Question Period Note: Canada Health Act Compliance Issues

Overview of federal action on key Canada Health Act compliance issues.

Our Government is firmly committed to Canada’s publicly funded health care system and the principle that everyone deserves access to quality, accessible and universal health care.
The Government of Canada will work with provinces and territories to ensure that its significant ten-year, close to $200 billion, investment in health care funding to provinces and territories is used in ways that respect the principles of the Canada Health Act.
The Canada Health Act ensures all Canadians have access to medically necessary health care services based on their health need, not their ability or willingness to pay.
This Government has demonstrated that it will uphold the Canada Health Act to ensure that patients do not face barriers when accessing medically necessary care. Toward that end, when provinces have permitted patient charges for medically necessary care, Health Canada has levied close to $188 million in deductions to Canada Health Transfer payments since 2015.
IF PRESSED ON PROVINCES AND TERRITORIES USING PRIVATE FACILITIES FOR THE DELIVERY OF INSURED SERVICES…
The Canada Health Act does not preclude private facilities from providing medically necessary services, so long as patients are not charged to access these services.
When provinces have not covered medically necessary services in private clinics, or have permitted clinics to charge patients, this Government has acted and levied deductions to provincial Canada Health Transfer Payments.
IF PRESSED ON MEMBERSHIP FEES AT PRIVATE PRIMARY CARE CLINICS…
The Government of Canada does not support a two-tiered health care system where patients may choose, or be required, to pay membership fees to access insured primary care services at clinics, or to gain preferential access to those services. These fees are considered patient charges under the Canada Health Act and raise concerns under the accessibility criterion of the Act.
Whenever Health Canada becomes aware of clinics charging such fees, the Department engages with their provincial or territorial counterparts, and works with them to eliminate these charges.
This Government will act whenever there is evidence of patients being charged to access medically necessary health care.
IF PRESSED CANADA HEALTH TRANSFER DEDUCTIONS LEVIED TO QUEBEC IN MARCH 2023…
In December 2022, all provinces and territories were required to report patient charges for medically necessary diagnostic services to Health Canada. As Quebec did not report any patient charges, Health Canada was required, under the Canada Health Act, to estimate the volume of patient charges for these services based on the best available data.
Quebec was consulted on this estimate, but in the absence of additional data from the Province Health Canada was required to levy a Canada Health Transfer deduction based on its estimate.
Health Canada continues to consult with the province to encourage them to eliminate patient charges. If they do so, they will be eligible for full reimbursement of their deduction.

Diagnostic Services Policy
The Diagnostic Services Policy confirms the federal position that all medically necessary services, including diagnostic MRI (Magnetic resonance imaging) and CT (computerized tomography scan) services, are insured services, regardless of the venue where the services are delivered. Seven provinces currently allow patients to pay privately for diagnostic services.
Under the Policy, provinces and territories were required to report on patient charges for medically necessary diagnostic services in December 2022. Patient charges for these services have resulted in $76,465,277 in mandatory dollar-for-dollar deductions from the Canada Health Transfer payments of the implicated provinces. Breakdowns by province are as follows:
• British Columbia - $17,165,309 (reimbursed $8,582,655);
• Alberta - $13,781,152;
• Saskatchewan - $742,447;
• Manitoba - $353,827;
• Quebec - $41,867,224;
• New Brunswick - $1,277,659; and
• Nova Scotia - $1,277,659.
Membership/enrollment fees and private primary care clinics
Health Canada is aware of private primary care clinics in several provinces and territories (PTs) that charge enrollment and annual membership fees of up to $7,200. These clinics offer members access to insured primary care services, uninsured services (e.g., massage therapy and nutritional services), as well as comprehensive health assessments, which combine insured and uninsured services. Enrollment and membership fees at clinics staffed by enrolled physicians are considered patient charges under the Canada Health Act and raise concerns under the accessibility criterion of the Act, if access to insured services is contingent or preferential on payment of these fees.
Patient Charges for Medically Necessary Services Delivered Virtually and/or by Non-Physician Health Care Providers
In March 2023, the former Minister of Health issued a statement citing federal concerns with the increase in reports of patient charges to access medically necessary care that would otherwise be covered if provided in-person by a physician. The statement also indicated that a new Canada Health Act Interpretation letter would be developed to address these concerns following engagement with the PTs.
Access to Abortion in Ontario
In summer 2019, evidence in Ontario confirmed that some private abortion clinics charged fees for uninsured services, while not consistently informing patients these fees were optional, with respect to accessing insured surgical abortion services. Since March 2021, deductions totaling $53,265 have been levied against ON’s CHT payments in respect of patient charges for surgical abortion services.
Under the Canada Health Act Reimbursement Policy provinces and territories that face mandatory deductions have the opportunity to be reimbursed if they work with Health Canada to develop a plan to eliminate patient charges for medically necessary services, and the circumstances that led to them within a specified timeframe. Ontario is in the process of implementing its Reimbursement Action Plan to eliminate patient charges for access to abortion services.
Access to Abortion in New Brunswick
In New Brunswick, Regulation 84-20 of the Medical Services Payment Act limits coverage of surgical abortion services to approved hospitals. This means that individuals who receive these services at the private clinic in Fredericton are required to pay out-of-pocket. New Brunswick is the only province with a private abortion clinic (Clinic 554) where the province does not provide coverage for services. Since March 2020, deductions totaling $334,766 have been levied against the NB’s Canada Health Transfer (CHT) payments in respect of patient charges for surgical abortion services.
The Reimbursement Policy
Under the Canada Health Act (CHA) Reimbursement Policy, which came into effect in 2018, provinces and territories that face mandatory deductions have the opportunity to be reimbursed if they work with Health Canada to develop a plan to eliminate patient charges for medically necessary services, and the circumstances that led to them. The plan must be successfully implemented within a specified timeframe (under the Reimbursement Policy, and as outlined in Section 25.01 of the Federal-Provincial Fiscal Arrangements Act, a province has up to two years from the date of a deduction to be reimbursed).

Mandatory Canada Health Transfer deductions, totaling over $82M in respect of deductions for medically-necessary services, were levied in March 2023. Of this amount, over $76 million were for patient charges levied for medically necessary diagnostic imaging services.
Mandatory deductions, are eligible for reimbursement provided the implicated province takes steps to eliminate patient charges and the circumstances that led to them, within two years after the deduction was taken.
Health Canada continues to work with the implicated provinces to provide assistance and guidance on next steps in the reimbursement process.