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AR 78/2006 OUT-OF-COUNTRY HEALTH SERVICES REGULATION

(Consolidated up to 135/2017)

ALBERTA REGULATION 78/2006

Alberta Health Care Insurance Act

OUT‑OF‑COUNTRY HEALTH SERVICES REGULATION

Table of Contents

                1       Interpretation

                2       Application

                3       OOCHSC continued


                4       Members

                5       Quorum and voting

                6       Functions of OOCHSC

                7       Screening of application

                8       Review and decision of OOCHSC

                9       Payment by Minister

              10       Appeal of OOCHSC decision

              11       Appeal Panel

              12       Majority decision

              13       Appeal Panel reviews application and OOCHSC decision

           13.1       Transitional

              14       Expiry

Interpretation

1(1)  In this Regulation,

                                 (a)    “Appeal Panel” means the Out‑of‑Country Health Services Appeal Panel continued under section 11;

                                 (b)    “Chair”, except in sections 11 and 12, means the chair of the Out-of-Country Health Services Committee;

                                 (c)    “dependant” means dependant as defined in the Alberta Health Care Insurance Regulation;

                                 (d)    “elective services” means insured services and insured hospital services that are not provided in an emergency or in other circumstances in which medical care is required without delay;

                                 (e)    “insured hospital services” means insured services as defined in Part 3 of the Hospitals Act;

                                 (f)    “OOCHSC” means the Out-of-Country Health Services Committee continued under section 3.

(2)  For the purposes of this Regulation, a service is available in Canada if a resident could have obtained the service in Canada within the time period generally accepted as reasonable by the medical or dental profession for any resident with a similar condition.

Application

2(1)  Subject to subsections (2) and (3), an application may be made to the OOCHSC for approval of the payment of expenses with respect to insured services or insured hospital services received outside of Canada, where the resident or the resident’s dependant has endeavoured to receive the services in Canada and the services are not available in Canada.

(2)  An application may only be made under subsection (1) with respect to

                                 (a)    elective services, if the application is made prior to receiving the services, or

                                 (b)    insured services or insured hospital services that are not elective services, if the application is made

                                           (i)    prior to receiving the services, or

                                          (ii)    not later than 365 days after the services were received.

(3)  An application under subsection (1) must

                                 (a)    be in writing in a form established by the OOCHSC,

                                 (b)    contain the information required under section 7(1)(b), and

                                 (c)    be made on the resident’s behalf by

                                           (i)    a physician registered under the Health Professions Act, if the services are insured medical services referred to in the Medical Benefits Regulation (AR 84/2006) or insured hospital services, or

                                          (ii)    a dentist registered under the Health Professions Act, if the insured services are oral and maxillofacial surgery services referred to in the Oral and Maxillofacial Surgery Benefits Regulation (AR 86/2006).

(4)  Repealed AR 80/2011 s2.

AR 78/2006 s2;80/2011

OOCHSC continued

3   The Out‑of‑Country Health Services Committee established under the Alberta Health Care Insurance Regulation (AR 216/81) is continued.

Members

4(1)  The OOCHSC consists of the following members appointed by the Minister:

                                 (a)    4 physicians;

                                 (b)    an employee of the Department of Health.

(2)  The term of a member appointed under subsection (1)(a) shall not exceed 3 years, and the member is eligible for reappointment.

(3)  The person referred to in subsection (1)(b) is the Chair.

(4)  The Minister may designate an employee of the Department of Health as an alternate for the member referred to in subsection (1)(b) to act as Chair in the place of that member when that member is temporarily absent or unable to act.

(5)  Members of the OOCHSC who are not employees of the Department of Health are entitled to

                                 (a)    $525 for up to and including four hours in any day and $131 for each additional hour or part of an hour in the day spent on the business of the OOCHSC, and

                                 (b)    travelling and living expenses in accordance with Schedule 1, Part A of the Committee Remuneration Order.

AR 78/2006 s4;240/2008;170/2012

Quorum and voting

5(1)  The quorum for the purpose of meetings of the OOCHSC is 3 members, one of whom must be the Chair.

(2)  The Chair is a non‑voting member of the OOCHSC.

(3)  A tie vote on a matter is deemed to be a vote against the matter.

(4)  A decision made by the majority of the members of the OOCHSC who are present at a meeting is, if the members present constitute a quorum, deemed to be a decision of the OOCHSC.

Functions of OOCHSC

6(1)  The OOCHSC shall review, evaluate and decide on all applications made under section 2 that are declared to be complete by the Chair under section 7.

(2)  The OOCHSC shall, on the request of the Minister,

                                 (a)    submit reports to the Minister on its activities, and

                                 (b)    carry out any other activities related to insured services and insured hospital services that the Minister considers appropriate.

Screening of application

7(1)  When an application under section 2 is received by the OOCHSC, the Chair shall conduct an initial screening of the application to ensure that the application

                                 (a)    is made by a person referred to in section 2, and

                                 (b)    contains any other information, including health information, that the Chair considers to be required for the proper review by the OOCHSC.

(2)  In carrying out the initial screening of an application under subsection (1), the Chair, or the person designated by the Chair for that purpose, may conduct any independent investigation that may be considered necessary in order to complete the initial screening of an application.

(3)  After the Chair has concluded the initial screening of an application and is satisfied that the application meets the requirements set out in subsection (1), the Chair may declare the application complete and forward that application to the OOCHSC for review.

AR 78/2006 s7;80/2011

Review and decision of OOCHSC

8(1)  Within 60 days from the date that the Chair has declared under section 7 that an application is complete, the OOCHSC shall decide

                                 (a)    whether the services referred to in the application are insured services or insured hospital services,

                                 (b)    whether to approve payment with respect to insured services and insured hospital services received or to be received outside of Canada, and

                                 (c)    whether, in respect of insured services and insured hospital services received or to be received outside of Canada, to impose conditions on payment.

(2)  In making a decision under subsection (1), the OOCHSC may not approve payment for

                                 (a)    subsistence and accommodation costs of the person receiving insured services or insured hospital services outside of Canada or of anyone who accompanies that person,

                                 (b)    insured services or insured hospital services provided outside Canada if the services are available in Canada, and

                                 (c)    services that the OOCHSC decides are experimental or applied research.

(3)  The OOCHSC may, if it considers it to be advisable or necessary, consult with health specialists in respect of the matter under its consideration before it renders its decision under subsection (1).

(4)  Where the OOCHSC consults with a health specialist under subsection (3), the Minister may pay that health specialist an appropriate fee in respect of that consultation.

(5)  The OOCHSC shall, within 10 days of making a decision under subsection (1), excluding Saturdays, Sundays and holidays, send

                                 (a)    a written copy of its decision with reasons to the Minister, the resident and the physician or dentist who made the application on the resident’s behalf, and

                                 (b)    notice of the right to appeal the decision to the resident and the physician or dentist who made the application on the resident’s behalf.

AR 78/2006 s8;80/2011

Payment by Minister

9   If the OOCHSC approves an application for payment under section 8, the Minister shall pay for those services approved by the OOCHSC.

Appeal of OOCHSC decision

10   The resident or a physician or dentist acting on the resident’s behalf may appeal a decision of the OOCHSC under section 8 to the Appeal Panel by submitting a notice of appeal to the Appeal Panel within 60 days of receipt of the decision.

AR 78/2006 s10;80/2011

Appeal Panel

11(1)  The Out‑of‑Country Health Services Appeal Panel established under the Alberta Health Care Insurance Regulation (AR 216/81) is continued.

(2)  The Appeal Panel consists of 6 members appointed by the Minister, of which 4 must be physicians, one must be an ethicist and one must be a member of the general public.

(3)  The term of the members referred to in subsection (2) shall not be more than 3 years, and those members are eligible for reappointment.

(4)  The Minister may designate a member of the Appeal Panel as the chair and a member of the Appeal Panel as the vice‑chair.

(5)  A quorum of the Appeal Panel consists of 3 members, 2 of whom must be physicians, and one of whom must be either the ethicist or the member of the general public.

(6)  Members of the Appeal Panel who are not employees of the Government are entitled to,

                                 (a)    in the case of the chair who is a physician,

                                           (i)    $790 for up to and including four hours in any day and $197 for each additional hour or part of an hour in the day spent on the business of the Appeal Panel, and

                                          (ii)    travelling and living expenses in accordance with Schedule 1, Part A of the Committee Remuneration Order,

                             (a.1)    in the case of a member who is a physician,

                                           (i)    $525 for up to and including four hours in any day and $131 for each additional hour or part of an hour in the day spent on the business of the Appeal Panel, and

                                          (ii)    travelling and living expenses in accordance with Schedule 1, Part A of the Committee Remuneration Order,

                                     and

                                 (b)    in the case of a member who is not a physician,

                                           (i)    remuneration in accordance with the Committee Remuneration Order at 1.5 times the rate set out in Schedule 1, Part A of that Order, and

                                          (ii)    travelling and living expenses in accordance with Schedule 1, Part A of the Committee Remuneration Order.

AR 78/2006 s11;240/2008;69/2009

Majority decision

12(1)  The chair and the vice‑chair of the Appeal Panel are voting members of the Appeal Panel.

(2)  A decision of the majority of the members of the Appeal Panel who review the appeal is deemed to be a decision of the Appeal Panel.

(3)  A tie vote on a matter is deemed to be a vote against the matter.

Appeal Panel reviews application and OOCHSC decision

13(1)  The Appeal Panel shall review the application and the OOCHSC’s decision if a notice of appeal is received within 60 days of the appellant receiving the decision under section 8.

(2)  In reviewing the OOCHSC’s decision, the Appeal Panel shall review only the written decision and reasons and the matters before the OOCHSC, and shall not review any new evidence.

(3)  An appeal must be reviewed and a decision made within 60 days of receipt of a notice of appeal.

(4)  The Appeal Panel may confirm or vary the decision of the OOCHSC or substitute its decision for the OOCHSC’s decision.

(5)  If the Appeal Panel confirms, varies or substitutes its decision for the OOCHSC’s decision approving the payment of services, the Minister shall pay for those services approved by the Appeal Panel.

(6)  The Appeal Panel shall, within 20 days of making a decision under this section, excluding Saturdays, Sundays and holidays, send a copy of its decision with reasons to

                                 (a)    the Minister,

                                 (b)    each member of the OOCHSC,

                                 (c)    the resident, and

                                 (d)    if the notice of appeal was submitted by a physician or dentist on the resident’s behalf, to that physician or dentist.

AR 78/2006 s13;80/2011

Transitional

13.1   Where

                                 (a)    a person has

                                           (i)    made an application to the OOCHSC, or

                                          (ii)    submitted a notice of appeal to the Appeal Panel,

                                          and a decision has not been rendered respecting the application or notice of appeal on the coming into force of this section, or

                                 (b)    the time for submitting a notice of appeal has not expired on the coming into force of this section,

the application or appeal, if any, must be dealt with or continue to be dealt with in accordance with this Regulation as it read immediately before August 1, 2011.

AR 80/2011 s7

Expiry

14   For the purpose of ensuring that this Regulation is reviewed for ongoing relevancy and necessity, with the option that it may be repassed in its present or an amended form following a review, this Regulation expires on August 15, 2020.

AR 78/2006 s14;5/2016;135/2017