jswizzle3737/ontario_laws_and_regs huggingface dataset:
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 Amendments with date in force (d/m/y) 2006, c. 19, Sched. L, s. 11 (5) - 22/06/2006
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 the regulations to be provided in such form as he or she specifies; (g) to perform such other function and discharge such other duties as are assigned to the General Manager by this Act and the regulations or by the Minister.  R.S.O. 1990, c. H.6, s. 4 (2); 2006, c. 19, Sched. L, s. 3 (1). Section Amendments with date in force (d/m/y) 2006, c. 19, Sched. L, s. 3 (1) - 22/06/2006
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 the purposes of establishing his or her entitlement to be or continue to be an insured person.  2007, c. 10, Sched. C, s. 2. Section Amendments with date in force (d/m/y) 1994, c.17, s. 70 - 01/04/1994 2000, c. 26, Sched. H, s. 1 (4) - 06/12/2000 2007, c. 10, Sched. C, s. 2 - 04/06/2007; 2007, c. 16, Sched. B, s. 1 - 03/12/2007
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 (6), the person shall return it to the General Manager as soon as possible. 2019, c. 15, Sched. 15, s. 6. Protection from liability (8) No proceeding for taking possession of a health card shall be commenced against a person who does so in accordance with subsection (6). 2019, c. 15, Sched. 15, s. 6. Fees (9) The General Manager may charge a fee provided in the regulations for a replacement health card, subject to any terms or conditions provided for in the regulations. 2019, c. 15, Sched. 15, s. 6. Section Amendments with date in force (d/m/y) 1993, c.32, s. 2 (4) - 14/12/1993 2019, c. 15, Sched. 15, s. 6 - 10/12/2019
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 person or the facilitation of a person’s coping, social support or identity exploration or development; and (b) sex-reassignment surgery or any services related to sex-reassignment surgery. 2015, c. 18, s. 1. Exceptions (2) Despite subsection (1), services that a person is entitled to under the insurance plan established under the Workplace Safety and Insurance Act, 1997 or under the Homes for Special Care Act or under any Act of the Parliament of Canada except the Canada Health Act
are not insured services.  1996, c. 1, Sched. H, s. 8; 1997, c. 16, s. 7. Restrictions (3) Such services as may be prescribed are insured services only if they are provided in or by designated hospitals or health facilities. Same (4) Such services as may be prescribed are insured services only if they are provided to insured persons in prescribed age groups. Same (5) Such services as may be prescribed are not insured services when they are provided to insured persons in prescribed age groups.  1996, c. 1, Sched. H, s. 8. Regulations (6) The Lieutenant Governor in Council may make regulations, (a) clarifying the meaning of “services”, “sexual orientation”, “gender identity” or “seek to change” for the purposes of subsection (1.1); (b) exempting services from the application of subsection (1.1). 2015, c. 18, s. 1. Section Amendments with date in force (d/m/y) 1996, c. 1, Sched. H, s. 8 - 01/05/1996; 1997, c. 16, s. 7 - 1/01/1998 2015, c. 18, s. 1 - 04/06/2015
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 America and who is entitled to enter into the contract by virtue of his or her employment.  R.S.O. 1990, c. H.6, s. 14 (3). Idem (4) Where payment is made to or on behalf of an insured person under a contract or agreement referred to in subsection (3) and such payment is less than would have been made under this Act and the regulations for the same insured services, the General Manager may pay to or on behalf of the insured person the difference between the amount paid under the contract or agreement and the amount established by the regulations for the insured services for which payment was made under the contract or agreement.  R.S.O. 1990, c. H.6, s. 14 (4). Exception (5) Subsections (1) and (2) do not apply during the period that a person who is a resident must wait to be registered as an insured person.  2000, c. 26, Sched. H, s. 1 (5); 2006, c. 19, Sched. L, s. 3 (5). Section Amendments with date in force (d/m/y) 1996, c. 1, Sched. H, s. 10 - 01/05/1996; 2000, c. 26, Sched. H, s. 1 (5) - 06/12/2000 2006, c. 19, Sched. L, s. 3 (5) - 22/06/2006 2007, c. 8, s. 209 - 01/07/2010
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 Plan constitutes payment in full of the account.  2004, c. 5, s. 36. Billing number (4) A physician may only submit claims for payment to the Plan, or receive payments from the Plan pursuant to an arrangement under clause 2 (2) (a), and an insured person may only submit claims for payment to the Plan that have been presented by a physician, if the physician has been granted a billing number by the General Manager. 2019, c. 15, Sched. 15, s. 7. Section Amendments with date in force (d/m/y) 2000, c. 42, Sched., s. 17 (1, 2) - 01/11/2001 2001, c. 8, s. 32 (1, 2) - 01/11/2001 2004, c. 5, s. 36 - 23/09/2004 2019, c. 15, Sched. 15, s. 7 - 10/12/2019
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 by the Plan for the insured services performed constitutes payment in full of the account; and (c) in the case of a non-designated practitioner, the payment by the Plan for that part of his or her account for an insured service rendered to an insured person that is payable by the Plan constitutes payment in full of that part of the account.  2004, c. 5, s. 36. Where s. 2 (2) applies (4) 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 Plan constitutes payment in full of the account.  2004, c. 5, s. 36. Billing number (4.1) A practitioner 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 practitioner has been granted a billing number by the General Manager. 2019, c. 15, Sched. 15, s. 8. Interpretation (5) In this section, “designated practitioner”, “non-designated practitioner” and “practitioner” have the same meanings as in Part II of the Commitment to the Future of Medicare Act, 2004.  2004, c. 5, s. 36. Section Amendments with date in force (d/m/y) 2004, c. 5, s. 36 - 23/09/2004 2019, c. 15, Sched. 15, s. 8 - 10/12/2019
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 a deemed election for the purposes of subsection 11 (6) of the Commitment to the Future of Medicare Act, 2004, but subsection 10 (3) of that Act applies to him or her during the time that he or she is temporarily required to submit accounts directly to the Plan. 4. All other applicable provisions of this Act apply to the physician or designated practitioner.  2004, c. 5, s. 36; 2019, c. 15, Sched. 15, s. 9. Same (2) Where a designated practitioner to whom section 11 of the Commitment to the Future of Medicare Act, 2004 applies submits his or her accounts for the rendering of insured services to insured persons directly to the Plan, subsections 25 (2) to (9) of this Act, as they existed before their repeal, apply to him or her with respect to accounts submitted before he or she commenced submitting his or her accounts directly to the Plan.  2004, c. 5, s. 36; 2007, c. 10, Sched. G, s. 5 (1). Same (2.1) Despite paragraph 2 of subsection (1), subsections 25 (3), (4), (5), (6) and (8), as they existed immediately before their repeal by the Commitment to the Future of Medicare Act, 2004
cease to apply to physicians on the day that this subsection comes into force.  2007, c. 10, Sched. G, s. 5 (2). Interpretation (3) In this section, “physician” and “designated practitioner” mean a physician or designated practitioner within the meaning of Part II of the Commitment to the Future of Medicare Act, 2004.  2004, c. 5, s. 36. Section Amendments with date in force (d/m/y) 2004, c. 5, s. 36 - 23/09/2004 2007, c. 10, Sched. G, s. 5 (1, 2) - 04/09/2007 2019, c. 15, Sched. 15, s. 9 - 10/12/2019
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 regulations.  2004, c. 5, s. 36. (5) Repealed: 2019, c. 15, Sched. 15, s. 11. Section Amendments with date in force (d/m/y) 2000, c. 42, Sched., s. 18 (1, 2) - 01/11/2001 2001, c. 8, s. 33 (1, 2) - 01/11/2001 2004, c. 5, s. 36 - 23/09/2004 2019, c. 15, Sched. 15, s. 11 - 10/12/2019
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 to the Plan by the physician or the practitioner may be recovered from the physician or practitioner personally.  2000, c. 42, Sched., s. 19. Interpretation (5) A reference in this Act or the regulations to a payment to a physician or a practitioner where the reference relates to a payment for services performed by the physician or practitioner shall be deemed to include a payment made to a person or entity pursuant to a direction made under this section.  2000, c. 42, Sched., s. 19. Keeping and inspection of records (6) Section 37.1 applies with necessary modifications to a person or entity to which payment is made pursuant to a direction by a physician or practitioner. 2015, c. 20, Sched. 15, s. 3 (1). Same (7) Subsections 37 (5), (6) and (7) apply with necessary modifications to a person or entity to which payment is made pursuant to a direction by a physician in respect of the records required to be kept. 2015, c. 20, Sched. 15, s. 3 (2). Section Amendments with date in force (d/m/y) 2000, c. 42, Sched., s. 19 - 01/11/2001 2004, c. 5, s. 37- 23/09/2004 2007, c. 10, Sched. G, s. 6 - 04/09/2007 2015, c. 20, Sched. 15, s. 3 (1, 2) - 29/10/2015
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 fee for an insured service is nil.  1996, c. 1, Sched. H, s. 12. Adjustment of amount (5) The basic fee payable for an insured service performed by a physician or practitioner may be increased or decreased as provided in the regulations based upon one or more of the following factors: 1. The professional specialization of the physician or practitioner. 2. The relevant professional experience of the physician or practitioner. 3. The frequency with which the physician or practitioner provides the insured service. 4. The geographic area in which the insured service is provided. 5. The setting in which the insured service is provided. 6. The period of time when the insured service is provided. 7. Such other factors as may be prescribed.  1996, c. 1, Sched. H, s. 12. Threshold amount (6) If the total amount payable for one or more prescribed insured services provided by a physician or practitioner during a prescribed period equals or exceeds a prescribed amount, the fee payable for an insured service may be increased or decreased in accordance with the regulations. The fee payable may be reduced to nil.  1996, c. 1, Sched. H, s. 12. Same (7) A change made under subsection (6) in the fee payable for an insured service is imposed in addition to any change made under subsection (5) in the basic fee payable.  1996, c. 1, Sched. H, s. 12. (8) Repealed:  2007, c. 10, Sched. G, s. 7. Section Amendments with date in force (d/m/y) 1996, c. 1, Sched. H, s. 12 - 01/05/1996 2007, c. 10, Sched. G, s. 7 - 04/09/2007 2019, c. 15, Sched. 15, s. 13 - 10/12/2019
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. Section Amendments with date in force (d/m/y) 1996, c. 1, Sched. H, s. 12 - 01/05/1996 2019, c. 15, Sched. 15, s. 14 - 10/12/2019; 2019, c. 15, Sched. 15, s. 15 (2) - no effect - see 2023, c. 4, Sched. 1, s. 76 (2)
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 establish whether a service they have provided is therapeutically necessary. 2019, c. 15, Sched. 15, s. 15 (1). Same (5) The records described in subsections (1), (2), (3) and (4) must be prepared promptly when the service is provided. 2019, c. 15, Sched. 15, s. 15 (1). Presumption (6) In the absence of a record described in subsection (1), (3) or (4), it is presumed that an insured service was provided and that the basic fee payable is nil. 2019, c. 15, Sched. 15, s. 15 (1). Different service provided (7) In the absence of a record described in subsection (2), the insured service that was provided is presumed to be the insured service, if any, that the General Manager considers to be described in the records as having been provided and not the insured service for which the claim for payment was prepared or submitted. 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
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
18.0.1 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/y) 2007, c. 10, Sched. G, s. 11 (1-3) - 04/09/2007 2019, c. 15, Sched. 15, s. 17 - 10/12/2019
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). Notice of request (2) A person or physician requesting a hearing under paragraph 1, 2, 3 or 5 of subsection (1) shall file a notice of the request within 30 days after receiving notice of the decision of the General Manager. 2019, c. 15, Sched. 15, s. 21 (1). Section Amendments with date in force (d/m/y) 1996, c. 1, Sched. H, s. 15 - 01/05/1996 2002, c. 18, Sched. I, s. 8 (10, 11) - 26/11/2002 2007, c. 10, Sched. G, s. 15 - 04/09/2007 2009, c. 26, s. 11 (4) - no effect - see 2019, c. 15, Sched. 15, s. 21 (1) - 10/12/2019 2015, c. 20, Sched. 15, s. 5 (1, 2) - 29/10/2015 2019, c. 15, Sched. 15, s. 21 (1) - 10/12/2019
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 section 13 of the Ministry of Health and Long-Term Care Appeal and Review Boards Act, 1998, a hearing under paragraph 3 or 4 of subsection 20 (1) shall be heard and decided as provided for in Schedule 1. 2019, c. 15, Sched. 15, s. 21 (1). Interest payable by the Plan (4) If the Appeal Board has concluded that an amount is payable by the Plan to a physician in a hearing under paragraph 3 of subsection 20 (1), interest calculated at the rate for postjudgment interest provided for under section 127 of the Courts of Justice Act accrues from the date that the claims were submitted in accordance with this Act and regulations. 2019, c. 15, Sched. 15, s. 21 (1). Interest payable to the Plan (5) If the Appeal Board has concluded that an amount is payable to the Plan by a physician in a hearing under paragraph 4 of subsection 20 (1), interest calculated at the rate for postjudgment interest provided for under section 127 of the Courts of Justice Act accrues from the date of the request for a hearing by the General Manager. 2019, c. 15, Sched. 15, s. 21 (1). (6) Repealed: 2019, c. 15, Sched. 15, s. 21 (2). Section Amendments with date in force (d/m/y) 1996, c. 1, Sched. H, s. 16 - 01/05/1996 2002, c. 18, Sched. I, s. 8 (12) - 26/11/2002 2007, c. 10, Sched. G, s. 16 (1, 2)- 04/09/2007 2015, c. 20, Sched. 15, s. 6 (1, 2) - 29/10/2015 2019, c. 15, Sched. 15, s. 21 (1) - 10/12/2019; 2019, c. 15, Sched. 15, s. 21 (2) - 28/06/2023
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 should be made known to the parties in order that they may make submissions as to the law.  R.S.O. 1990, c. H.6, s. 23 (2). Recording evidence (3) The oral evidence taken before the Appeal Board at a hearing shall be recorded and, if so required, copies of a transcript thereof shall be furnished upon the same terms as in the Superior Court of Justice.  R.S.O. 1990, c. H.6, s. 23 (3); 2006, c. 19, Sched. C, s. 1 (1). Findings of fact (4) The findings of fact of the Appeal Board pursuant to a hearing shall be based exclusively on evidence admissible or matters that may be noticed under section 15 or 16 of the Statutory Powers Procedure Act.  R.S.O. 1990, c. H.6, s. 23 (4). (5) Repealed:  1998, c. 18, Sched. G, s. 54 (5). Release of documents, etc. (6) Documents and things put in evidence at the hearing shall, upon the request of the person who produced them, be released to the person by the Appeal Board within a reasonable time after the matter in issue has been finally determined.  R.S.O. 1990, c. H.6, s. 23 (6). Section Amendments with date in force (d/m/y) 1998, c. 18, Sched. G, s. 54 (5) - 01/02/1999 2006, c. 19, Sched. C, s. 1 (1) - 22/06/2006
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 or otherwise upon the argument of an appeal under this section. Powers of court on appeal (4) An appeal under this section may be made on questions of law or fact or both and the court may affirm or may rescind the decision of the Appeal Board and may exercise all powers of the Appeal Board to direct the General Manager to take any action which the Appeal Board may direct the General Manager to take and as the court considers proper and for such purposes the court may substitute its opinion for that of the General Manager or of the Appeal Board, or the court may refer the matter back to the Appeal Board for rehearing, in whole or in part, in accordance with such directions as the court considers proper.  R.S.O. 1990, c. H.6, s. 24 (2-4). (5) Repealed: 2015, c. 20, Sched. 15, s. 8. Section Amendments with date in force (d/m/y) 1996, c. 1, Sched. H, s. 18 - 01/05/1996; 1998, c. 18, Sched. G, s. 54 (6) - 01/02/1999 2015, c. 20, Sched. 15, s. 8 - 29/10/2015 2019, c. 15, Sched. 15, s. 22 - 10/12/2019 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 that the notice was not received until a later date for reasons that he, she or it could not control, in which case service is effective on the day that the notice is actually received.  2007, c. 10, Sched. G, s. 19. Section Amendments with date in force (d/m/y) 2007, c. 10, Sched. G, s. 19- 04/09/2007 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. 15, s. 25. Section Amendments with date in force (d/m/y) 1996, c. 1, Sched. H, s. 22 - 01/05/1996 2004, c. 3, Sched. A, s. 85 (2) - 01/11/2004 2019, c. 15, Sched. 15, s. 25 - 10/12/2019 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