Health Insurance Act

1 In this Act, “Appeal Board” means the Health Services Appeal and Review Board under the Ministry of Health and Long-Term Care Appeal and Review Boards Act, 1998; (“Commission d’appel”) “billing number” means the unique identifying number issued by the General Manager to a physician, practitioner or health facility that has been granted a billing number by the General Manager under section 16.2; (“numéro de facturation”) “Deputy Minister” means the Deputy Minister of Health and Long-Term Care; (“sous-ministre”) “future cost of insured services” means the estimated total cost of the future insured services made necessary as the result of an injury that will probably be required by a patient after the date of settlement or, where there is no settlement, the first day of trial; (“coût futur des services assurés”) “General Manager” means the General Manager appointed under section 4; (“dire…

Administration

2 (1) The Minister is responsible in respect of the administration and operation of the Plan and is the public authority for Ontario for the purposes of the Canada Health Act. R.S.O. 1990, c. H.6, s. 2 (1). Duties of Minister (2) The Minister may, (a) enter into arrangements for the payment of remuneration to physicians, practitioners and health facilities rendering insured services to insured persons on a basis other than fee for service; (b) enter into agreements with persons, organizations and government agencies outside Ontario for the provision of insured services to insured persons. (c), (d), (e) Repealed: 2009, c. 33, Sched. 18, s. 11 (2). R.S.O. 1990, c. H.6, s. 2 (2); 2009, c. 33, Sched. 18, s. 11 (2); 2017, c. 11, Sched. 3, s. 11. Collection of personal information (3) The Minister may collect, directly or indirectly, (a) personal information that relates to the eligibility of …

3 (1) The Government of Ontario, represented by the Minister of Finance, may enter into and amend from time to time an agreement with the Government of Canada under which Canada will contribute to the cost of that part of the Plan related to the provision of any insured services in or by hospitals and health facilities in accordance with such terms and conditions as the agreement provides. R.S.O. 1990, c. H.6, s. 3 (1); 2006, c. 19, Sched. L, s. 11 (5). Idem (2) The Government of Ontario, represented by the Minister, may enter into and amend from time to time an agreement with the Government of Canada under which Canada will contribute to the cost of that part of the Plan related to insured services other than insured services provided in or by a hospital or health facility, in accordance with such terms and conditions as the agreement provides. R.S.O. 1990, c. H.6, s. 3 (2). Section Ame…

4 (1) A General Manager for the Plan shall be appointed by the Lieutenant Governor in Council. R.S.O. 1990, c. H.6, s. 4 (1). Duties (2) Subject to this Act and the regulations, it is the function of the General Manager and he or she has the power, (a) to administer the Plan as the chief executive officer of the Plan; (b) to carry out registrations in the Plan, including the determination of eligibility and the verification of eligibility; (c) to make payments by the Plan for insured services, including the determination of eligibility and amounts; (d) to establish and maintain branch offices for the administration of the Plan; (e) to conduct actions and negotiate settlements on behalf of the Plan under the subrogation of the Plan under this Act to the rights of insured persons; (f) to require any information required or permitted to be provided to the General Manager under this Act or t…

4.1 (1) The Minister and the General Manager may directly or indirectly collect personal information, subject to such conditions as may be prescribed, for purposes related to the administration of this Act, the Commitment to the Future of Medicare Act, 2004 or the Integrated Community Health Services Centres Act, 2023 or for such other purposes as may be prescribed. 1996, c. 1, Sched. H, s. 3; 2006, c. 19, Sched. L, s. 3 (2); 2023, c. 4, Sched. 1, s. 71 (2). Use of personal information (2) The Minister and the General Manager may use personal information, subject to such conditions as may be prescribed, for purposes related to the administration of this Act, the Commitment to the Future of Medicare Act, 2004 or the Integrated Community Health Services Centres Act, 2023 or for such other purposes as may be prescribed. 1996, c. 1, Sched. H, s. 3; 2006, c. 19, Sched. L, s. 3 (3); 2023, c. 4…

5 Repealed: 2019, c. 15, Sched. 15, s. 4 (2). Section Amendments with date in force (d/m/y) 1993, c. 32, s. 2 (2) - 14/12/1993; 1996, c. 1, Sched. H, s. 4 (1, 2) - 01/05/1996 2000, c. 26, Sched. H, s. 1 (1-3) - 06/12/2000 2007, c. 10, Sched. G, s. 2 (1) - 04/09/2007 2009, c. 33, Sched. 18, s. 11 (3-5) - 15/12/2009 2019, c. 15, Sched. 15, s. 4 (1) - 10/12/2019; 2019, c. 15, Sched. 15, s. 4 (2) – 28/06/2023

5.1 Repealed: 2019, c. 15, Sched. 15, s. 4 (1). Section Amendments with date in force (d/m/y) 2007, c. 10, Sched. G, s. 2 (1, 4) - 04/09/2007 2017, c. 34, Sched. 46, s. 17 - 01/01/2018 2019, c. 15, Sched. 15, s. 4 (1) - 10/12/2019

5.2, 5.3 Repealed: 2019, c. 15, Sched. 15, s. 4 (1). Section Amendments with date in force (d/m/y) 2007, c. 10, Sched. G, s. 2 (1) - 04/09/2007 2019, c. 15, Sched. 15, s. 4 (1) - 10/12/2019

5.4 Repealed: 2019, c. 15, Sched. 15, s. 4 (1). Section Amendments with date in force (d/m/y) 2007, c. 10, Sched. G, s. 3- 01/05/2009 2009, c. 33, Sched. 18, s. 11 (6) - 15/12/2009 2019, c. 15, Sched. 15, s. 4 (1) - 10/12/2019

6 Repealed: 2015, c. 20, Sched. 15, s. 2. Section Amendments with date in force (d/m/y) 1993, c. 32, s. 2 (3) - 14/12/1993; 1996, c. 1, Sched. H, s. 5 (1, 2) - 01/05/1996; 1998, c. 18, Sched. G, s. 54 (2, 3) - 01/02/1999 2006, c. 35, Sched. C, s. 53 -28/08/2007 2009, c. 26, s. 11 (2) - no effect; 2009, c. 33, Sched. 18, s. 11 (1, 7) - 15/12/2009 2015, c. 20, Sched. 15, s. 2 - 29/10/2015

7 Repealed: 2019, c. 15, Sched. 15, s. 5 (2). Section Amendments with date in force (d/m/y) 1996, c. 1, Sched. H, s. 6 - 01/05/1996 2019, c. 15, Sched. 15, s. 5 (1) - 10/12/2019; 2019, c. 15, Sched. 15, s. 5 (2) - 28/06/2023

Report to Assembly

8 Repealed: 1998, c. 18, Sched. G, s. 54 (4). Section Amendments with date in force (d/m/y) 1998, c. 18, Sched. G, s. 54 (4) - 01/02/1999

9 The Minister shall make a report annually to the Lieutenant Governor in Council upon the affairs of the Plan and the Minister shall lay the report before the Assembly if it is in session or, if not, at the next session. R.S.O. 1990, c. H.6, s. 9.

Ontario Health Insurance Plan

10 The Ontario Health Insurance Plan is continued for the purpose of providing for insurance against the costs of insured services on a non-profit basis on uniform terms and conditions available to all residents of Ontario, in accordance with this Act, and providing other health benefits related thereto. R.S.O. 1990, c. H.6, s. 10.

11 (1) Every person who is a resident of Ontario is entitled to become an insured person upon application therefor to the General Manager in accordance with this Act and the regulations. R.S.O. 1990, c. H.6, s. 11 (1). Establishing entitlement (2) It is the responsibility of every person to establish his or her entitlement to be, or to continue to be, an insured person. 1994, c. 17, s. 70. Military families (2.1) Where an application under subsection (1) is made with respect to a spouse or dependant of a member of the Canadian Forces, he or she is exempt from any waiting period that would otherwise apply. 2007, c. 16, Sched. B, s. 1. Change in information (3) It is the responsibility of every person who has been registered as an insured person to report to the General Manager, within 30 days of its occurrence, every change in the information that was reported to the General Manager for t…

11.1 (1) The General Manager shall issue a health card to each insured person. 2019, c. 15, Sched. 15, s. 6. Non-transferable (2) A health card is non-transferable. 2019, c. 15, Sched. 15, s. 6. Must be presented (3) An insured person shall present their health card upon the request of the hospital, physician, practitioner or health facility from which the person receives insured services. 2019, c. 15, Sched. 15, s. 6. Form of card (4) A health card shall be in the form approved by the Minister. 2019, c. 15, Sched. 15, s. 6. Property of Minister (5) A health card remains the property of the Minister at all times. 2019, c. 15, Sched. 15, s. 6. Taking possession of card (6) A prescribed person may take possession of a health card that is surrendered to the person voluntarily. 2019, c. 15, Sched. 15, s. 6. Return to General Manager (7) On taking possession of a health card under subsection …

11.2 (1) The following services are insured services for the purposes of the Act: 1. Prescribed services of hospitals and health facilities rendered under such conditions and limitations as may be prescribed. 2. Prescribed medically necessary services rendered by physicians under such conditions and limitations as may be prescribed. 3. Prescribed health care services rendered by prescribed practitioners under such conditions and limitations as may be prescribed. 1996, c. 1, Sched. H, s. 8. Efforts to change sexual orientation or gender identity (1.1) Despite subsection (1) and subject to the regulations, if any, any services that seek to change the sexual orientation or gender identity of a person are not insured services. 2015, c. 18, s. 1. Exception (1.2) The services mentioned in subsection (1.1) do not include, (a) services that provide acceptance, support or understanding of a perso…

12 (1) Every insured person is entitled to payment to himself or herself or on his or her behalf for, or to be otherwise provided with, insured services in the amounts and subject to such conditions and co-payments, if any, as are prescribed. R.S.O. 1990, c. H.6, s. 12. (2), (3) Repealed: 2007, c. 10, Sched. G, s. 4. Section Amendments with date in force (d/m/y) 1996, c. 1. Sched. H, s. 9 - no effect 2007, c. 10, Sched. G, s. 4 - 04/09/2007

13 This Act shall not be administered or construed to affect the right of an insured person to choose his or her own physician or practitioner, and does not impose any obligation upon any physician or practitioner to treat an insured person. R.S.O. 1990, c. H.6, s. 13.

14 (1) Every contract of insurance, other than insurance provided under section 268 of the Insurance Act, for the payment of or reimbursement or indemnification for all or any part of the cost of any insured services other than, (a) any part of the cost of hospital, ambulance and long-term care home services that is not paid by the Plan; (b) compensation for loss of time from usual or normal activities because of disability requiring insured services; (c) any part of the cost that is not paid by the Plan for such other services as may be prescribed when they are performed by such classes of persons or in such classes of facilities as may be prescribed,

performed in Ontario for any person eligible to become an insured person under this Act, is void and of no effect in so far as it makes provision for insuring against the costs payable by the Plan and no person shall enter into or renew such a contract. R.S.O. 1990, c. H.6, s. 14 (1); 1996, c. 1, Sched. H, s. 10; 2007, c. 8, s. 209. Resident not to benefit from prohibited insurance (2) A resident shall not accept or receive any benefit under any contract of insurance prohibited under subsection (1) whereby the resident or his or her dependants may be provided with or reimbursed or indemnified for all or any part of the costs of, or costs directly related to the provision of any insured service. R.S.O. 1990, c. H.6, s. 14 (2). Exceptions (3) Subsections (1) and (2) do not apply to a contract of insurance entered into by a resident whose principal employment is in the United States of Amer…

15 (1) A physician shall submit all of his or her accounts for the performance of insured services rendered to an insured person directly to the Plan in accordance with and subject to the requirements of this Act and the regulations, unless an agreement under subsection 2 (2) provides otherwise. 2004, c. 5, s. 36. Requirements where Plan billed (2) Where a physician submits his or her accounts directly to the Plan under this section, (a) payment shall be made, (i) directly to the physician, or (ii) as the physician directs in accordance with section 16.1; and (b) the payment by the Plan for the insured services rendered to an insured person constitutes payment in full of the account. 2004, c. 5, s. 36. Where s. 2 (2) applies (3) Where an account is submitted to the Plan in accordance with subsection 2 (2) with respect to insured services rendered to an insured person, the payment by the …

15.1 (1) A designated practitioner shall submit all of his or her accounts for the performance of insured services directly to the Plan in accordance with and subject to the requirements of this Act and the regulations, unless an agreement under subsection 2 (2) provides otherwise. 2004, c. 5, s. 36. Same – non-designated (2) A non-designated practitioner shall submit directly to the Plan that part of his or her account for insured services rendered to an insured person that is payable by the Plan, unless an agreement under subsection 2 (2) provides otherwise. 2004, c. 5, s. 36. Requirements where Plan billed (3) Where a practitioner submits his or her accounts directly to the Plan under this section, (a) payment shall be made, (i) directly to the practitioner, or (ii) as the practitioner directs in accordance with section 16.1; (b) in the case of a designated practitioner, the payment b…

15.2 (1) The following rules apply with respect to a physician or designated practitioner to whom subsection 11 (7) of the Commitment to the Future of Medicare Act, 2004 applies: 1. Sections 15 and 15.1 do not apply to him or her, other than subsection 15 (4). 2. Subsections 15 (5), 16 (5), 16.1 (2), 17 (2), 25 (2) to (9), and 27.2 (3) and (4), as applicable, as they existed immediately before their repeal by the Commitment to the Future of Medicare Act, 2004 continue to apply to the physician or designated practitioner, as the case may be, as if they had not been repealed, except in respect of any prescribed accounts or classes of accounts, and subject to any prescribed circumstances or conditions. 3. Where, under subsection 27.2 (3), the physician or designated practitioner is required to temporarily submit his or her accounts directly to the Plan, the submission of the accounts is not…

15.3 A health facility may only submit claims for payment to the Plan, or receive payments from the Plan pursuant to an arrangement under clause 2 (2) (a), if the health facility has been granted a billing number by the General Manager. 2019, c. 15, Sched. 15, s. 10. Section Amendments with date in force (d/m/y) 2019, c. 15, Sched. 15, s. 10 - 10/12/2019

16 (1) An account or claim submitted in the name of a physician or practitioner in conjunction with the billing number issued to the physician or practitioner, and any payment made pursuant to the account or claim is deemed to have been, (a) submitted personally by the physician or practitioner; (b) paid to the physician or practitioner personally; (c) received by the physician or practitioner personally; and (d) made by and submitted with the consent and knowledge of the physician or practitioner. 2004, c. 5, s. 36. Health facilities (2) Subsection (1) applies with necessary modifications to health facilities. 2004, c. 5, s. 36. Applies despite direction (3) This section applies despite a direction given pursuant to section 16.1. 2004, c. 5, s. 36. Exception (4) This section does not apply to an account, claim or payment in the circumstances and on the conditions prescribed in the regul…

16.1 (1) A physician or a practitioner may direct that payments for services performed by the physician or practitioner and to which the physician or practitioner is lawfully entitled may be directed to such person or entity as may be prescribed and in such circumstances and on such conditions as may be prescribed, including such requirements and other matters with respect to directions as may be prescribed. 2000, c. 42, Sched., s. 19. (2) Repealed: 2004, c. 5, s. 37. Person or entity not entitled (3) The entitlement to payment for services performed by a physician or a practitioner is that of the physician or practitioner and not that of the person or entity to which the physician or practitioner has directed that such a payment be made. 2000, c. 42, Sched., s. 19. Repayment to Plan (4) Where payment is made by the Plan to a person or entity pursuant to subsection (1), any money owing t…

16.2 Subject to an application process set out in the regulations, if any, the General Manager shall grant a billing number to a physician, practitioner or health facility. 2019, c. 15, Sched. 15, s. 12. Section Amendments with date in force (d/m/y) 2019, c. 15, Sched. 15, s. 12 - 10/12/2019

17 (1) Physicians, practitioners and health facilities shall prepare accounts for their insured services in such form as the General Manager may require. The accounts must meet the prescribed requirements. 1996, c. 1, Sched. H, s. 11. (2) Repealed: 2004, c. 5, s. 38. Time for submitting (3) The physician, practitioner, health facility or, in the case of a patient who is billed directly, the patient must submit an account for an insured service to the General Manager within such time after the service is performed as may be prescribed. When submitted, the account must be in the required form and meet the prescribed requirements. 1996, c. 1, Sched. H, s. 11; 2000, c. 26, Sched. H, s. 1 (6). Section Amendments with date in force (d/m/y) 1996, c. 1, Sched. H, s. 11 - 01/05/1996 2000, c. 26, Sched. H, s. 1 (6) - 24/01/2002 2004, c. 5, s. 38 - 23/09/2004

17.1 (1) Subject to section 18, a physician or practitioner who has been granted a billing number and who submits a claim for payment to the General Manager in accordance with this Act for insured services provided by the physician or practitioner shall be paid in accordance with this Act and the regulations. 2019, c. 15, Sched. 15, s. 13. Same (2) An insured person who submits a claim for payment to the General Manager in accordance with this Act for insured services provided by a physician or practitioner who has been granted a billing number shall be paid in accordance with this Act and the regulations. 2019, c. 15, Sched. 15, s. 13. Amount (3) The basic fee payable for an insured service is the amount set out in the regulations. The amount may differ for different classes of physician or practitioner. 1996, c. 1, Sched. H, s. 12. Same (4) The regulations may provide that the basic fe…

17.2 (1) Subject to sections 18 and 28, a health facility that has been granted a billing number and that submits a claim for payment to the General Manager in accordance with this Act for insured services performed by the facility shall be paid in accordance with this Act and the regulations. 2019, c. 15, Sched. 15, s. 14. Same (2) Subsections 17.1 (3) and (4) apply, with necessary modifications, with respect to the basic fee payable for an insured service. 1996, c. 1, Sched. H, s. 12. Adjustment of amount (3) The basic fee payable for an insured service performed by a health facility may be increased or decreased as provided in the regulations based upon such factors as may be prescribed. 1996, c. 1, Sched. H, s. 12. Threshold amount (4) Subsections 17.1 (6) and (7) apply, with necessary modifications, with respect to the fee payable to a health facility. 1996, c. 1, Sched. H, s. 12. S…

17.3 (1) Every physician, practitioner, health facility, hospital and integrated community health services centre shall give the General Manager records or other information, including personal information, that the General Manager may require, (a) for purposes related to the administration of this Act, the Commitment to the Future of Medicare Act, 2004 or the Integrated Community Health Services Centres Act, 2023; or (b) for other prescribed purposes. 2023, c. 4, Sched. 1, s. 71 (3). Same (2) Such persons or organizations as may be prescribed shall give the General Manager such information, including personal information, as may be prescribed and such information as the General Manager may require for the purpose of administering this Act. 2019, c. 15, Sched. 15, s. 15 (1). Form and time (3) The records and other information shall be provided in the form, and within the time, specified …

17.4 (1) For the purposes of this Act, every physician, practitioner and health facility shall maintain such records as may be necessary to establish whether they have provided an insured service to a person. 2019, c. 15, Sched. 15, s. 15 (1). Same (2) For the purposes of this Act, every physician, practitioner and health facility shall maintain such records as may be necessary to demonstrate that a service for which they prepare or submit a claim for payment is the service that they provided. 2019, c. 15, Sched. 15, s. 15 (1). Same (3) For the purposes of this Act, every physician and health facility shall maintain such records as may be necessary to establish whether a service they have provided is medically necessary. 2019, c. 15, Sched. 15, s. 15 (1). Same (4) For the purposes of this Act, every practitioner and health facility shall maintain such records as may be necessary to estab…

17.5 The General Manager shall refuse to pay for an insured service if the claim for payment for the service is not prepared in the required form, does not meet the prescribed requirements or is not submitted to the General Manager within the prescribed time. However, the General Manager may pay for the service if, in the General Manager’s opinion, there are extenuating circumstances. 2019, c. 15, Sched. 15, s. 15 (1). Section Amendments with date in force (d/m/y) 2019, c. 15, Sched. 15, s. 15 (1) - 10/12/2019

18 (1) The General Manager shall determine all issues relating to accounts for insured services in accordance with this Act and shall make the payments from the Plan that are authorized under this Act. 2019, c. 15, Sched. 15, s. 16 (1). Practitioners and health facilities, refuse to pay (2) The General Manager may refuse to pay a claim for payment for an insured service submitted by a practitioner or health facility or may pay a reduced amount in the following circumstances: 1. If the General Manager is of the opinion that all or part of the insured service was not in fact rendered. 2. If the General Manager is of the opinion that the nature of the service is misrepresented, whether deliberately or inadvertently. 3. For a service provided by a practitioner, if the General Manager is of the opinion, after consulting with a practitioner who is qualified to provide the same service, that al…

18.0.1 The General Manager may make a decision to require a person to reimburse the Plan for an amount paid for an insured service rendered to the person if, after the payment is made, the General Manager determines that the person was not an insured person and was not entitled to have a payment paid from the Plan with respect to the service. 2019, c. 15, Sched. 15, s. 16 (1). Section Amendments with date in force (d/m/y) 2004, c. 13, s. 1 - 01/09/2004 2007, c. 10, Sched. G, s. 9, 10 - 04/09/2007 2019, c. 15, Sched. 15, s. 16 (1) - 10/12/2019

18.0.2 A requirement to reimburse the Plan created by a decision of the General Manager under subsection 18 (3) creates a debt owed to the Crown in right of Ontario in the amount set out in the decision of the General Manager, and a requirement to reimburse the Plan created by a decision of the Appeal Board creates a debt owed to the Crown in right of Ontario in the amount set out in the decision of the Appeal Board. 2019, c. 15, Sched. 15, s. 16 (1). Section Amendments with date in force (d/m/y) 2004, c. 13, s. 1 - 01/09/2004 2007, c. 10, Sched. G, s. 9, 10 - 04/09/2007 2019, c. 15, Sched. 15, s. 16 (1) - 10/12/2019

18.0.3 Sections 18 and 18.0.1 apply whether the service or payment in question occurred before or after the coming into force of subsection 17 (1) of Schedule 15 to the Plan to Build Ontario Together Act, 2019. 2019, c. 15, Sched. 15, s. 16 (1). Note: On a day to be named by proclamation of the Lieutenant Governor, section 18.0.3 of the Act is repealed. (See: 2019, c. 15, Sched. 15, s. 16 (2)) Section Amendments with date in force (d/m/y) 2004, c. 13, s. 1 - 01/09/2004 2007, c. 10, Sched. G, s. 9, 10 - 04/09/2007 2019, c. 15, Sched. 15, s. 16 (1) - 10/12/2019; 2019, c. 15, Sched. 15, s. 16 (2) - not in force

18.0.4 Nothing in this Act prevents the General Manager and a person, physician, practitioner or health facility from entering into an agreement at any time, and despite any other provision of this Act, with respect to amounts to be paid or recovered with respect to claims for services. However, for greater certainty, the General Manager is not required to enter into any such agreement. 2019, c. 15, Sched. 15, s. 16 (1). Section Amendments with date in force (d/m/y) 2004, c. 13, s. 1 - 01/09/2004 2007, c. 10, Sched. G, s. 9, 10 - 04/09/2007 2019, c. 15, Sched. 15, s. 16 (1) - 10/12/2019

18.0.5 Repealed: R.S.O. 1990, c. H.6, s. 18.0.5 (2). (See: 2007, c. 10, Sched. G, s. 10.) Section Amendments with date in force (d/m/y) 2004, c. 13, s. 1 - 01/09/2004 2007, c. 10, Sched. G, s. 10 - 04/09/2007

18.0.6 (1) Where, during the time that any of sections 18.0.1, 18.0.2, 18.0.3 and 18.0.4 and paragraph 3 of subsection 20 (1) are in force, the General Manager and a physician come to an agreement regarding a matter to which one of those sections applies, the General Manager shall be deemed to have had the authority to enter into the agreement, and no action shall, either during the time they are in force or after, be commenced against any of the following as a result of entering into the agreement: 1. The General Manager. 2. The Minister, the Crown in right of Ontario or an employee or agent of the Crown. 3. The Medical Review Committee, any of its members, inspectors or employees or agents, if any. 4. The Appeal Board or any of its members, employees or agents. 2007, c. 10, Sched. G, s. 11 (1). (2), (3) Repealed: 2019, c. 15, Sched. 15, s. 17. Section Amendments with date in force (d/m…

18.0.7 (1) Where, by virtue of subsection 18.0.2 (11) as it existed during the time it was in force, payments to a physician continued to be suspended, the suspension shall remain in effect until the physician has complied with subsections 37 (1) and (3) to the satisfaction of the General Manager. 2007, c. 10, Sched. G, s. 12. (2) Repealed: 2019, c. 15, Sched. 15, s. 18. Section Amendments with date in force (d/m/y) 2007, c. 10, Sched. G, s. 12 - 04/09/2007 2019, c. 15, Sched. 15, s. 18 - 10/12/2019

18.1 Repealed: 2015, c. 20, Sched. 15, s. 4. Section Amendments with date in force (d/m/y) 1996, c. 1, Sched. H, s. 13 - 01/05/1996 2002, c. 18, Sched. I, s. 8 (1-6) - 26/11/2002 2007, c. 10, Sched. G, s. 13 (1-15) - 04/09/2007 CTS 23 OC 07 - 1

18.2 If the General Manager is of the opinion that a service performed by a physician, practitioner, health facility or an integrated community health services centre is not medically necessary, and that service was requested by a physician other than the one who performed the service, the General Manager may give notice to the Appeal Board of a request to hold a hearing and at the same time give notice to the physician who requested the provision of the service. 2019, c. 15, Sched. 15, s. 19; 2023, c. 4, Sched. 1, s. 71 (4). Section Amendments with date in force (d/m/y) 1996, c. 1, Sched. H, s. 13 - 01/05/1996 2002, c. 18, Sched. I, s. 8 (7-9) - 26/11/2002 2007, c. 10, Sched. G, s. 14 - 31/03/2010 2017, c. 25, Sched. 9, s. 97 (5) - no effect - see 2019, c. 15, Sched. 15, s. 19 - 10/12/2019 2019, c. 15, Sched. 15, s. 19 - 10/12/2019 2023, c. 4, Sched. 1, s. 71 (4) - 25/09/2023

18.2.1 Section Amendments with date in force (d/m/y) 2009, c. 26, s. 11 (3) - no effect - see Table of Public Statute Provisions Repealed Under Section 10.1 of the Legislation Act, 2006 - 31/12/2019 2017, c. 25, Sched. 9, s. 97 (6) - no effect - see 2009, c. 26, s. 11 (3) - 31/12/2019

18.3 Where the General Manager has required reimbursement under section 18, interest accrues on the amount that is required to be paid commencing on the date of the General Manager’s decision at the rate for postjudgment interest provided for under section 127 of the Courts of Justice Act. 2019, c. 15, Sched. 15, s. 19. Section Amendments with date in force (d/m/y) 2007, c. 10, Sched. G, s. 14 - 31/03/2010 2019, c. 15, Sched. 15, s. 19 - 10/12/2019

19 Repealed: 2019, c. 15, Sched. 15, s. 20. Section Amendments with date in force (d/m/y) 2019, c. 15, Sched. 15, s. 20 - 10/12/2019

19.1 Repealed: 2004, c. 5, s. 39. Section Amendments with date in force (d/m/y) 1993, c. 32, s. 2 (5) - 14/12/1993; 1996, c. 1, Sched. H, s. 14 - no effect 2004, c. 5, s. 39 - 23/09/2004

19.2 (1) The General Manager may refuse a claim for payment for insured services if, in the opinion of the General Manager, the person who received the services was not an insured person at the time the services were rendered. Direction by Appeal Board to pay (2) The Appeal Board may direct the General Manager to pay any claims he or she refused to pay under subsection (1) if, after a hearing, the Appeal Board determines that the person to whom the insured services were rendered was an insured person at the time the services were rendered. 1994, c. 17, s. 71. Section Amendments with date in force (d/m/y) 1994, c. 17, s. 71 - 18/05/1994

20 (1) The following persons may request a hearing by the Appeal Board: 1. A person who has applied to become or continue to be an insured person, in respect of the review of a decision of the General Manager refusing the application. 2. An insured person who has made a claim for payment for insured services, in respect of the review of a decision of the General Manager refusing the claim or reducing the amount so claimed to an amount less than the amount payable by the Plan. 3. A physician, in respect of a decision of the General Manager referred to in subsection 18 (7). 4. The General Manager, where the General Manager has formed an opinion under subsection 18 (8) or section 18.2. 5. A person who has been required to reimburse the Plan under section 18.0.1, in respect of the review of the decision of the General Manager requiring the reimbursement. 2019, c. 15, Sched. 15, s. 21 (1). No…

21 (1) If a person requests a hearing under section 20, the Appeal Board shall appoint a time for and hold the hearing and following the hearing may, by order, direct the General Manager to take such action as the Appeal Board considers the General Manager should take in accordance with this Act and the regulations. 2019, c. 15, Sched. 15, s. 21 (1). Extension of time for hearing (2) The Appeal Board may extend the time for the giving of notice by a person requesting a hearing under this section, either before or after expiration of such time, where it is satisfied that there are apparent grounds for granting relief to the claimant pursuant to a hearing and that there are reasonable grounds for applying for the extension, and the Appeal Board may give such directions as it considers proper consequent upon the extension. 2019, c. 15, Sched. 15, s. 21 (1). Certain hearings (3) Despite sect…

22 (1) The General Manager is a party to all proceedings before the Appeal Board. 2015, c. 20, Sched. 15, s. 7. Same (2) The Appeal Board may add any other parties to a proceeding that it considers appropriate. 2015, c. 20, Sched. 15, s. 7. Section Amendments with date in force (d/m/y) 1996, c. 1, Sched. H, s. 17 - 01/05/1996 2007, c. 10, Sched. G, s. 17 - 04/09/2007 2015, c. 20, Sched. 15, s. 7 - 29/10/2015 Evidence

23 (1) A person who is a party to proceedings before the Appeal Board shall be afforded an opportunity to examine before the hearing any written or documentary evidence that will be produced or any report the contents of which will be given in evidence at the hearing. R.S.O. 1990, c. H.6, s. 23 (1). Board members not to have investigated prior to hearing (2) Members of the Appeal Board holding a hearing shall not have taken part, before the hearing, in any investigation or consideration of the subject-matter of the hearing and shall not communicate directly or indirectly in relation to the subject-matter of the hearing with any person or with any party or representative of the party except upon notice to and with opportunity for all parties to participate, but the Appeal Board may seek legal advice from an adviser independent from the parties and in such case the nature of the advice sho…

24 (1) Any party to the proceedings before the Appeal Board under this Act may appeal from its decision or order to the Divisional Court in accordance with the rules of court. R.S.O. 1990, c. H.6, s. 24 (1); 1998, c. 18, Sched. G, s. 54 (6). Exception (1.1) Despite subsection (1), a party may not appeal from a decision or order of the Appeal Board respecting a matter heard under paragraph 3 or 4 of subsection 20 (1). 2019, c. 15, Sched. 15, s. 22. Record to be filed in court (2) Where any party appeals from a decision or order of the Appeal Board, the Appeal Board shall forthwith file in the Divisional Court the record of the proceedings before it in which the decision was made, which, together with the transcript of evidence if it is not part of the Appeal Board’s record, shall constitute the record in the appeal. Minister to be heard (3) The Minister is entitled to be heard by counsel …

25 Repealed: 2019, c. 15, Sched. 15, s. 23. Section Amendments with date in force (d/m/y) 2002, c. 18, Sched. I, s. 8 (13-17) - 26/11/2002 2004, c. 5, s. 40 (1-4) - 23/09/2004 2007, c. 10, Sched. G, s. 18 - 04/09/2007 2019, c. 15, Sched. 15, s. 23 - 10/12/2019

26 (1) Except where otherwise provided, any notice required by or provided for in this Act may be served, (a) by personal service; (b) by courier; (c) by registered mail; or (d) by any other prescribed method. 2007, c. 10, Sched. G, s. 19. When effective (2) Service of a notice is effective, (a) in the case of a notice under clauses (1) (a) to (c), on the day of delivery; and (b) in the case of a notice under clause (1) (d), as provided for in the regulations. 2007, c. 10, Sched. G, s. 19. Service by lettermail (3) Where an attempt has been made to effect service by a method set out in subsection (1), and for any reason service could not be effected, service may be made by lettermail. 2007, c. 10, Sched. G, s. 19. Same (4) Service by lettermail shall be deemed to be effective 14 business days after the day of mailing, unless the person or entity on whom service is to be made establishes …

26.1 Repealed: 1996, c. 1, Sched. H, s. 19. Section Amendments with date in force (d/m/y) 1996, c. 1, Sched. H, s. 19 - 01/05/1996

27 At least six months before any proposed revision of the schedule of fees of the Ontario Medical Association, the Ontario Medical Association shall notify the Minister of the proposed revision and the Minister shall arrange and implement discussions with representatives of the said Association respecting the details and extent of any proposed changes in the schedule of fees. R.S.O. 1990, c. H.6, s. 27.

27.1 (1) Every physician, practitioner and health facility who provides insured services shall make such contribution to the Plan as may be prescribed relating to the amount of fees payable to him, her or it under the Plan during such prior period as may be prescribed. Amount (2) The amount of the basic contribution from each physician, practitioner or health facility shall be determined in accordance with the regulations. Adjustment (3) The basic contribution from a physician, practitioner or health facility may be increased or decreased as provided in the regulations based upon such factors as may be prescribed. Exemption (4) Such classes of physicians, practitioners or health facilities as may be prescribed are exempt from making a contribution to the Plan. 1996, c. 1, Sched. H, s. 20. Section Amendments with date in force (d/m/y) 1996, c. 1, Sched. H, s. 20 - 01/05/1996

27.2 (1) The General Manager may obtain or recover money that a physician, practitioner or health facility owes to the Plan by set off against any money payable to him, her or it under the Plan. 1996, c. 1, Sched. H, s. 21. (2) Repealed: 2019, c. 15, Sched. 15, s. 24. (3), (4) Repealed: 2004, c. 5, s. 41. Section Amendments with date in force (d/m/y) 1996, c. 1, Sched. H, s. 21 - 01/05/1996 2004, c. 5, s. 41 - 23/09/2004 2007, c. 10, Sched. G, s. 20 - 04/09/2007 2015, c. 20, Sched. 15, s. 9 - 29/10/2015 2019, c. 15, Sched. 15, s. 24 - 10/12/2019

28 Any amounts payable to or on behalf of an insured person under the Plan in respect of insured services provided by or in a hospital or health facility may be paid in the form of the payment by the Province of all or any part of the annual expenditures of such hospital or health facility, where such payment by the Province is authorized under any Act. R.S.O. 1990, c. H.6, s. 28.

29 (1) Every insured person shall be deemed to have authorized his or her physician or practitioner, a hospital or health facility which provided a service to the insured person and any other prescribed person or organization to give the General Manager particulars of services provided to the insured person, (a) for the purpose of obtaining payment under the Plan for the services; (b) for the purpose of enabling the General Manager to monitor and control the delivery of insured services; (c) for the purpose of enabling the General Manager to monitor and control payments made under the Plan or otherwise for insured services; and (d) for such other purposes as may be prescribed. 1996, c. 1, Sched. H, s. 22. Immunity (2) No action lies against a person or organization for giving information to the General Manager under the Act. 1996, c. 1, Sched. H, s. 22. (3) Repealed: 2019, c. 15, Sched. …

29.1-29.8 Repealed: 2007, c. 10, Sched. G, s. 21. Section Amendments with date in force (d/m/y) 1996, c. 1, Sched. H, s. 23 - no effect 2007, c. 10, Sched. G, s. 21 - 04/09/2007

Subrogation

30 (1) Where, as the result of the negligence or other wrongful act or omission of another, an insured person suffers personal injuries for which he or she receives insured services under this Act, the Plan is subrogated to any right of the insured person to recover the cost incurred for past insured services and the cost that will probably be incurred for future insured services, and the General Manager may bring action in the name of the Plan or in the name of that person for the recovery of such costs. Payment by Plan recoverable by insured (2) For the purposes of subsection (1), the payment by the Plan for insured services shall not be construed to affect the right of the insured person to recover the amounts so paid in the same manner as if such amounts are paid or to be paid by the insured person. Cost of hospital services (3) For the purposes of this section, the cost of insured s…

31 (1) Any person who commences an action to recover for loss or damages arising out of the negligence or other wrongful act of a third party, to which the injury or disability in respect of which insured services have been provided is related shall, unless otherwise advised in writing by the General Manager, include a claim on behalf of the Plan for the cost of the insured services. R.S.O. 1990, c. H.6, s. 31 (1). Recovery paid to Ontario (2) Where a person recovers a sum in respect of the cost of insured services, the person shall forthwith pay the sum recovered to the Minister of Finance. R.S.O. 1990, c. H.6, s. 31 (2); 2006, c. 19, Sched. L, s. 11 (5). Section Amendments with date in force (d/m/y) 2006, c. 19, Sched. L, s. 11 (5) - 22/06/2006

32 The Plan is not an insurer within the meaning of the Insurance Act, as referred to in section 22 of the Motor Vehicle Accident Claims Act, and may be awarded payment from the Motor Vehicle Accident Claims Fund. R.S.O. 1990, c. H.6, s. 32.

33 The judge at trial shall, if the evidence permits, apportion the elements of the injured person’s loss and damages so as to clearly designate the amount of the Plan’s recovery for the past cost of insured services and separate it from the amount of the Plan’s recovery of future cost of insured services, if any. R.S.O. 1990, c. H.6, s. 33.

34 No release or settlement of a claim for damages for personal injuries in a case where the injured person has received insured services under this Act shall be binding on the Plan unless the General Manager has approved the release or settlement. R.S.O. 1990, c. H.6, s. 34.

35 A liability insurer shall notify the General Manager of negotiations for settlement of any claim for damages including insured services and may pay to the Minister of Finance any amount referable to a claim for recovery of the cost of insured services and such payment discharges the obligation of the liability insurer to pay that amount to the insured person. R.S.O. 1990, c. H.6, s. 35; 2006, c. 19, Sched. L, s. 11 (5). Section Amendments with date in force (d/m/y) 2006, c. 19, Sched. L, s. 11 (5) - 22/06/2006

36 Where a judgment or settlement includes future cost of insured services, the Plan shall provide the future insured services included in the judgment or settlement. R.S.O. 1990, c. H.6, s. 36.

Direct Recovery

36.0.1 (1) If the Plan has paid for insured services as a result of the negligence or other wrongful act or omission of a person, the Plan has a right, independent of its subrogated right under subsections 30 (1) and 46 (5), to recover, directly against that person, the costs for insured services that have been incurred in the past and that will probably be incurred in the future as a result of the negligence or the wrongful act or omission. Action (2) The General Manager may bring an action in the name of the Plan or the Minister may bring an action in his or her own name for recovery of the costs referred to in subsection (1). Exception (3) The Plan shall not recover costs under this section, (a) against a physician if the negligence or wrongful act or omission of the physician occurred while the physician was acting within the scope of his or her practice and in such circumstances as …

Third Party Services

36.1 (1) For the purposes of this section and sections 36.2 to 36.4, a third party service is a service that, (a) is provided by a service provider in connection or partly in connection with, (i) a request or requirement, made by a person or entity, that information or documentation relating to an insured person be provided, or (ii) a request or requirement, made by a person or entity, that an insured person obtain a service from a service provider; (b) is not an insured service or is deemed, by a regulation made under clause 45 (1) (i), not to be an insured service; and (c) is prescribed as a third party service or is prescribed as a third party service in circumstances specified in the regulation. 1993, c. 32, s. 2 (7). Third party (2) For the purposes of this section and sections 36.2 to 36.4, a third party is a person or entity who makes a request or requirement referred to in clause…

36.2 (1) If a service provider who provides a third party service to an insured person renders an account for payment to the third party, the third party is liable for payment of the account, subject to subsection 36.3 (3). Same (2) If an insured person pays all or part of an account rendered to him or her by a service provider for a third party service provided to the insured person, the third party is liable to reimburse the insured person for the amount paid, subject to subsection 36.3 (4). Insured person’s liability to pay (3) Nothing in this section affects any liability of an insured person to pay a service provider’s account for a third party service. Right to render account at time of service (4) Nothing in sections 36.1 to 36.4 affects any right of a service provider to render an account for a third party service at the time the service is rendered. No double recovery (5) The to…

36.3 (1) This section applies to, (a) an amount owing by a third party to a service provider under subsection 36.2 (1); (b) an amount owing by a third party to an insured person under subsection 36.2 (2); and (c) an amount owing by an insured person to a service provider for a third party service provided to the insured person by the service provider. Proceeding to recover payment (2) An amount referred to in subsection (1) may be recovered in a court proceeding or, if a body is designated or established under clause 45 (1.1) (f), in a proceeding before the body. Court, body may reduce amount payable (3) In a proceeding to recover an amount referred to in clause (1) (a) or (c), the court or body, in addition to any other order it may make, may order the third party or the insured person, as the case may be, to pay the service provider an amount that is less than the amount charged by the…

36.4 If, under subsection 36.3 (4), the court or body orders the third party to pay the insured person an amount that is less than the amount paid by the insured person to the service provider for the third party service, the service provider is liable to repay the difference to the insured person. 1993, c. 32, s. 2 (7). Section Amendments with date in force (d/m/y) 1993, c. 32, s. 2 (7) - 14/12/1993

General

37 Repealed: 2019, c. 15, Sched. 15, s. 26. Section Amendments with date in force (d/m/y) 1996, c. 1, Sched. H, s. 30 - 01/05/1996 2006, c. 19, Sched. L,s. 3 (6) - 22/06/2006 2007, c. 10, Sched. G, s. 22 (1, 2) - 04/09/2007; 2007, c. 10, Sched. P, s. 16 - 1/07/2015 2009, c. 26, s. 11 (5) - no effect - see 2019, c. 15, Sched. 15, s. 38 - 10/12/2019 2017, c. 25, Sched. 9, s. 97 (8, 9) - no effect - see 2019, c. 15, Sched. 15, s. 39 - 10/12/2019 2019, c. 15, Sched. 15, s. 26 - 10/12/2019

37.1 Repealed: 2019, c. 15, Sched. 15, s. 26. Section Amendments with date in force (d/m/y) 1996, c. 1, Sched. H, s. 31 - 01/05/1996 2002, c. 18, Sched. I, s. 8 (18, 19) - 26/11/2002 2007, c. 10, Sched. G, s. 23 (1-5) - see Table of Public Statute Provisions Repealed Under Section 10.1 of the Legislation Act, 2006 - 31/12/2017; 2007, c. 10, Sched. G, s. 23 (6) - no effect - see 2015, c. 20, Sched. 15, s. 19 - 04/06/2015; 2007, c. 10, Sched. G, s. 23 (7) - 31/03/2010 2009, c. 26, s. 11 (6-10) - no effect - see 2019, c. 15, Sched. 15, s. 38 - 10/12/2019 2015, c. 20, Sched. 15, s. 10 - 29/10/2015 2017, c. 25, Sched. 9, s. 97 (10) - no effect - see 2019, c. 15, Sched. 15, s. 26 - 10/12/2019 2019, c. 15, Sched. 15, s. 26 - 10/12/2019

38 (1) The persons listed in subsection (1.1) shall preserve secrecy with respect to all matters that come to their knowledge in the course of their employment or duties pertaining to insured persons and any insured services rendered and the payments made for those services, and shall not communicate any such matters to any other person except as otherwise provided in this Act, the Personal Health Information Protection Act, 2004 and the Freedom of Information and Protection of Privacy Act. 2007, c. 10, Sched. G, s. 24 (1). Persons referred to in subs. (1) (1.1) The following are listed for the purposes of subsection (1): 1. The members of the Appeal Board. 2. The employees and agents, if any, of the Appeal Board. 3. The General Manager and persons engaged in the administration of this Act. 2007, c. 10, Sched. G, s. 24 (1); 2015, c. 20, Sched. 15, s. 11 (1, 2); 2019, c. 15, Sched. 15, s.…

38.1 (1) A copy of any of the following may be filed with the Superior Court of Justice after the time in which an appeal may be made has passed, and once filed shall be entered in the same way as a judgment or order of the Superior Court of Justice and is enforceable as an order of that court: 1. A decision of the Appeal Board made under this Act. 2. Repealed: 2019, c. 15, Sched. 15, s. 28 (1). 3. An agreement to reimburse the Plan signed by a physician. 4. Repealed: 2019, c. 15, Sched. 15, s. 28 (2). 2007, c. 10, Sched. G, s. 25; 2019, c. 15, Sched. 15, s. 28 (1, 2). Personal property charge (2) Anything that may be filed under subsection (1) may also be entered as a lien and charge with the registrar under the Personal Property Security Act. 2019, c. 15, Sched. 15, s. 28 (3). Set-off (3) For greater certainty, nothing under this section affects any right of set-off that the General Ma…