R.R.O. 1990, Reg. 552 (General) under the Health Insurance Act (out-of-country subset)

Section 1.3§Sections

(1) Upon application to be an insured person, a person must meet the following requirements in order to be considered a resident, unless subsection (2) or (3) or another provision of this Regulation provides otherwise:

1. The person must possess an eligible status set out in section 1.4. A person who has an eligible status, then loses it, is no longer a resident, but may regain resident status at a later date by meeting the necessary requirements at that time.

2. The person’s primary place of residence must be in Ontario. For this purpose, the General Manager will consider a child under 16 years old to have the primary place of residence of a person who has lawful custody of the child unless the General Manager has information to the contrary. O. Reg. 133/09, s. 2; O. Reg. 302/22, s. 2 (1).

(2) The following persons are residents, even if they do not meet the other requirements in this Regulation, and they are not affected by any of the other rules in this Regulation regarding recognition as a resident, other than the requirements under sections 3 and 4:

1. Inmates at a correctional institution that is established or designated under Part II of the Ministry of Correctional Services Act.

2. Children who are in the care of a children’s aid society under the Child, Youth and Family Services Act, 2017.

2.1 Children who are receiving services and supports by agreement with a children’s aid society under section 77 of the Child, Youth and Family Services Act, 2017.

3. Young persons who are detained in a place of temporary detention or committed to a place of secure or open custody under Part VI (Youth Justice) of the Child, Youth and Family Services Act, 2017.

4. People who are present in Ontario because they have a work permit issued under the program of the Government of Canada known as the “Seasonal Agricultural Worker Program”. O. Reg. 133/09, s. 2; O. Reg. 253/09, s. 1; O. Reg. 13/18, s. 1; O. Reg. 166/18, s. 1.

(3) Persons who have been granted an emergency authorization to enter into and remain in Canada for humanitarian reasons are residents for the duration of that authorization or any subsequent authorizations issued for the same purpose and they are not affected by any of the other rules in this Regulation regarding recognition as a resident, other than the requirements under paragraphs 1 and 3 of subsection 1.5 (1) and under sections 3 and 4. O. Reg. 302/22, s. 2 (2).

Section 1.4§Sections

A person cannot be recognized as a resident, unless the person has one of the following eligible statuses:

1. Being a Canadian citizen.

2. Being a landed immigrant under the former Immigration Act (Canada), or a permanent resident under the Immigration and Refugee Protection Act (Canada).

3. Being registered as an Indian under the Indian Act (Canada).

4. Being a “protected person”, as that term is used in the Immigration and Refugee Protection Act (Canada).

5. Being a person who has submitted an application for permanent residence in Canada to the proper federal government authority, even if the application has not yet been approved, as long as Citizenship and Immigration Canada has confirmed that the person meets the eligibility requirements to apply for permanent residency in Canada, and the application has not yet been denied.

6. Being a person who holds a valid work permit or other document issued under the Immigration and Refugee Protection Act (Canada) that permits the person to work in Canada, if the person also has a formal agreement in place to work full-time for an employer in Ontario and is working under that agreement, and if the work permit or other document issued under that Act or a letter provided by the employer or other document provided by the employer,

i. sets out the employer’s name,

ii. states the person’s occupation with the employer, and

iii. states that the person will be working for the employer for no less than six consecutive months.

7. Being a person who holds a valid work permit or other document issued under the Immigration and Refugee Protection Act (Canada) that permits the person to work at an occupation in Canada while self-employed, if the person is self-employed full-time in that occupation in Ontario and will continue to be so for no less than six consecutive months.

8. Being a member of the clergy of a religious denomination, if the member has finalized an agreement to minister to a religious congregation or group in Ontario for at least six months, as long as the member is legally entitled to stay in Canada. The main duties of ministering to the congregation or group must be preaching doctrine, performing functions related to gatherings of the congregation or group or providing spiritual counselling.

9. Being the spouse or a dependant of a person who meets the requirements under paragraph 6 or 7 or of a member of the clergy who meets the requirements provided for in paragraph 8, as long as the spouse or dependant is legally entitled to stay in Canada.

10. Having a valid “temporary resident permit” under the Immigration and Refugee Protection Act (Canada), if the permit is for a member of an “inadmissible class”, with a “case type” of 86, 87, 88, 89, 90, 91, 92, 93, 94 or 95, or, if the permit is issued for the purpose of adoption to a child mentioned in subsection 6 (2), (3) or (4), “case type 80”.

11. Being a person who has submitted an application for Canadian citizenship under section 5.1 of the Citizenship Act (Canada) to the proper federal government authority, even if the application has not yet been approved, as long as Citizenship and Immigration Canada has confirmed that the person meets the eligibility requirements to apply for citizenship under that section and the application has not yet been denied.

12. Having a valid work permit under the Government of Canada program known as “Live-in Caregiver Program”.

13. Being a child born out of country to a mother who is receiving insured services referred to in section 1.9, if at the time the mother left Ontario to receive those insured services she was pregnant with that child and if at the time of the child’s birth the mother was receiving the insured services out of country. O. Reg. 133/09, s. 2; O. Reg. 253/09, s. 2.

Section 1.5§Sections

(1) The following requirements must be met for a person to be continued to be recognized as a resident:

1. The person must be in Ontario for at least 153 of the first 183 days after becoming a resident, except for,

i. a person who has moved to Ontario directly from another province or territory of Canada where he or she was insured under a publicly funded health care insurance plan,

ii. a mobile student or a mobile worker,

iii. a child to whom section 6 applies, or

iv. a person who is a spouse or dependant of a member of the Canadian Forces.

2. Except for those persons listed in subsection 1.3 (2), the person must continue to maintain his or her primary place of residence in Ontario.

3. Subject to sections 1.6 to 1.14, the person must be physically present in Ontario for at least 153 days in any given 12-month period.

4. The person must continue to hold an eligible status as listed in section 1.4. However, in order to maintain their eligible status as a resident, a person referred to in paragraph 13 of section 1.4 must be legally entitled to remain in Canada and will only maintain their eligible status under that paragraph as long as reasonable efforts are being made for the person to obtain one of the other eligible statuses under section 1.4. O. Reg. 133/09, s. 2; O. Reg. 67/20, s. 2.

(2) For the purposes of subsection (1), the General Manager will consider a child under 16 years old to be physically present with and have the primary place of residence of a person who has lawful custody of the child unless the General Manager has information to the contrary. O. Reg. 133/09, s. 2.

(3) Despite subsection (1), a resident who leaves Ontario permanently to reside in another province or territory of Canada remains a resident, even though he or she is not physically present in Ontario or does not have Ontario as his or her primary place of residence, as long as he or she continues to have an eligible status, but only until the end of the last day of the second full month after leaving Ontario. O. Reg. 133/09, s. 2.

Section 1.6§Sections

(1) A resident is considered to meet the physical presence requirement for up to 12 full months, if he or she temporarily goes to another province or territory of Canada. O. Reg. 133/09, s. 2.

(2) A person mentioned in subsection (1) ceases to be a resident on the last day of his or her 12th consecutive month of absence from Ontario, or, if the move becomes permanent, the last day of the second full month after the move becomes permanent, whichever occurs first. O. Reg. 133/09, s. 2.

(3) This section only applies if the resident meets any of the following requirements, or any combination of the following requirements, for at least 153 days out of the 12 months immediately before he or she leaves Ontario:

1. Being physically present in Ontario.

2. Being a mobile student or mobile worker. O. Reg. 133/09, s. 2.

(4) This section does not apply if subsection 1.8 (1) applies to the person. O. Reg. 133/09, s. 2.

Section 1.7§Sections

(1) A resident is considered to meet the physical presence requirement during a maximum of five 12-month periods if he or she leaves Canada in order to either work full-time for payment for an employer with whom he or she has a contract of employment, or to serve full-time for a charity that is registered under the Income Tax Act (Canada). O. Reg. 133/09, s. 2.

(2) Subsection (1) only applies if the resident meets any of the following requirements, or any combination of the following requirements, for at least 153 days in each of the two consecutive 12-month periods immediately before he or she leaves Canada to work or serve:

1. Being physically present in Ontario.

2. Being a mobile student or mobile worker. O. Reg. 133/09, s. 2.

Section 1.8§Sections

(1) A resident who goes to another province or territory of Canada to attend as a student one or more full-time academic programs in an educational institution in that province or territory is considered to meet the physical presence requirement as long as he or she maintains continuous full-time enrolment. O. Reg. 133/09, s. 2.

(2) Subsection (1) only applies if the resident meets any of the following requirements, or any combination of the following requirements, for at least 153 days in the 12 months immediately before going to the other province or territory:

1. Being physically present in Ontario.

2. Being a mobile student or mobile worker.

3. Remaining a resident by virtue of subsection (3). O. Reg. 133/09, s. 2.

(3) A resident who goes to another jurisdiction outside Canada to attend as a student one or more full-time academic programs in an educational institution in that jurisdiction is considered to meet the physical presence requirement as long as he or she maintains continuous full-time enrolment. O. Reg. 133/09, s. 2.

(4) Subsection (3) only applies if the resident meets any of the following requirements, or any combination of the following requirements, for at least 153 days in each of the two consecutive 12-month periods immediately before going to the other jurisdiction:

1. Being physically present in Ontario.

2. Being a mobile student or mobile worker.

3. Remaining a resident by virtue of subsection (1). O. Reg. 133/09, s. 2.

Section 1.9§Sections

A resident who leaves Ontario is considered to meet the physical presence requirement during the time that he or she is out of Ontario receiving insured services for which an application for approval for payment by the General Manager is required to be submitted by this Regulation, and for which payment has been approved. O. Reg. 133/09, s. 2.

Section 1.10§Sections

A resident who is a member of the Canadian Forces or Royal Canadian Mounted Police or who is a Canadian diplomat and who was a resident immediately before leaving for a posting outside Canada is considered to meet the physical presence requirement during the time he or she is posted outside of Canada. O. Reg. 133/09, s. 2.

Section 1.11§Sections

(1) In addition to the other circumstances in which a resident is also considered to meet the physical presence requirement, a resident who travels outside Ontario is considered to meet the physical presence requirement for a maximum of two 12-month periods if the resident meets any of the following requirements, or any combination of the following requirements, for at least 153 days in each of the two consecutive 12-month periods immediately before he or she leaves Ontario:

1. Being physically present in Ontario.

2. Being a mobile student or mobile worker. O. Reg. 133/09, s. 2.

(2) Subsection (1) does not apply to a person more than once unless he or she has been physically present in Ontario or a mobile student or mobile worker for at least 153 days in each of at least five consecutive 12-month periods before each subsequent time that subsection (1) applies. O. Reg. 133/09, s. 2.

Section 1.12§Sections

(1) A resident who is the spouse or a dependant of someone who continues to be a resident under sections 1.7 or 1.8 and who accompanies that person while they are in another province, territory or jurisdiction, as the case may be, is considered to meet the physical presence requirement while they are accompanying the person to whom section 1.7 or 1.8 applies, if they met the applicable requirements under those sections that applied to the person they are accompanying immediately before going to the other province, territory or jurisdiction. O. Reg. 133/09, s. 2.

(2) A resident who is the spouse or a dependant of someone who continues to be a resident under section 1.9 and who accompanies that person while they are out of Ontario is considered to meet the physical presence requirement while they are accompanying the person. O. Reg. 133/09, s. 2.

(3) A resident who is the spouse or a dependant of a member of the Canadian Forces or Royal Canadian Mounted Police who continues to be a resident under section 1.10 or of a Canadian diplomat who continues to be a resident under that section and who accompanies that member or diplomat while they are out of Canada is considered to meet the physical presence requirement while they are accompanying the person. O. Reg. 133/09, s. 2.

Section 1.13§Sections

A resident is considered to meet the physical presence requirement during any period of time where that person is unable to return to Ontario as a result of activity by another person that would be considered to be unlawful in Canada. O. Reg. 133/09, s. 2.

Section 1.14§Sections

A resident is considered to meet the physical presence requirement during any period of time where he or she is out of Ontario because he or she is a mobile student or a mobile worker. O. Reg. 133/09, s. 2.

Section 25§Sections

(1) The following services rendered outside of Ontario by physicians shall be deemed not to be insured services in respect of insured persons who are under the age of sixteen years:

1. Ligation, cauterization or removal of vas deferens — uni or bilateral (vasectomy).

2. Hysterectomy or ligation, cauterization or removal of fallopian tubes — uni or bilateral by abdominal or vaginal approach, including laparoscopy, culdoscopy, or hysteroscopy — for sterilization (any method). R.R.O. 1990, Reg. 552, s. 25 (1).

(2) All services rendered outside of Ontario by hospitals in connection with the services specified in subsection (1) shall be deemed not to be insured services in respect of insured persons who are under the age of sixteen years. R.R.O. 1990, Reg. 552, s. 25 (2).

(3) Subsections (1) and (2) do not apply where the surgeon or the attending physician believes that the surgical operation is medically necessary for the protection of the physical health of the insured person. R.R.O. 1990, Reg. 552, s. 25 (3).

Section 28§Sections

(1) In-patient or out-patient services rendered in a hospital outside Ontario but within Canada are prescribed as insured services if,

(a) the hospital that supplied the service is approved by the General Manager for the purpose of the Plan;

(b) the hospital that supplied the service is licensed or approved as a hospital by the governmental hospital licensing authority in whose jurisdiction the hospital is situated;

(c) the service, if performed in Ontario, is one to which the insured person would be entitled without charge pursuant to section 7 in the case of an in-patient service or section 8 in the case of an out-patient service;

(d) in the case of an in-patient service, in Ontario, the insured person would ordinarily have been admitted as an in-patient of a public hospital to receive the service;

(e) the hospital or the insured person provides to the General Manager such information and records as the General Manager may require for the purpose of assessing and verifying the claim; and

(f) the services received, including accommodation, do not constitute, in the opinion of the General Manager, the domiciliary type of care provided in a long-term care home, an infirmary or other institution of a similar character. O. Reg. 135/09, s. 3; O. Reg. 100/10, s. 7.

(2) An insured person may be reimbursed by the Plan for the receipt of insured services prescribed by subsection (1) on presentation to the General Manager of an account, including a detailed receipt, from the hospital for payment made by the person to the hospital, or the General Manager may cause reimbursement to be made directly to the hospital. O. Reg. 135/09, s. 3.

(3) The amount to be reimbursed under subsection (2) is determined as follows:

1. If the insured services are rendered in a hospital whose operator is a preferred provider, the amount payable is the amount provided in the preferred provider arrangement.

2. If the insured services are covered by a preferred provider arrangement in the province in which the services are rendered, but the insured person receives services performed by an identical or equivalent procedure in a hospital in that province whose operator is not a preferred provider, the amount payable is the lesser of the following:

i. The amount provided in the preferred provider arrangement.

ii. The amount actually paid by the insured person.

3. If the insured services are not covered by a preferred provider arrangement in the province in which the services are rendered, the amount payable is the amount payable in accordance with the applicable interprovincial reciprocal billing agreement entered into by the Minister under clause 2 (2) (b) of the Act, and if there is no such agreement, the lesser of the following:

i. The usual and customary amount charged under similar circumstances by similar facilities in the jurisdiction where the insured services are rendered.

ii. The amount actually paid by the person. O. Reg. 135/09, s. 3.

(4) If an insured person receives in-patient or out-patient services in a hospital outside Ontario but within Canada for an acute attack of tuberculosis, the Plan may reimburse the insured person for the cost of the treatment for a period not exceeding 60 days and subsection (3) applies. O. Reg. 135/09, s. 3.

(5) Subsection (3) applies, and is deemed to have always applied, with respect to services rendered on or after June 3, 2008. O. Reg. 135/09, s. 3.

Section 28.0.1§Sections

(1) In-patient or out-patient services rendered in a health facility outside Ontario but within Canada are prescribed as insured services if the Minister has entered into a preferred provider arrangement with the operator of that facility for the delivery of those services and the services are rendered in accordance with the preferred provider arrangement. O. Reg. 135/09, s. 3.

(2) On application by the health facility or by or on behalf of the insured person, the General Manager may cause reimbursement to be made to the health facility for the rendering of insured services prescribed under subsection (1). O. Reg. 135/09, s. 3.

(3) The amount to be reimbursed under subsection (2) is the amount provided in the preferred provider arrangement. O. Reg. 135/09, s. 3.

(4) No amount shall be reimbursed if the Minister has entered into a preferred provider arrangement with the operator of a health facility outside Ontario but within Canada for the delivery of services where,

(a) a person receives services from that health facility that are covered by the preferred provider arrangement, but the services are not rendered in accordance with the preferred provider arrangement;

(b) a person receives services from that health facility that are not covered by the preferred provider arrangement; or

(c) a person receives services performed by an identical or equivalent procedure in another health facility outside Ontario but within Canada whose operator is not a preferred provider for those services. O. Reg. 135/09, s. 3.

(5) This section applies, and is deemed to have always applied, with respect to services rendered on and after June 3, 2008. O. Reg. 135/09, s. 3.

Section 28.0.2§Sections

(1) A therapeutic laboratory service or diagnostic laboratory test that is performed outside Ontario but within Canada for an insured person is prescribed as an insured service if that kind of service or test is not performed in Ontario but the service or test is generally accepted in Ontario as appropriate for a person in the same circumstances as the insured person. O. Reg. 27/14, s. 1.

(2) Despite subsection (1), a service or test is not prescribed as an insured service if,

(a) the service or test is experimental or the service or test is performed for research purposes; or

(b) the service or test does not constitute a test as defined in section 5 of the Laboratory and Specimen Collection Centre Licensing Act. O. Reg. 27/14, s. 1.

(3) Subject to subsection (4), an amount is payable for an insured service prescribed by subsection (1) if the service is provided to an insured person and an application for approval of payment is submitted to the General Manager on behalf of the insured person by a physician who practises medicine in Ontario and,

(a) the application includes written confirmation from the physician that, in his or her opinion, the conditions in subsection (1) are satisfied; and

(b) written approval of payment of the amount for the service is granted by the General Manager before the service is rendered and the service is rendered within the time limit set out in the written approval. O. Reg. 27/14, s. 1.

(4) Where an insured service prescribed by subsection (1) is a genetic service or test, an amount is not payable for the insured service unless the application under subsection (3) includes written confirmation from a physician who practises medicine in Ontario and who is a specialist, as defined in the schedule of benefits, in treating the medical condition to which the test or service for which approval of payment is sought relates that, in that specialist’s opinion, the conditions in subsection (1) are satisfied. O. Reg. 27/14, s. 1; O. Reg. 208/23, s. 2.

(5) The amount payable by the Plan for a service or test prescribed by subsection (1) is the amount determined by the General Manager. O. Reg. 27/14, s. 1.

(6) An insured person may be reimbursed by the Plan for an amount paid for insured services prescribed by subsection (1) on presentation to the General Manager of an account, including a detailed receipt, from the laboratory that performed the service for payment made by the person to the laboratory, or the General Manager may cause reimbursement to be made directly to the laboratory. O. Reg. 27/14, s. 1.

Section 28.0.3§Sections

In the case of any service prescribed under sections 28 to 29, the General Manager may require information and records to be provided in order to assess and verify the claim for payment, and where such information and records are not provided to the satisfaction of the General Manager, the amount payable for the insured service is nil. O. Reg. 27/14, s. 1.

Section 28.1§Sections

Licensed facilities outside Canada where medical or surgical services are rendered are prescribed as health facilities for the purposes of the Act. O. Reg. 178/21, s. 5.

Section 28.2§Sections

(1) Out-patient services described in subsection (3) and rendered outside Canada are prescribed as insured services if,

(a) they are medically necessary;

(b) they are rendered by persons other than physicians, dental surgeons, optometrists, osteopaths or podiatrists;

(c) they are rendered,

(i) in a hospital that is licensed or approved as a hospital by the government in whose jurisdiction the hospital is situated, or

(ii) in a health facility that is licensed by the government in whose jurisdiction the health facility is situated and in which medical or surgical services are routinely rendered on an out-patient basis; and

(d) they are rendered for the purpose of treating an illness, disease, condition or injury that,

(i) is acute and unexpected,

(ii) arose outside Canada, and

(iii) requires immediate treatment. O. Reg. 178/21, s. 5.

(2) Subsection (1) does not apply to an out-patient service that is,

(a) the provision of a drug or other substance for the insured person to take away from the hospital or facility;

(b) a visit solely to administer a drug or other substance;

(c) a physiotherapy, radiotherapy, speech therapy, occupational therapy or diet counselling service; or

(d) a laboratory service. O. Reg. 178/21, s. 5.

(3) The following are the amounts payable by the Plan for insured services prescribed in subsection (1):

1. $50 for services that include Magnetic Resonance Imaging (one scan) prescribed by a physician.

2. $50 for services that include cancer chemotherapy prescribed by a physician.

3. $50 for services that support a surgical procedure that is ordinarily rendered in an operating room and ordinarily requires the services of an anaesthetist.

4. $50 for services that include a Computerized Axial Tomography scan prescribed by a physician.

5. $50 for services that include either lithotripsy or Magnetic Resonance Imaging (more than one scan), prescribed by a physician.

6. $50 for services not otherwise described in this section that are rendered,

i. in a hospital, or

ii. in a health facility, if the services are necessary for the provision of a service that is set out in the schedule of benefits and preceded in the schedule by the symbol “#”.O. Reg. 178/21, s. 5.

(4) The amounts set out in subsection (3) are daily amounts that cover all the out-patient services rendered during the day by persons other than physicians, dental surgeons, optometrists, osteopaths or podiatrists. O. Reg. 178/21, s. 5.

(5) If a day’s services are described by more than one paragraph in subsection (3), the highest amount listed in those paragraphs is the amount payable for the services. O. Reg. 178/21, s. 5.

(6) An amount payable under this section for out-patient services shall be reduced by any amount paid or payable under section 28.3 for in-patient services rendered to the insured person on the same day. O. Reg. 178/21, s. 5.

(7) If the amount payable under this section is more than the amount that would be payable under the Act and this Regulation if the services were rendered in Ontario, then only that latter amount is payable. O. Reg. 178/21, s. 5.

(8) Subsection (7) does not apply if no amount would be payable under the Act and this Regulation if the services were rendered in Ontario. O. Reg. 178/21, s. 5.

Section 28.3§Sections

(1) In-patient services rendered outside Canada in an eligible hospital or health facility are prescribed as insured services if,

(a) the services are medically necessary;

(b) it is medically necessary that the services be provided on an in-patient basis;

(c) in Ontario, the insured person would ordinarily have been admitted as an in-patient of a public hospital to receive the services; and

(d) the services are rendered for the purpose of treating an illness, disease, condition or injury that,

(i) is acute and unexpected,

(ii) arose outside Canada, and

(iii) requires immediate treatment. O. Reg. 178/21, s. 5.

(2) In subsection (1),

“eligible hospital or health facility” means,

(a) a hospital licensed or approved as a hospital by the government in whose jurisdiction the hospital is situated in which complex medical and complex surgical procedures are routinely performed, or

(b) a health facility licensed by the government in whose jurisdiction the health facility is situated in which complex medical and complex surgical procedures are routinely performed. O. Reg. 178/21, s. 5.

(3) Despite subsection (1), if all the services rendered during a day are part of a domiciliary type of care that, in Ontario, would ordinarily be provided in a long-term care home, the services are not prescribed as insured services. O. Reg. 178/21, s. 5.

(4) The amount payable by the Plan for in-patient services prescribed in subsection (1) is the amount actually billed to a maximum of,

(a) $400 per day for the higher level of care described in subsection (5); or

(b) $200 per day for any other kind of care. O. Reg. 178/21, s. 5.

(5) The higher level of care for the purposes of subsection (4) is care for a condition for which the primary treatment ordinarily provided in Ontario is provided in a public hospital in any of the following:

1. A coronary care unit.

2. An intensive care unit.

3. A neonatal or paediatric special care unit.

4. An operating room. O. Reg. 178/21, s. 5.

(6) An amount payable under this section covers all the in-patient services rendered during the day including diagnostic procedures or interpretations rendered by physicians but not including any other kind of service rendered by a physician. O. Reg. 178/21, s. 5.

Section 28.4§Sections

(1) In this section,

“emergency circumstances” means medical circumstances in which an insured person faces immediate risk of,

(a) death, or

(b) medically significant irreversible tissue damage;

“emergency patient referral service” means a person, agency or organization operating in Ontario that,

(a) is approved by the General Manager, and

(b) provides information to physicians, hospitals or health facilities about health services available in emergency circumstances;

“health facility” means,

(a) a health facility licensed as a health facility by the government in whose jurisdiction the health facility is situated in which complex medical and complex surgical procedures are routinely performed,

(b) whether or not described in clause (a), a facility licensed by the government in whose jurisdiction the facility is situated with whose operator the Minister has entered into a preferred provider arrangement;

“hospital” means a hospital licensed or approved as a hospital by the government in whose jurisdiction the hospital is situated in which complex medical and complex surgical procedures are routinely performed;

“urgent circumstances” means emergency circumstances in which it would be impossible or so impractical as to be impossible for a hospital or health facility in which services are rendered to give notice to the General Manager before the services are rendered. O. Reg. 135/09, s. 4.

(2) Services that are rendered outside Canada at a hospital or health facility are prescribed as insured services if,

(a) the service is generally accepted by the medical profession in Ontario as appropriate for a person in the same medical circumstances as the insured person;

(b) the service is medically necessary;

(c) either,

(i) the identical or equivalent service is not performed in Ontario, or

(ii) the identical or equivalent service is performed in Ontario but it is necessary that the insured person travel out of Canada to avoid a delay that would result in death or medically significant irreversible tissue damage;

(d) in the case of a hospital service or a service rendered in a health facility, the service, if performed in Ontario, is one to which the insured person would be entitled without charge pursuant to section 7 in the case of an in-patient service or section 8 in the case of an out-patient service; and

(e) in the case of a service performed for an insured person who is admitted as an in-patient at a hospital or for an overnight stay at a health facility in Ontario, the insured person would ordinarily have been admitted to a public hospital as an in-patient. O. Reg. 135/09, s. 4; O. Reg. 76/12, s. 7 (1).

(3) Services that are rendered outside Canada at a hospital or health facility are prescribed as insured services if,

(a) the conditions in clauses (2) (a), (b), (d) and (e) are satisfied; and

(b) the service is rendered in urgent circumstances in order to treat medical complications resulting or arising from services,

(i) that are insured services under subsection (2),

(ii) that are rendered in circumstances that are not emergency circumstances, and

(iii) for which written approval of payment was granted before the services are rendered, in accordance with subparagraph 1 i of subsection (4). O. Reg. 135/09, s. 4.

(3.1) Despite anything in this section, this section does not apply to a service that is a therapeutic laboratory service or a diagnostic laboratory test, unless the therapeutic laboratory service or diagnostic laboratory test is necessary for the purpose of rendering a service that is insured under this section and that is not a therapeutic laboratory service or diagnostic laboratory test. O. Reg. 83/11, s. 3 (1).

(4) Despite anything in this section as it read before April 1, 2009, a service is not, and is deemed never to have been, an insured service under this section unless the following conditions are satisfied:

1. For services rendered in circumstances that are not emergency circumstances,

i. written approval of payment of the amount for the services is granted by the General Manager before the services are rendered, and

ii. the services are rendered within the time limit set out in the written approval.

2. For services rendered in emergency circumstances, written approval of payment of the amount for the services is granted by the General Manager, either before or after the services are rendered. O. Reg. 135/09, s. 4.

(5) For the purposes of clause (2) (c), a service is performed in Ontario if the service can be legally obtained by an insured person in Ontario and includes,

(a) services that are prescribed as insured services, other than under this section;

(b) services that are publicly funded, in whole or in part;

(c) services that are for sale anywhere in Ontario to a person in the same medical circumstances as the insured person; and

(d) services that a person in the same medical circumstances as the insured person is eligible to receive in Ontario under or through any program or policy, including a program or policy permitting special or extraordinary access to the services. O. Reg. 135/09, s. 4.

(6) The amount payable for insured services prescribed by subsections (2) and (3) is determined as follows:

1. If the services are rendered in a hospital whose operator is a preferred provider, the amount payable is the amount provided in the preferred provider arrangement.

2. If the services are covered by one or more preferred provider arrangements, but the insured person receives identical or equivalent services in or from a hospital or health facility whose operator is not a preferred provider, the amount payable is nil.

3. If the services are not covered by a preferred provider arrangement, the amount payable is the usual and customary amount charged by similar facilities under similar circumstances to major insurers for services rendered, to persons they insure, in facilities located in the jurisdiction where the insured services are rendered. O. Reg. 135/09, s. 4.

(7) An amount is payable for insured services prescribed by subsection (2) if the following conditions are met:

1. An application for approval of payment is submitted to the General Manager on behalf of the insured person,

i. by a physician who practises medicine in Ontario, or

ii. by an emergency patient referral service, but only in emergency circumstances.

2. The application mentioned in paragraph 1 includes written confirmation that the conditions set out in clauses (2) (a) and (b) and one of the conditions set out in clause (2) (c) are satisfied, from,

i. a physician who is a specialist, as defined in the schedule of benefits, in the type of service for which approval of payment is sought,

ii. a general practitioner, if the type of service for which approval of payment is sought is within the general practitioner’s scope of practice, or

iii. in emergency circumstances, a physician who practises medicine in Ontario or an emergency patient referral service.

3. In circumstances that are not emergency circumstances, a service that is identical or equivalent to the service for which payment is sought is not covered by a preferred provider arrangement entered into,

i. between the Minister and the operator of a hospital outside Ontario but within Canada under subsection 27 (1),

ii. between the Minister and the operator of a health facility outside Ontario but within Canada under subsection 27 (2), or

iii. between the Minister and a physician or practitioner outside Ontario but within Canada under subsection 27 (4).

4. For a service that consists primarily of the administration of a drug, including the provision of the drug that is administered, there is a recommendation from the executive officer appointed under the Ontario Drug Benefit Act for payment for the drug for a person in the same medical circumstances as the insured person. O. Reg. 135/09, s. 4; O. Reg. 83/11, s. 3 (2, 3).

(7.1) For the purposes of subclause (2) (c) (i), if there is a physician in Ontario who has provided written confirmation that he or she is available to provide the service that is the subject of an application under subsection (7) and the service is within the physician’s scope of practice, the service is deemed to be identical or equivalent to the service that is the subject of the application. O. Reg. 83/11, s. 3 (4).

(7.2) For the purposes of paragraph 3 of subsection (7), if there is a physician in Canada who has provided written confirmation that he or she is available to provide the service that is the subject of an application under subsection (7) and the service is within the physician’s scope of practice, the service is deemed to be identical or equivalent to the service that is the subject of the application. O. Reg. 83/11, s. 3 (4).

(8) An amount is payable for insured services prescribed by subsection (3) if the following conditions are met:

1. An application for approval of payment is submitted to the General Manager by or on behalf of the insured person.

2. The application includes written confirmation from the hospital or health facility in which the service is rendered that, in the opinion of the hospital or health facility,

i. the service is rendered in urgent circumstances in order to treat medical complications resulting or arising from services that are insured services under subsection (2), and

ii. the service is medically necessary. O. Reg. 135/09, s. 4.

(9) Subject to subsection (4), this section, as it read immediately before April 1, 2014, continues to apply to applications for approval of payment for services in circumstances that are not emergency circumstances,

(a) if the applications were mailed, faxed or otherwise delivered to the General Manager before that date; or

(b) if the applications are in respect of the continuation or extension of the same service for which approval was granted before that date, as long as,

(i) the service is for the same insured person,

(ii) the service is for the same medical condition, and

(iii) the insured person has been outside of Canada receiving the service at a hospital or health facility on a continuous basis without having returned to Ontario since before April 1, 2014. O. Reg. 76/12, s. 7 (2).

Section 28.5§Sections

(1) A therapeutic laboratory service or diagnostic laboratory test that is performed outside Canada is prescribed as an insured service if that kind of service or test is not performed in Ontario but the service or test is generally accepted in Ontario as appropriate for a person in the same circumstances as the insured person. O. Reg. 31/92, s. 3.

(2) Despite subsection (1), a service or test is not prescribed as an insured service if the service or test is experimental or the service or test is performed for research purposes. O. Reg. 31/92, s. 3.

(3) The amount payable by the Plan for a service or test prescribed by subsection (1) is the amount determined by the General Manager. O. Reg. 31/92, s. 3.

(4) An amount is payable for an insured service prescribed by subsection (1) if the following conditions are met:

1. An application for approval of payment is submitted to the General Manager on behalf of the insured person by a physician who practises medicine in Ontario.

2. The application mentioned in paragraph 1 includes written confirmation from the physician who submits the application that, in his or her opinion, the conditions in subsection (1) are satisfied.

3. Written approval of payment of the amount for the service is granted by the General Manager before the service is rendered and the service is rendered within the time limit set out in the written approval.

4. The service is a test as defined in section 5 of the Laboratory and Specimen Collection Centre Licensing Act. O. Reg. 83/11, s. 4 (1).

(4.1) Where an insured service prescribed by subsection (1) is a genetic service or test, an amount is not payable for the insured service unless, in addition to the written confirmation required under paragraph 2 of subsection (4), there is written confirmation from a physician who practises medicine in Ontario and who is a specialist, as defined in the schedule of benefits, in treating the medical condition to which the service or test for which approval of payment is sought relates that, in that specialist’s opinion, the conditions in subsection (1) are satisfied. O. Reg. 267/13, s. 3; O. Reg. 208/23, s. 3.

(4.2) This section, as it read immediately before April 1, 2013, continues to apply to applications for approval of payment for services if the applications were mailed, faxed or otherwise delivered to the General Manager before that date. O. Reg. 76/12, s. 8.

(5) A payment under this section may only be made directly to the person who performed the service or test. O. Reg. 31/92, s. 3.

(6) This section, as it read immediately before April 1, 2011, continues to apply to an application for approval of payment for a service if the application was mailed, faxed or otherwise delivered to the General Manager before that date. O. Reg. 83/11, s. 4 (2).

Section 28.6§Sections

(1) For in-patient services, it is a condition of the payment of any amount under section 28.3 or 28.4 that the General Manager receive, from the hospital or health facility where the services were rendered, a written statement showing,

(a) the day the insured person was admitted;

(b) the diagnosis of the condition for which the insured person was admitted;

(c) the date of discharge or death of the insured person;

(d) the nature of any complications, if any, that warranted a stay in the hospital or health facility that was longer than the average stay of persons with the same condition or disease as the insured person;

(e) the kind and number of any laboratory, radiological or other diagnostic tests performed;

(f) the nature of any treatment, procedure or surgery that was performed;

(g) the discharge diagnosis or cause of death, as the case may be; and

(h) any other information required by the General Manager. O. Reg. 31/92, s. 3; O. Reg. 259/19, s. 8 (1); O. Reg. 178/21, s. 6 (1).

(2) For out-patient services, it is a condition of the payment of any amount under section 28.2 or 28.4 that the General Manager receive, from the hospital or health facility where the services were rendered, a written statement showing,

(a) the diagnosis of the condition for which the insured person was treated;

(b) the kind and number of any laboratory, radiological or other diagnostic tests performed;

(c) the nature of any treatment, procedure or surgery that was performed;

(d) the date or dates when the insured person was treated; and

(e) any other information required by the General Manager. O. Reg. 31/92, s. 3; O. Reg. 259/19, s. 8 (2); O. Reg. 178/21, s. 6 (2).

(3) It is a condition of payment of any amount for services under section 28.2, 28.3 or 28.4 that the General Manager receive,

(a) for payments to the insured person, a detailed receipt; or

(b) for payments directly to the person billing for the services, a detailed invoice in a form specified by the General Manager and a written direction from the insured person authorizing payment to the person billing for the services. O. Reg. 31/92, s. 3; O. Reg. 259/19, s. 8 (3); O. Reg. 178/21, s. 6 (3).

(4) It is a condition for the payment of any amount for services under section 28.5 that the General Manager receive from the hospital or health facility where the service or test was performed,

(a) a written statement showing the kind and number of service or test performed and any other information required by the General Manager; and

(b) a detailed invoice in a form specified by the General Manager. O. Reg. 31/92, s. 3.

Section 29§Sections

(1) A service rendered by a physician outside Ontario is an insured service if, at the time the service is rendered,

(a) the physician is authorized to practice in the jurisdiction outside Ontario where the physician and insured person are both physically located at the time of the service;

(b) both the physician and the insured person are physically located in the jurisdiction referred to in clause (a); and

(c) the service is referred to in the schedule of benefits and rendered in such circumstances or under such conditions as may be specified in the schedule of benefits. O. Reg. 502/22, s. 2.

(2) The amount payable by the Plan for an insured service rendered by a physician outside Ontario to an insured person is as follows:

1. If payment for the service is provided for in a preferred provider arrangement, the amount payable is the amount provided for in the preferred provider arrangement.

2. In all other cases, the amount payable is the lesser of the following:

i. The amount actually billed by the physician.

ii. The amount payable for the service in the schedule of benefits. O. Reg. 259/19, s. 9; O. Reg. 178/21, s. 7 (2).

(3) The amount payable by the Plan for an insured service specified in sections 16 to 20 rendered by a practitioner outside Ontario to an insured person is as follows:

1. If payment for the service is provided for in a preferred provider arrangement, the amount payable is the amount provided for in the preferred provider arrangement.

2. In all other cases, the amount payable is the lesser of the following:

i. The amount actually billed by the practitioner.

ii. The amounts prescribed under sections 16 to 20. O. Reg. 259/19, s. 9; O. Reg. 178/21, s. 7 (3).

(4) It is a condition of payment by the Plan for an insured service rendered outside Canada by a physician or a practitioner that the service is rendered in connection with an illness, disease, condition or injury that,

(a) is acute and unexpected;

(b) arose outside Canada; and

(c) requires immediate treatment. O. Reg. 178/21, s. 7 (4).

(5) In the case of insured services rendered outside Canada that are covered by a preferred provider arrangement, if the insured person receives services performed by an identical or equivalent procedure from a physician or practitioner who is not a preferred provider, the amount payable is nil. O. Reg. 178/21, s. 7 (4).