Regulation - LGIC

Amendments to the Health Insurance Act and Regulation 552 – Evidence Based Changes to the Schedule of Benefits for Physician Services and the Out of Country Prior Approval Program

Regulation Number(s):
Instrument Type:
Regulation - LGIC
Bill or Act:
Health Insurance Act
Summary of Decision:
Made: March 23, 2011
Filed: March 25, 2011
Published on e-Laws: March 29, 2011
Printed in The Ontario Gazette: April 9, 2011
Analysis of Regulatory Impact:
No new administrative cost for business.
Further Information:
Proposal Number:
Posting Date:
February 23, 2011
Summary of Proposal:
The proposed amendments will focus on evidence based recommendations and quality services related to the payment of fee-for-service physician services and Out of Country (OOC) funding for health services by OHIP. The proposed effective dates of these changes are April 1, 2011, with the exception of the Executive Office approval for OOC drug therapy which would be effective October 1, 2011.

To support evolving technology the ministry is proposing to:
- introduce new fee schedule codes for CT colonoscopy and CT cardiac angiography which will allow access to patients for testing who may otherwise have difficulty or an inability to undergo a colonoscopy or angiography; and
- remove the payment for sinus ultrasounds which is an ineffective test that has been replaced by CT or sinus endoscopy.

In an effort to address patient safety and the appropriate use of system resources, changes will be made to restrict pre-operative testing (ECG and x-ray) for colonoscopy, cystoscopy, carpal tunnel release and arthroscopic surgery. Physicians will still be able to request pre-operative testing by demonstrating medical necessity and obtaining prior approval.

Strengthening the legal framework of the Out of Country (OOC) Prior Approval (PA) program will be implemented with the following amendments:
- require a recommendation from the executive officer of the Ontario public drug programs before funding OOC drug therapy;
- clarify that an identical or equivalent service is performed in Ontario if there is an available Ontario physician who can perform that service within their scope of practice;
- require that an application for funding of an OOC health service be endorsed in writing by a specialist;
- promote the use of providers in other provinces over the use of out-of-country providers where reasonable;
- require that an application for payment of an OOC laboratory test be endorsed by an Ontario physician with a designation as a Fellow of the Canadian College of Medical Geneticists;
- require that an OOC laboratory test including a genetic test must be for the same purposes as funded laboratory tests in Ontario (diagnosis, prophylaxis, or treatment); and
- clarify that the funding of OOC laboratory testing is to be determined under the laboratory provisions and not under the more general OOC hospitals and health facilities provisions of the regulation.

At the same time the ministry will be revoking Regulation 883/93 under the HIA. Regulation 883/93 defined physician eligibility for the purposes of subsection 19.1(3) and 19.1(4) of the HIA. Section 19.1 of the HIA was intended to define which physicians were eligible to receive payments for insured service rendered in Ontario before April 1, 1996. Since subsection 19.1 of the HIA was repealed in 2004, Regulation 883/93 is being revoked as it is no longer necessary.
Contact Address:
370 Select Drive
Kingston ON K7M 8T4
Effective Date:
April 1, 2011