more than 3
years, and those members are eligible for reappointment.
(4) The
Minister may designate a member of the Appeal Panel as the chair and a member
of the Appeal Panel as the vice‑chair.
(5) A
quorum of the Appeal Panel consists of 3 members, 2 of whom must be physicians,
and one of whom must be either the ethicist or the member of the general
public.
(6) Members
of the Appeal Panel who are not employees of the Government are entitled to,
(a) in
the case of a member who is a physician,
(i) remuneration in accordance with the Committee Remuneration
Order at 2 times the rate set out in Schedule 1, Part A of that Order, and
(ii) travelling and living expenses in accordance with Schedule 1,
Part A of the Committee Remuneration Order,
and
(b) in
the case of a member who is not a physician,
(i) remuneration in accordance with the Committee Remuneration
Order at 1.5 times the rate set out in Schedule 1, Part A of that Order,
and
(ii) travelling and living expenses in accordance with Schedule 1,
Part A of the Committee Remuneration Order.
Majority decision
12(1) The
chair and the vice‑chair of the Appeal Panel are voting members of the
Appeal Panel.
(2) A
decision of the majority of the members of the Appeal Panel who review the
appeal is deemed to be a decision of the Appeal Panel.
(3) A
tie vote on a matter is deemed to be a vote against the matter.
Appeal Panel reviews
application and OOCHSC decision
13(1) The
Appeal Panel shall review the applicant’s application and the OOCHSC’s decision
if a notice of appeal is received within 60 days of the appellant receiving the
decision under section 8.
(2) In
reviewing the OOCHSC’s decision, the Appeal Panel shall review only the written
decision and reasons and the matters referred to in section 7(1) and shall not
review any new evidence.
(3) An
appeal must be reviewed and a decision made within 60 days of receipt of a
notice of appeal.
(4) The
Appeal Panel may confirm or vary the decision of the OOCHSC or substitute its
decision for the OOCHSC’s decision.
(5) If
the Appeal Panel confirms, varies or substitutes its decision for the OOCHSC’s
decision approving the payment of services, the Minister shall pay for those
services approved by the Appeal Panel.
(6) The
Appeal Panel shall, within 10 days of making a decision under this section,
excluding Saturdays, Sundays and holidays, send a written copy of its decision
with reasons to the Minister, each member of the OOCHSC, the appellant and, if
the appellant is a person referred to in section 2(4), to the resident on whose
behalf the appeal is made.
Expiry
14 For the purpose of ensuring that this
Regulation is reviewed for ongoing relevancy and necessity, with the option
that it may be repassed in its present or an amended form following a review,
this Regulation expires on February 15, 2016.
