Complex Continuing Care Co-payment 2007

In Ontario, the term “complex continuing care” (CCC) is used interchangeably with “chronic care”. Complex continuing care provides continuing, medically complex and specialized services to both young and old, sometimes over extended periods of time. CCC is provided in hospitals for people who have long-term illnesses or disabilities typically requiring skilled, technology-based care not available at home or in long-term care facilities. CCC provides patients with room, board and other basic necessities in addition to medical care.

Any individual who is an insured person in accordance with the requirements of the Ontario Health Insurance Plan.

The co-payment is the patient's contribution toward accommodation and meals.

The CCC co-payment was introduced in 1979. Following consultations with consumers and associations like the Ontario Hospital Association, the Ontario Nursing Home Association and Services for Seniors, the CCC co-payment policy was revised in January 1997 to ensure fairness. All patients who require CCC have since been charged the same co-payment regardless of the type of hospital bed they happen to occupy.

In the past, patients occupying a regular hospital bed while awaiting a CCC or long-term care bed were not charged. Also, patients in CCC beds were charged a lower co-payment rate than those receiving similar care in long-term care facilities. This was unfair to patients paying the higher co-payment rate. To ensure fairness with other patients and residents in long-term care facilities, and to prevent inappropriate use of acute care resources, everyone is now charged the same rate. This policy allows for better use of limited hospital resources, allowing hospitals to direct more resources to patient care, rather than accommodation.

The co-payment is charged to a patient whose doctor has determined that the patient requires complex continuing care and is more or less a permanent resident in a hospital or other institution. This includes some Alternative Level of Care (ALC) patients in a regular acute bed who are awaiting placement in a chronic care hospital/bed or long-term care facility. The co-payment applies once their doctor designates them as requiring complex continuing care. In some cases a patient who has been so designated may pay a lesser amount; in some cases the co-payment may not apply.

The money is not government revenue. Each hospital collects the co-payment and uses the money to support its endeavors. This will allow hospitals to direct more of their government funding to direct patient care.

The CCC co-payment is $1,543.95/month or $50.76/day.

Changes to the amount charged cannot be made until the hospital has given the patient at least 30 days written notice.

The co-payment does not apply to the following CCC patients :

• patients who are under the age of 18;
• patients who were receiving benefits from under the General Welfare Assistance Act or the Family Benefits Act, income support under the Ontario Disability Support Program Act, 1997, or income assistance under the Ontario Works Act, 1997 on the day before they were admitted to the hospital where they are receiving insured in-patient services.

There are two ways that a lesser CCC co- payment may be paid.

1.  The CCC co-payment that a patient must pay is set out in the Table below. The amount depends on the patient’s monthly income, established annually, and the number of dependents that a patient has.

Income level will be established by a declaration of estimated income of the patient and his/her dependants, not by a means test where assets would have to be declared. Patients may be required to provide financial information to the hospital.

Table 1 shows the monthly income levels that qualify for a reduced CCC co-payment rate.

Table 1 : CCC Co-payment rate levels for 2007-2008
(Based on Monthly Family Incomes and number of dependents)

For purposes of chronic care co-payment rates, a "Dependent" means :

1. a spouse
   • who is
     not receiving benefits
     under the Old Age Security Act (Canada) or the Ontario Guaranteed Annual Income Act and
   • who was co-habiting with the insured person immediately prior to the person being admitted to the hospital, or if continuously hospitalized, immediately before first admitted; or
2. a child under 18 years of age.

For purposes of chronic care co-payment rates, "Estimated Income" means :

• the average monthly income of any nature or kind whatsoever, so long as it is taxable under the Income Tax Act (Canada) of an insured person or of a dependant of an insured person, as estimated by the insured person or the insured person's representative, including :
1. Payments made under any Act of Parliament of Canada or by Ontario, except for payments made under the Universal Child Care Benefit Act (Canada);
2. Income from salaries and wages;
3. Income from interest in or operation of a business, less expenses incurred in earning, such as gross income; and
4. Income from investments, less expenses incurred in earning such income.
• If income falls in the range for partial rate reduction, patients will pay a portion of the co-payment.

2.  The other way that a patient may pay a lesser CCC co-payment is if there is financial hardship for a spouse in the community, but the spouse does not meet the test for “dependent” set out above. In such cases, the patient may apply for a rate reduction from the hospital.

There are forms, which a hospital staff member will help patients complete, to determine eligibility for co-payment rate reductions. Forms are available at www.forms.ssb.gov.on.ca

A third party (such as the Workers’ Safety Insurance Board, an insurance company, the Department of Veterans Affairs, or other Federal Government agency) may pay either the total hospital cost or the co-payment on behalf of the patient.

June 2007