Lesson 4

Question 1

1.1 Describe how national health care responsibilities are divided among the various Canadian legislative jurisdictions

Answer 1

Constitutionally the assignment of most aspects of health care is to the provinces. There are certain groups that the responsibility falls to the federal gov’t. Funding is joint federal and provincial

The system is called national since it is linked through adherence to national principles set at the federal level through Canada Health Act.

Question 2

1.2 What is involved in the federal government’s role in health care (5)

Answer 2

1) Setting and administering national principles or standards through the CHA

2) Assisting in the financing of provincial/territorial health care services through fiscal transfers known as the Canada Health Transfer

3) Ensuring the requirements of the CHA

4) Delivering primary and supplemental services to certain groups of people

5) Protecting and regulating health, consumer safety, disease surveillance and prevention and support for health promotion and health research

Question 3

1.2 What groups is the federal government primarily responsible for delivering health care for (6)

Answer 3

• First nations people living on reserves.
• Inuit
• serving members of the armed forces
• eligible veterans
• inmates in federal penitentiaries
• some groups of refugee claimants

Question 4

1.2 What do provinces need to do to get full CHT from the federal government

Answer 4

Health care plans must meet the national principles set out under the CHA

Question 5

1.2 What are the provincial/territorial jurisdictions administration responsibilities? (8)

Answer 5

1) Determining benefits eligible for coverage

2) Planning/paying for hospitals, physicians and public health facilities

3) Registering those eligible for benefits

4) Enrolling health care practitioners

6) Registering Diagnostic facilities

7) Processing and paying practitioners bills

8) Auditing benefit claims for payment and auditing patterns of practice or billings submitted

Question 6

1.3 What is the CHAD

Answer 6

Canadian Health Act Division

Question 7

1.3 What are the responsibilities of the CHAD (9)

Answer 7

1) Monitoring provincial health plans for compliance with criteria, conditions, and extra billing and user charge provisions of CHA

2) Working in partnership with provinces to investigate and resolve compliance issues

3) Informing the minister of potential noncompliance issues and recommending appropriate actions

4) Developing/maintaining formal and informal relationships with health officials in provinces

5) Disseminating information on CHA

6) Responding to information requests relating to the CHA

7) Conducting issue analysis and policy research to provide policy advice

8) Collaborating with provincial department reps through the Interprovincial health insurance agreements coordinating committee

9) Working with health canada legal services and the department of justice on litigation issues that implicate the CHA

Question 8

1.4 Identify the first step that an individual must take to access public health services in Canada

Answer 8

Register for health care with the applicable jurisdicition

Question 9

1.5) Describe the general approach taken by the provincial/territorial jurisdictions in regards to when coverage under their public health plan becomes effective (5)

Answer 9

1) New borns upon birth
2) Insured residents moving to a new jurisdiction are covered as of the first day of the third month of residence

3) Persons arriving from outside canada to reestablish residence as of the day of arrival (citizens and perm residents)

4) For new Canadians or immigrants not greater than 3 months from the day of arrival

5) Discharged members of the Canadian Forces and released federal inmates as of the day of discharge/release

Question 10

2.1 Define primary health care services

Answer 10

Services provided at first point of contact with the health care system.

Question 11

2.1 what are the dual functions of primary health care services

Answer 11

1) Providing a first point of contact

2) Coordinating patient health services to ensure continuity of care and ease of movement across systems where more specialized care is needed

Question 12

2.1 Who are the usual providers of primary health care (4 examples)

Answer 12

1) Family doctor
2) Nurse
3) Nurse practitioner
4) pharmacists etc

can also include dentists, and other allied health care professionals

Question 13

2.2 Identify secondary health care services available in Canada (3 examples)

Answer 13

Specialized care at a hospital or services at home or in the community.

Or long term care facilities.

Can include nursing care, homemaker services, adult day care - often for individuals who are partially or totally incapacitated

Question 14

2.3 Describe services that are considered supplementary health care services in Canada (5)

Answer 14

• prescription drugs outside the hospital
• dental care
• vision care
• medical equipment and appliances
• services of health professionals outside of the hospital such as physiotherapists

Question 15

3.1 List the 5 program criteria applicable to insured health services that provincial/territorial health care insurance must meet to be eligible for the full federal CHT cash contribution

Answer 15

1) Public Administration

2) Comprehensiveness

3) Universality

4) Portability

5) Accessibility

Question 16

3.1 In the context of criteria for full funding from the federal gov’t for health care describe: Public administration

Answer 16

Ensures that the insurance plan is administered and operated on a nonprofit basis by a public authority.

This authority is accountable to the provincial/territorial gov’t for decision making on benefit levels and services and its records are publicly audited.

Question 17

3.1 In the context of criteria for full funding from the federal gov’t for health care describe: Comprehensiveness

Answer 17

That provincial/territorial gov’ts cover all insured health services provided by hospitals, physicians or dentists (in hospitals)

Question 18

3.1 In the context of criteria for full funding from the federal gov’t for health care describe: Universality

Answer 18

All insured residents must be entitled to the insured health services provided by the provincial/territorial health care insurance plan on uniform terms and conditions

Question 19

3.1 In the context of criteria for full funding from the federal gov’t for health care describe: Portability

Answer 19

Residents moving from one province to another must continue to be covered for insured health care services by the home jurisdiction during any waiting period imposed by the new province or territory

Question 20

3.1 In the context of criteria for full funding from the federal gov’t for health care describe: Accessability

Answer 20

The intent of the accessibility provision is to ensure that insured residents of a province/territory have reasonable access to insured hospital, medical, and surgical dental care on uniform terms and conditions.

This must be unimpeded and unprecluded by other charges or means (discrimination on the basis of age, health status or financial circumstances)

Question 21

3.2 Outline two additional requirements of CHA as it relates to payments by provincial/territorial health care insurance plans to providers of insured services

Answer 21

1) Reasonable compensation to physicians and dentists for all insured health care services

Question 22

3.3 Define insured persons under the CHA

Answer 22

Eligible residents of a province or territory.

A person lawfully entitled to remain in Canada who makes their home and is ordinarily present on the province or territory but the term doesn’t include a tourist, transient or a visitor

Question 23

3.3 list the 3 criteria for “ordinarily present” as it pertains to being an insured person under the CHA

Answer 23

1) Makes their permanent home in the province or territory

2) Is physically present in the province or territory at least 183 days in any calendar year

3) Is a Canadian Citizen, permanent resident or landed immegrant

Question 24

3.3 Define excluded person under CHA

Answer 24

serving members of the Canadian Armed Forces or inmates of a federal penitentiary

Question 25

3.4 Describe the process used to implement the portability provisions of the CHA

Answer 25

Bilateral reciprocal billing agreements between provinces/territories

All prov/terr participate in reciprocal hospital agreements and all except QC in reciprocal physician agreements.

The health care of another province will be accepted and then that province will be billed.

Insured services are to be paid at the host provinces rate except for QC physician services which are billed under QC rates

Question 26

3.5 Identify the effective date of health care coverage for insured services for a person moving provinces/territories

Answer 26

Generally on the first day of the third month of residence

Question 27

3.5 Identify the effective date of health care coverage for insured services for a person returning form outside Canada to reestablish residence.

Answer 27

On the day of arrival provided they are a citizen or permanent resident

Question 28

3.6 Describe how the costs of supplementary insured health care services are reimbursed by provincial/territorial health care insurance plans if they are received outside of the individual’s province of residence

Answer 28

For most supplemental health care services there is no reimbursement if the service is rendered outside the province or territory of residence or coverage is limited to what would have been payable in the home province

Question 29

3.7 Define extra billing infer the CHA

Answer 29

Billing for an insured health care service rendered to a insured person for any amount in addition to the amount paid by the provincial/territorial health care insurance plan

Question 30

3.7 define User charges under the CHA

Answer 30

Charges for insured health service other than extra billing that are permitted by a provincial/territorial health care insurance plan and not payable by the plan.

For example if patients were charged a facility fee for receiving insured services in a hospital or clinic that is a user charge

Question 31

3.7 What is the mandatory penalty provision should extra billing or user charges occurr

Answer 31

Provinces that allow extra billing or user charges are subject to mandatory dollar for dollar deductions from the federal transfer payments under CHT

Question 32

3.8 Outline circumstances under which provinces and territories are permitted to charge a user fee for insured hospital services

Answer 32

If the hospitalization is for chronic care (in the opinion of the attending physician) and the patient is more or less permanently a resident of the health care facility

Question 33

3.9 Define chronic care in the context of the CHA and identify the types of services provided in a chronic care facility

Answer 33

Required by a person who is chronically ill or has a functional disability, 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.

A chronic care facility is a facility providing ongoing long term, in patient medical services. This does not include nursing homes.

Question 34

3.10 Describe how the CHA defines: Insured hospital services

Answer 34

Necessary inpatient and outpatient services

Question 35

3.10 Describe how the CHA defines: Insured physician services

Answer 35

medically required services rendered by medical practitioners.

Question 36

3.10 Describe how the CHA defines Insured surgical dental services

Answer 36

provided by a dentist in a hospital where a hospital is required to properly perform the procedure

Question 37

3.10 Describe how the CHA defines Extended health care services

Answer 37

Aspects of long term residential care and health aspects of home care and ambulatory services

Question 38

3.11 Outline the types of practitioners who can provide insured physician services under the CHA (3)

Answer 38

1) General practitioners who engage in the general practice of medicine

2) Physicians who are not specialists within the meaning of the clause

3) Specialists who are physicians and are recognized as specialists by the appropriate licensing body of the jurisdiction in which they practice

Question 39

3.11 Outline the services considered insured physician services under the CHA (5)

Answer 39

1) Diagnosis and treatment of illness and injuries

2) Surgical services

3) Maternity services

4) Anesthesia services

5) X-Ray, laboratory and other diagnostic procedures

Question 40

3.12 Describe the categories of insured surgical dental services under the CHA

Answer 40

1) Oral and maxillary facial surgery

2) Routine extraction services for cardiac, transplant, immune compromised or radiation patients when these patients are undergoing active treatment in a hospital setting and the attendant medical procedure so requires

3) All precancerous or cancerous dental biopsies

Question 41

3.13 Identify the types of health care programs and services that fall outside the scope of the CHA (2)

Answer 41

1) Noninsured hospital services such as preferred hospital accommodations, private duty nurses and telephones/TVs

2) Noninsured physician services such as telephone advice, provision of medical certificates for work, testimony in court and cosmetic services

Question 42

4.1 Describe health Canada’s approach to resolving possible CHA compliance issues with provinces/territories

Answer 42

Emphasizes transparency, consultation, and dialogue with provinces.

In most instances this resolves the issue. Deductions are only applied when all other options have been exhausted

Question 43

4.2 List 3 sources of clarification of the CHA that have been issued by the federal government

Answer 43

1) The EPP letter

2) The Marleau letter

3) A 2002 letter issued by the federal minister of health to provincial/territorial counterparts outlining the Canada Health Act Dispute Avoidance and Resolution process

Question 44

4.2 What is in the EPP letter

Answer 44

The federal government’s interpretation of CHA criteria, conditions and regulatory provisions

Question 45

4.2 What is in the Marleau letter

Answer 45

The federal policy on private clinics.

Issued in 1995

States that hospital as defined in the CHA includes any public facility that provides acute, rehabilitative or chronic care.

So when a provincial/territorial health care insurance plan pays the physician fee for a medically necessary service delivered at a private clinic it must also pay the facility fee or face a deduction in transfer payments

Question 46

4.2 What is the Canada Health Act Dispute Avoidance and Resolution process?

Answer 46

Includes dispute avoidance techniques like talking to your counterparts, discussion and clarification of issues as they arise.

When dispute avoidance fails dispute resolution is initiated beginning with gov’t to gov’t talks.

If these are unsuccessful either minister of health may refer the issue to a third party panel to undertake fact finding and provide advice and recommendations.

The federal minster has the final authority to interpret and enforce the CHA and takes the panel’s report into consideration.

Question 47

5.1 Describe how the provincial/territorial jurisdictions determine the health care services to cover under their representative system

Answer 47

The CHA doesn’t define medically necessary services but it does require that they be covered by the public insurance plan. The provinces and territories in consultation with the respective physician colleges or groups determine what is medically necessary.

Since non-medically necessary services don’t need to be covered and the definition is determined by the provinces there is variation in what is covered between provinces.

Question 48

5.2 Identify the general categories of insured hospital services provided under provincial/territorial health plans (8)

Answer 48

Acute care facilities for the entire period during which such services are required.

General categories include :

1) Accommodation and meals in the public ward

2) Necessary nursing services

3) Laboratory, radiological and other diagnostic services

4) Drugs when administered in a hospital

5) Use of operating room, case room and anesthetic facilities

6) Use of radiotherapy and physiotherapy facilities

7) Medical and surgical equipment and supplies

8) Outpatient services

Question 49

5.3 Describe how long term secondary health services are provided in the public health care system (2 points)

Answer 49

All provinces and territories provide and pay for certain secondary services such as home and continuing care services but many secondary services are not covered by CHA. Regulation and range of covered services vary across jurisdictions.

Long term secondary health care services are for the most part paid by provinces/territorial governments but the costs of room and board are the responsibility of the individual receiving care. (Sometimes these are subsidized)

Question 50

5.4Outline the extent to which long care services are funded through the public health care system (4 points)

Answer 50

The majority of nursing costs are covered for those who are without means by providing ward rates in a shared room.

In all provinces and territories most clients/residents pay a portion of nursing home costs.

Residents pay for semiprivate and private accommodation in most institutions.

Health aspects of home care at least to the level of public health nursing are covered by provincial/territorial plans

Question 51

5.5 Describe the general extent of supplementary health care services provided by provincial/territorial health care insurance plans

Answer 51

There is considerable variation among jurisdictions for what drugs and user fees apply.

Costs are subsidized for some residents particularly low income individuals and seniors.

Plans vary between covering a wide range of drugs for a targeted group and those that provide a narrower range of drugs and serve a larger number of people. Higher copayments and deductibles may be used to limit utilization.

Question 52

5.5 Are eye examinations covered by provincial/territorial health plans

Answer 52

Only for seniors and or children

Question 53

5.5 Is nonhospitalized dental care covered by provincial/territorial health plans?

Answer 53

In some jurisdictions for children

Question 54

5.5 What independent living aids are covered by provincial/territorial health plans

Answer 54

Varies by jurisdiction. Can include hearing aids, wheelchairs and medical supplies

Question 55

5.5 Are physiotherapy and chiropractic services covered by provincial/territorial health plans

Answer 55

IN some jurisdictions, provided certain conditions are met

Question 56

6.1 Outline how hospitals are reimbursed for covered services

Answer 56

Hospital operating costs are paid out of an annual budget negotiated between the hospital and the provincial/territorial ministry of health or regional health authority.

Question 57

6.1 Outline how hospitals and physicians are reimbursed for covered services

Answer 57

In private practice through fee for service schedules

In other practice settings such as clinics, community health centers and group practices usually through an alternative payment method such as salaries or a blended system, such as FFS plus incentives

Question 58

6.2 Describe the method of reimbursement for insured services provided by provincial/territorial health care insurance plans to medical providers who are participating practitioners.

Answer 58

The public health care administrator reimburses the health care provider directly at the rate defined by the jurisdictions fee schedule.

If the jurisdiction imposes specific dollar limits on the amount that the public plan will reimburse the insured person is responsible for paying any charges over the limit to the practitioner or health care facility

Question 59

6.3 Describe reimbursement for medical care providers who are opted out practitioners and the information they must provide to receive reimbursement

Answer 59

The health care provider bills the patient directly at the rate set by the jurisdiction and then the patient seeks reimbursement from the public health care administrator.

The patient must receive sufficient billing information from the practitioner to satisfy the public administrator

Question 60

6.4 Describe what makes medical providers “nonparticipating” practitioners and how they are paid for the health care services they provide

Answer 60

The provider doesn’t participate in the public plan and bills the patient at a fee level established by the provider.

The practitioner must advise patients of this and neither the practitioner nor patient is eligible for reimbursement from the health authority

Question 61

7.1 Describe how publicly funded health care is financed

Answer 61

With general revenues raised through taxes.

Some provinces charge health care premiums but nonpayment doesn’t limit access to medically necessary services

Question 62

7.1 Describe why the health care system is called “single payer”

Answer 62

Canadians don’t pay directly for services provided under public health plans nor are they required to fill out forms at the time of receiving those services.

Question 63

7.2 Distinguish between the financing of primary, secondary and supplemental health care services

Answer 63

Primary: financed through public health care plans

Supplementary - paid by the individual for the most part other than for certain groups