Canada Health Act
Glossary of Terms
The terms discribed in this glossary are defined within the context
of the Canada Health Act. In other situations, these terms
may have different definition or interpretation.
Accessibility
The accessibility criterion of the Canada Health Act (section
12) requires that health care insurance plans of provinces and territories
provide:
- insured health care services on uniform terms and conditions, on a
basis that does not impede or preclude reasonable access to these services
by insured persons, either directly or indirectly;
- payment for insured health services according to a system of payment
authorized by the law of the province or territory;
- reasonable compensation for all insured health care services rendered
by physicians and dentists; and
- payment to hospitals to cover the cost of insured health care services.
Acute Care
Acute care includes health services provided to persons suffering from
serious and sudden health conditions that require ongoing professional
nursing care and observation. Examples of acute care include post-operative
observation in an intensive care unit, and care and observation while
waiting for emergency surgery.
Acute Care Facility
An acute care facility is a health care facility providing care or treatment
of patients with an acute disease or health condition.
Admission
The official acceptance into a health care service facility and the assignment
of a bed to an individual requiring medical or health services on a time-limited
basis.
Block Fee
This is a fee charged by a physician for services that are not insured
by the provincial or territorial health insurance plan, such as telephone
advice, renewal of prescriptions by telephone, and completion of forms
or documents.
Canada Health Act (CHA)
The Canada Health Act received Royal Assent on April 17, 1984,
with the unanimous support of the House of Commons and the Senate. The
Act, which replaced the Hospital Insurance and Diagnostic Services Act (1957) and the Medical Care Act (1968), sets out the national
standards that the provincial and territorial health insurance plans must
meet in order to receive the full federal cash contribution under the
Canada Health and Social Transfer (CHST). The health portion of the CHST
was replaced by the Canada Health Transfer effective April 1, 2004.
Canada Health and Social Transfer (CHST)
Coming into effect April 1, 1996, the Canada Health and Social Transfer
(CHST) to provinces and territories provided support of health care, post-secondary
education, social assistance and social services. The CHST replaced the
Canada Assistance Plan, which cost-shared provincial and territorial social
assistance programs. It also replaced the Established Programs Financing
(EPF), which provided funding to support health care and post-secondary
education.
The CHST was composed of a tax transfer and a cash transfer. The tax
transfer component went back to 1977 when, under EPF, the federal government
agreed with provincial and territorial governments to reduce its personal
and corporate income tax rates in all provinces while they increased their
tax bases by an equivalent amount. As a result, revenue that would have
flowed to the federal government began to flow directly to provincial
and territorial governments.
The CHST gave provinces and territories the flexibility to allocate payments
among social programs according to their priorities, while upholding the
principles of the CHA and the condition that there be no period of minimum
residency with respect to social assistance.
Canada Health Transfer (CHT)
Effective April 1, 2004, the CHST was restructured into two new transfers,
the Canada Health Transfer (CHT) and the Canada Social Transfer (CST).
The CHT supports the Government of Canada’s ongoing commitment to
maintain the national criteria and conditions of the Canada Health Act. The CST is a block fund in support of post-secondary education,
social assistance and social services. It provides provinces and territories
with the flexibility to allocate funds among social programs according
to their respective priorities.
Chronic Care
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.
Chronic Care Facility
A chronic care facility is a health care facility that provides ongoing,
long-term, in-patient medical services. Chronic care facilities do not
include nursing homes.
Comprehensiveness
A criterion of the Canada Health Act (section 9), which states that the health insurance plans of the provinces and territories must insure all insured health services (hospital, physician, surgical-dental) and, where provided by law in a province or territory, services rendered by other health care practitioners.
Consultation Process
Under Section 14(2) of the Canada Health Act, the Minister of
Health must consult with a province or territory with respect to a potential
breach of the five criteria and two conditions of the Act, before discretionary
penalties can be levied for that province or territory.
Convention Refugee
A Convention refugee is a person who meets the definition of refugee
in the 1951 United Nations Convention Relating to the Status of Refugees.
In general, it is someone who has left his or her home country and has
a well-founded fear of persecution based on race, religion, nationality,
political opinion, or membership in a particular social group and is unable
or, by reason of his or her fear, unwilling to seek the protection of
the home country. In Canada, the Immigration and Refugee Board, Convention
Refugee Determination Division, decides who is a Convention Refugee.
Coordinating Committee for Reciprocal Billing (CCRB)
Please see "Interprovincial Health Insurance Agreements Coordinating Committee."
Diagnostic Imaging
A procedure that detects or determines the presence of various diseases and/or conditions with the use of medical imaging equipment. Medical imaging equipment may include bone mineral densitometry, mammography, magnetic resonance imaging (MRI), nuclear medicine, ultrasound, computed tomography (CT), and X-ray/fluoroscopy.
Diagnostic Physician Service
For purposes of reporting on the Canada Health Act, a diagnostic
physician service is any medically required service rendered by a medical
practitioner that detects or determines the presence of diseases or conditions.
Discretionary Penalties
Discretionary penalties are outlined in sections 14 to 17 of the Canada Health Act. Under these provisions, the federal minister of health
may authorize that a reduction in federal payments to a province or territory
under the Canada Health and Social Transfer (CHST) be made when a breach
of any of the five criteria or two conditions of the Canada Health Act have been identified and could not otherwise be resolved through
consultations between the respective levels of government. The amount
of any deduction is based on the gravity of the default.
Dispute Avoidance and Resolution (DAR)
In April 2002, provincial and territorial governments accepted a Canada Health Act dispute avoidance and resolution (DAR) process that would apply to the interpretation of the principles of the Canada Health Act as outlined by the Honourable A. Anne McLellan, federal Minister
of Health, in a letter to the Honourable Gary Mar, Alberta Minister of
Health and Wellness. The Canada Health Act dispute avoidance and
resolution process commits governments to continue to actively participate
in ad-hoc federal, provincial and territorial committees on Canada Health Act issues and undertake government-to-government information
exchange, discussions and clarification on issues as they arise. Health
Canada will also continue to provide advance assessments on provincial
and territorial measures and direction, when requested.
Eligibility and Portability Agreement
The original Interprovincial/Territorial Agreement on Eligibility and
Portability was approved by provincial and territorial Ministers of Health
in 1971 and was implemented in 1972. The Agreement sets minimum standards
with respect to interprovincial and territorial eligibility and portability
of health insurance programs. Provinces and territories voluntarily apply
the provisions of this agreement, thereby facilitating the mobility of
Canadians and their access to health services throughout Canada. Officials
meet periodically to review and revise the Agreement.
Enhanced Medical Goods and Services
These are medical goods or services provided in conjunction with insured
services. They are usually a higher-grade service or product that is not
medically necessary and provided to a patient for personal choice and
convenience.
Epp Letter
In June 1985, approximately one year following the passage of the Canada Health Act in Parliament, the federal Health Minister, Jake Epp wrote
to his provincial and territorial counterparts to set out and confirm
the federal position on the interpretation and implementation of the Canada Health Act.
Minister Epp's letter followed several months of consultation with his
provincial and territorial counterparts. The letter sets forth statements
of federal policy intent which clarify the criteria, conditions and regulatory
provisions of the Canada Health Act. These clarifications have
been used by the federal government in the assessment and interpretation
of compliance with the Act. The Epp letter remains an important reference
for interpretation of the Canada Health Act.
Established Programs Financing (EPF)
Introduced in 1977, the Federal-Provincial Fiscal Arrangements and Established Programs Financing Act, also known as the EPF Act,
replaced previous federal cost-sharing programs for insured hospital,
medical and post-secondary transfers to provinces and territories.
The EPF transfer was a block fund which increased annually on the basis
of economic and population growth. Under the EPF, cash and tax transfers
were provided to provinces and territories in support of health and post-secondary
education. Tax transfers consisted of income tax points transferred by
the federal government to provincial and territorial governments in 1977.
In 1995-1996, the last year of EPF, provinces and territories received
$22.0 billion in EPF entitlement (cash plus tax), 71.2 percent of which
was intended for health care and the rest for post-secondary education.
The EPF transfer was replaced in 1996 by the Canada Health and Social
Transfer.
Extended Health Care Services
Section 2 of the Canada Health Act defines extended health care
services as nursing home intermediate care service; adult residential
care service; home care service; and ambulatory health care service.
Extra-billing
Section 2 of the Canada Health Act defines extra-billing as the
billing for an insured health service rendered to an insured person by
a medical practitioner or a dentist in an amount in addition to any amount
paid or to be paid for that service by the health insurance plan of a
province or territory.
Extra-billing and User Charges Information Regulations
The only regulations in force under the Canada Health Act are
the Extra-billing and User Charges Information Regulations, which require
provincial and territorial governments to provide to the federal Minister
of Health, prior to the beginning of a fiscal year, estimates of extra-billing
and user charges that are permitted to exist under their health care insurance
plans so that appropriate deductions to federal transfers can be levied.
Provincial and territorial governments are also required under these Regulations
to provide financial statements showing the amounts of extra-billing and
user charges actually charged in a fiscal year so that reconciliations
with previously estimated deductions can be applied.
Family-based Registration
A method for registering or enrolling persons under a health care insurance
plan whereby insured persons are registered as family units.
Federal Policy on Private Clinics (Marleau Letter)
On January 6, 1995, federal Minister of Health Diane Marleau wrote to each of her provincial and territorial counterparts, providing them with the federal policy position and legal interpretation that the definition of "hospital" as set out in the Canada Health Act includes any facility providing acute, rehabilitative or chronic care and includes those health care facilities known as "clinics." She informed them that after October 15, 1995, it was her intention to interpret facility fees charged to patients in such facilities or clinics as user fees. Any province or territory not in compliance with the federal policy on private clinics faced mandatory penalties under the Canada Health Act calculated
from October 15, 1995. These penalties take the form of deductions from
monthly cash transfer payments under the Canada Health and Social Transfer.
Fee-for-service
This is a method of payment for physicians based on a fee schedule that
itemizes each service and provides a fee for each service rendered.
General Practitioner
This is a licensed physician in a province or territory who practises
community-based medicine and refers patients to specialists when the diagnosis
suggests it is appropriate. Some services a general practitioner may provide
are: consultation, diagnosis, reference, counselling, advice on health
care and prevention of illness, minor surgeries, and prescribing medicines.
Health Care Facility
A health care facility is a building or group of buildings under a common
corporate structure that houses health care personnel and health care
equipment to provide health care services (e.g., diagnostic, surgical,
acute care, chronic care, dental care, physiotherapy) on an in-patient
or out-patient basis to the public in general or to a designated group
of persons or residents.
Health Care Insurance Plan
The Canada Health Act (section 2) defines a health care insurance
plan as a plan or plans established by the law of a province or territory
to provide for insured health services as defined under this same Act.
Health Insurance Supplementary Fund (HISF)
This is a fund, administered by the Canada Health Act Division to assist
eligible individuals who, through no fault of their own, have lost or
been unable to obtain provincial or territorial coverage for insured health
services under the Canada Health Act. The fund was first established
in 1972, when the portability of insurance between provinces varied and
allowed for discrepancies in eligibility rules whereby a resident of Canada
could become temporarily ineligible for health insurance in a province
or territory following a change of province or a change of health care
eligibility status (e.g., discharge from RCMP or Canadian Forces). The
passage of the Canada Health Act in 1984 eliminated the discrepancies
in interprovincial eligibility periods that were the source of most concerns
for which the fund was established. There is currently $28,387 in the
fund. There have been 5 applications for claims to the HISF since 1984;
however, none of these have qualified under the terms and conditions for
reimbursement.
Hospital
Section 2 of the Canada Health Act defines a hospital as any facility
or portion thereof that provides hospital care, including acute, rehabilitative
or chronic care, but does not include a hospital or institution primarily
for the mentally disordered, or a facility or portion thereof that provides
nursing home intermediate care service or adult residential care service,
or comparable services for children.
Hospital Reciprocal Billing Agreement
This is a bilateral agreement between two provinces, or a province and
a territory, or two territories that allows for the reciprocal processing
of out-of-province or out-of-territory claims for hospital in- and out-patient
services from either jurisdiction. Under such an agreement, insured hospital
services are payable at the approved rates of the host province or territory
or as otherwise agreed upon by the parties involved or by the Interprovincial
Health Insurance Agreements Coordinating Committee (IHIACC).
In-patient
This is a patient who is admitted to a hospital, clinic or other health
care facility for treatment that requires at least one overnight stay.
Insured Health Services
Under Section 2 of the Canada Health Act, insured health services
means hospital services, physician services and surgical-dental services
provided to insured persons, but does not include any health services
that a person is entitled to and eligible for under any other Act of Parliament
or under any act of the legislature of a province that relates to workers'
or workmen's compensation.
Insured Hospital Services
Under Section 2 of the Canada Health Act and the Federal Policy
on Private Clinics, insured hospital services include any of the following
services provided to in-patients or out-patients at a hospital or clinic
if the services are medically necessary for the purpose of maintaining
health, preventing disease or diagnosing or treating an injury, illness
or disability, namely:
- accommodation and meals at the standard or public ward level and
preferred accommodation if medically required;
- nursing service;
- laboratory, radiological and other diagnostic procedures, together
with the necessary interpretations;
- drugs, biologicals and related preparations when administered in the
hospital or clinic;
- use of operating room, case room and anaesthetic facilities, including
necessary equipment and supplies;
- medical and surgical equipment and supplies;
- use of radiotherapy facilities;
- use of physiotherapy facilities; and
- services provided by persons who receive remuneration from the hospital
or clinic.
Insured Person
An insured person is interpreted under the Canada Health Act as
a resident of a province or territory other than:
- a member of the Canadian Forces;
- a member of the Royal Canadian Mounted Police who is appointed to
rank therein;
- a person serving a term of imprisonment in a penitentiary as defined
in the Penitentiary Act; or
- a resident of the province or territory who has not completed such
minimum period of residence or waiting period, not exceeding three months,
as may be required by the province or territory for eligibility for
or entitlement to insured health services.
Insured Physician Service
Please see "Physician Services."
Insured Surgical-Dental Service
Please see "Surgical-Dental Services."
Interprovincial Health Insurance Agreements Coordinating Committee (IHIACC)
The Interprovincial Health Insurance Agreements Coordinating Committee,
comprised of federal, provincial and territorial health department officials,
was established in 1991 as the Coordinating Committee for Reciprocal Billing
(CCRB), with the mandate to identify and resolve administrative issues
related to interprovincial/territorial billing arrangements for medical
(physician) and hospital services. The general intent of the provincial-territorial
reciprocal billing agreements is to ensure that eligible Canadians have
access to medically necessary health services when referred for these
services outside their province or territory, when travelling or during
educational leave or temporary employment. In 2002, the Committee changed
its name to the Interprovincial Health Insurance Agreements Coordinating
Committee to better reflect that the Committee's scope also extends to
eligibility for health insurance coverage as well as interprovincial-territorial
billing issues.
Mandatory Penalties
Provinces that allow extra-billing and user charges are subject to mandatory
dollar-for-dollar deductions from federal transfer payments. Mandatory
penalties are outlined in sections 20 to 21 of the Canada Health Act.
Under these provisions, the federal minister of health may authorize that
a reduction in federal payments to a province or territory under the Canada
Health and Social Transfer (CHST) be made when a breach any of the extra-billing
and user charges provisions of the Canada Health Act has been identified and could not otherwise be resolved through consultations between the respective levels of government.
Medical Necessity
Under the Canada Health Act, the provincial and territorial governments
are required to provide medically necessary hospital and physician services
to their residents on a prepaid basis, and on uniform terms and conditions.
The Act does not define medical necessity. The provincial and territorial
health insurance plans, in consultation with their respective physician
colleges or groups, are primarily responsible for determining which services
are medically necessary for health insurance purposes. If it is determined
that a service is medically necessary, the full cost of the service must
be covered by public health insurance to be in compliance with the Act.
If a service is not considered to be medically required, the province
or territory need not cover it through its health insurance plan.
Medical Practitioner
Section 2 of the Canada Health Act defines a medical practitioner
as a person lawfully entitled to practise medicine in the place in which
the practice is carried on by that person.
Medical Reciprocal Billing Agreement
This is a bilateral agreement between two provinces, or a province and
a territory, or two territories that allows the reciprocal processing
of out-of-province/territory claims for medical services provided by a
licenced physician to residents of the other jurisdiction. Where a reciprocal
billing agreement exists, an insured medical service is payable at the
approved rate of the host province or territory.
Non-Participating Physician
This is a physician operating completely outside provincial or territorial
health insurance plans. Neither the physician nor the patient is eligible
for any cost coverage for services rendered or received from the provincial
or territorial health insurance plans. A non-participating physician may
therefore establish his or her own fees, which are paid directly by the
patient.
Opted-out Physician
These are physicians who operate outside the provincial or territorial
health insurance plans, and who bill their patients directly at provincial
or territorial fee schedule rates. The provincial or territorial plans
reimburse patients of opted-out physicians for charges up to, but not
more than the amount paid by the plan under fee schedule agreement.
Out-patient
This is a patient admitted to a hospital, clinic or other health care
facility for treatment that does not require an overnight stay.
Out-patient Diagnostic Care
Out-patient diagnostic care includes health care services in a health
care facility for procedures that do not require an overnight stay and
that detect and/or determine various diseases or health conditions.
Out-patient Surgical Facility
This is a health care facility providing short-term (day only) surgical
services.
Participating Physician/Dentist
These are licensed physicians or dentists who are enrolled in provincial
or territorial health insurance plans.
Physician Services
Section 2 of the Canada Health Act defines physician services
as any medically required services rendered by medical practitioners.
Portability
This criterion of the Canada Health Act (section 11) requires
that provincial and territorial health insurance plans not impose any
minimum period of residence, or waiting period in excess of three months
before residents become eligible for insured health services. In addition,
the plans must cover and pay for insured services provided to insured
persons while they are temporarily outside the province and during any
period of residence, or waiting period imposed by the health care insurance
plan of another province or territory.
Private Diagnostic Facility
This is a privately owned health care facility providing laboratory tests,
radiological services and other diagnostic procedures.
Private (for-profit) Health Care Facility
This is a privately owned health care facility that pays out dividends
or profits to its owners, shareholders, operators or members.
Private (not-for-profit) Health Care Facility
This is a privately owned health care facility that is recognized as
operating on a non-profit basis under the laws of the provincial, territorial
or federal governments.
Private Surgical Facility
This is a privately owned health care facility providing surgical health
services.
Provision of Information Condition
The Canada Health Act (section 13 (a)) requires that provincial
and territorial governments provide information to the federal minister
of health as may be reasonably required, in relation to insured health
care services and extended health care services, for the purposes of administering
the Act.
Public Administration Criterion
The public administration criterion set out in section 8 of the Canada Health Act requires that each provincial and territorial health care
insurance plan be administered and operated on a non-profit basis by a
public authority that is responsible to the provincial or territorial
government, and whose accounts and financial transactions are publicly
audited.
Public Health Care Facility
A public health care facility is a publicly administered institution
located within Canada that provides insured health care services under
a provincial or territorial health care insurance plan on an in- or out-patient
basis.
Recognition Condition
The Canada Health Act (section 13(b)) requires that provincial
and territorial governments give recognition to the Canada Health and
Social Transfer (CHST) in any public documents, advertisements or promotional
material relating to insured health care services and extended health
services in the province or territory.
Refugee Claimant
A refugee claimant is a person of non-Canadian nationality who has arrived
in Canada and has applied for refugee protection status in Canada under
the Immigration and Refugee Protection Act. If a refugee claimant
receives a final determination from the Immigration and Refugee Board
that he or she meets the definition of refugee in the 1951 United Nations
Convention Relating to the Status of Refugees, then he or she may apply
for permanent residence status in Canada.
Rehabilitative Care
Rehabilitative care includes health care services for persons requiring
professional assistance to restore physical skills and functionality following
an illness or injury. An example is therapy required by a person recovering
from a stroke (e.g., physiotherapy and speech therapy).
Resident
Section 2 of the Canada Health Act defines a resident as a person
lawfully entitled to be or to remain in Canada who resides and is ordinarily
present in the province or territory, but does not include a tourist,
a transient or a visitor to the province or territory.
Specialist
A specialist is a licensed physician in a province or territory whose
practice of medicine is primarily concerned with specialized diagnostic
and treatment procedures. Specialties include anaesthesia, dermatology,
general surgery, gynaecology, internal medicine, neurology, neuropathology,
ophthalmology, paediatrics, plastic surgery, radiology, and urology.
Surgery
The treatment of disease, injury or other types of ailment by using the
hands or instruments to mend, remove or replace an organ, tissue, or part,
or to remove foreign matter in the body.
Surgical-Dental Services
Section 2 of the Canada Health Act defines surgical-dental services
as any medically or dentally required surgical-dental procedures performed
by a dentist in a hospital, where a hospital is required for the proper
performance of the procedures.
Surgical Physician Service
For purposes of reporting on the Canada Health Act, a surgical
physician service is any medically required surgery rendered by a medical
practitioner.
Temporarily Absent
Under the portability criterion of the Canada Health Act (section 11(1)(b)), the term "temporarily absent" is used to denote when a person is absent from their home province or territory of residence for reasons of business, education, vacation or other reasons, without taking up permanent residence in another province, territory or country.
Third-Party Payers
These are organizations such as workers' compensation boards, private
health insurance companies and employer-based health care plans that pay
for insured health services for their clients and employees.
Tray Fees
Tray fees are charges permitted under a provincial or territorial health
care insurance plan for medical supplies and equipment such as alcohol
swabs, instruments, sutures, etc., that are associated with the provision
of an insured physician service.
Universality
This criterion of the Canada Health Act (section 10) requires
that each provincial or territorial health care insurance plan entitle
one hundred per cent of the insured persons of the province or territory
to the insured health services provided for by the plan on uniform terms
and conditions.
User Charge
Section 2 of the Canada Health Act defines a user charge as any
charge for an insured health service that is authorized or permitted by
a provincial or territorial health care insurance plan that is not payable,
directly or indirectly, by a provincial or territorial health care insurance
plan, but does not include any charge imposed by extra-billing. Please
refer as well to the definition for extra-billing. |
