Bill 122 — The Health Insurance Statutes Amendment Act, 1972 Honourable Miss Hunley (Legislature 17, Session 1)

L17 S1 5103

Alberta — Bills

19,. Bill 122'-i ., - ; cal First Session, 17th Legislature, 21 Elizabeth II THE LEGISLATIVE ASSEMBLY OF ALBERTA BILL 122 The Health Insurance Statutes Amendment Act, 1972 HONOURABLE MISS HUNLEY First Reading Second Reading . Third Reading .............................. . Printed by the QUEEN'S PRINTER for the Province of Alberta, EDMONTON

Bill 122 BILL 122 1972 THE HEALTH INSURANCE STATUTES AMENDMENT ACT, 1972 ( Assented to , 1972) HER MAJESTY, by and with the advice and consent of the Legis}ative Assembly of Alberta, enacts as follows:

PART 1 THE ALBERTA HEALTH CARE INSURANCE ACT 1. The Alberta Health Care Insurance, Act is amended by this Part.

Section 19 is amended (

a) as to subsection (3) by striking out the words "Penitentaries Act" and by substituting the words "Penitentiary Act", (

b) by adding the following subsection:

(4) The Commission shall not pay benefits in respect of basic health services provided to a resi dent where that resident was not registered under

Part 3 at the time the services were provided.

Section 20 is amended by adding the following sub

section aft.er subsection (3):

(4) Notwithstanding subsection (3), in any case in which the person who is temporarily abs'ent from Alberta is a resident who is in arrears of the payment of premiums under The Health Insurance Premiums Act, or is a depen dant of a resident who is in arrears of the payment of pre miums thereunder, the Commission may withhold the pay ment of benefits until it is satisfied that the arrears of premiums have been paid.

Section 21, subse,ction (1) is amended by adding the following clauses after clause (i): (

j) requiring practitioners to file with the Commission such kinns of information as the regulations may prescribe for the purpose of facilitating the ha?d ling, assessing and payment of claims for benefIts;

Explanatory Notes I. PaTt 1 of this Bill amends chaprter 166 of the Revised Sitatutes of Alberta. See also The Alberta Health Care InsuralIlce Amend ment Act, 1972 (S.A. 1972, c. 45) assented to on June 2, 1972 (Bill 69).

Part 2 of this Bill amends The Health Insurance Premiums Act. 2. (

a) Corrects a statutory reference. (

b) The new subsection (4) will make regis:tration w1th the Commission a condition to enititlement for benefits under the Plan. Regulations under

section 21(1)(

e) of the Act have been made to establish a waiting period of up to three months from the date of Iregis'tra:tion and during which the resi dent so registered will nQit be entitled to benefits. 3. Empowers the Commission to withhold the payment of bene fits in respect IQf temporarily absent residents who are in arrears of the payment of premiums under The Health Insurance Premiums Act until the aTrears are paid.

Section 20, subsection (3) presently reads:

(3) A resident does not cease to be entitled to benefits for insured services by reason of being temporarily absent from Alberta. 4.

Section 21(1) authorizes the Lieutenant Governor in Council to make regulations. The new cLauses will authorize regulations for the obtaining of information respecting praotitioners for the pur pose of processing and paying of claims submitted hy them.

(

k) prescribing the times by which, or the circum stances under which practitioners are required to file information pursuant to the regulations under 'Clause (j); (1) authoriizing the Commissiop. to withold the payment of benefits to any practitioner until he 'has complied with the regulations under clauses (

j) and (k). 5. The following sections are added after

section 22: 22.1 ( 1 ) In this

section (a) "aslsociation" or "professional association" means (

i) The Alberta M'edical Association (C.M.A. - Alberta Division), or (

U) The Alberta Dental Association, or (iii) The Alberta Opltometric Association, or (.iv) the Alberta Chiropractic Association, or (

v) the Alberta Podiatry Association; (b) "council" or "council of a prof'essional association" means (

i) the board of directors of The Alber~ta Medical Association (C.M.A. - Alberta Division), or (ii) the board of dir:ectors of The Alberta Dental Association, or (iii) the Council of Management of The Alberta 9pitom'etrk Association, or (iv) the council of the Alberta Chiropractic Associa tion, or (

v) the Council of Management of the Alberta Podiatry Association; (c) "prof'essional review committee" or "committee" means a professional review committee appointed by a council pursuant to this section.

(2) Each council of a professional association (

a) shall appoint a 'committee for ,its association called the "professional review committee" consisting of at least three members of the association; (b) (c) (

d) shall designate one of t4e members as chairman; shall inform the Commission of the names of the persons who are from time to time the chairman and members of its professional review committee; may in its by-laws provide for the regulation of the proceedings, business and affairs of the committee.

(3) The Commission may, on its own motion or upon the complaint of any person, direct that the appropriate pro- 2

5. The new sec·tions 22.1 land 22.2 provide for a procedure for the review of claims records of a practitioner by members of his own profession who will report their findings to their governing body. That body in turn w!ll advise the Commissiron which may in turn endeavour to ;settle the matter or, f,ailing selttlement, apply to the Supreme Court for a judgment. The Commission may, with respect to future claims, make an order under sectio'l1 22.2 to pro-rate claims. The proceedings relate to claims by praotitioners which are excessive or unjustifiable in the circumstances al!though they aTe technically chargeable on a literal application of the Commission's

schedule of benefits. 2

fessional review committee conduct a review of the records of the Commission pertaining to claims for benefits paid in respect of basic health services provided by the practitioner named in the direction during the period specified in the direction.

(4) The committee shall, upon the receipt by its chair man of a direction under subsection (1), proceed to conduct the review referred to in the direction.

(5) The chairman of the committee shall by written notice invite the practitioner concerned to participate in the review or such part of the review as the chairman may direct, and the practitioner may in participating in the re view be accompanied by legal counsel.

(6) Upon completion of its review, the committee shall submit a report to the council containing its findings under subs'ection (7) and its recommendations. ,

(7) The report of the committee shall show, with respect to any particular basic health service or class thereof, any cases where, in the opinion of the committee, (

a) the service was provided with a frequency that, in the circumstances, was unjustifiable, or (

b) the total amount of benefits received for the ser~ vices was, in the circumstances, greater compensa tion to the practitioner for those services than it should have been, or (

c) the service provided was, in the circumstances, in appropriate or unnecessary, or (

d) the service provided could have been replaced by another professionally acceptable s'ervice for which a lower rate of benefits was payable.

(8) In its report the committee shall also indicate its calculation of the following: (

a) in cases coming wi thin subsection (7) , clauses (

a) and (b), the difference between the benefits actually paid for the S'ervices and the amount that, in its opinion, would have been reasonable compen sation for those services; (

b) in cases coming within subsection (7), clause (c), the amount of benefits paid for the services it con sidered w'ere inappropriately or 'unnecessarily pro vided; (

c) in cases coming within subsection (7), clause (d), the difference between the benefits actually paId for the services and the amount of benefits for the other services that it considers could have replaced them.

(9) In making findings under subsections ~7) and (8), the committee shall have regard to all the CIrcumstances which, without limitation, shall include 3

(

a) normal patterns of practice in Alberta of practition ers of their profession who carryon similar types of practice in similar circumstances; (

b) accepted professional standards of practice in their proflession in Alberta; (

c) in cases referrecl to in subsection (7), clause (b), the amount that would have been reasonable com pensation for the :;;ervice provided, in view of the time and degree of skill involved in providing the serviee.

(10) Upon receipt of the committee's report, the council shall consider it and make a further report showing either (

a) that the council concurs in the r€'port and recom mendations of the -committee, or (

b) where the council does not concur entirely with the committee's report and recommendations, the coun cil's own findings and recommendation in respect of the review, in which case subsections (7), (8) and (9), with the necessary modifications, apply.

(11) The council shall send its report to the Commiss ion together with a copy of the committee's report and thereupon the Commission shall, if it Iconsiders it advis able to take further action thereon, (

a) send copies of the committee's report and the coun cil's report to the practitioner concerned, and (

b) make arrangements, or use its best efforts to make arrangements, with the practitioner for the purpose of giving the practitioner the opportunity of discus sing the reports with the Commission with a view to negotiating ::m agreement in accordance with sub section (12).

(12) The Commission and the pra0titioner concerned may enter into an agreement whereby the practitioner agrees to pay to the Commission a fixed sum of money upon execution of the agreement or upon such terms as to repay ment as may be specified and upon 'execution of the agre~ ment the Commission has no further claims under thIS

section against that practitioner with respect to services provided by him during the period covered by the review of the committee.

(13) Where the practitioner neglects or refuses to enter info discussions with the Commission under subsection (12) or ilt has become impossible, in the opinion of the Commis sion, to negotiate or conclude an agreement under that sub section, the Commission 4 (

a) on the basis of the reports before it and its own records, shall determine whether there are any cases

coming within subsection (7) and, if so, make its own calculation of the amount referred to in sub section (8), and (

b) may recover the amount so calculated by acti0n in the Supreme Court of Alberta.

(14) In an action under subsection (13), the Court shall determine (

a) whether in its opinion and on the basis of the re ports of the council and the committee and the evidence adduced before it, there are any cases coming within subsection (7), and (

b) if there are such cases, the Court's own calculation of the amount referred to in subsection (8), and for that purpose, subsection (9), with the necessary modifications, applies.

(15) Subject to subsections (5) and (11), a practitioner is not entitled to bE' heard before a professional review com mittee, the councilor the Commissjon in respect of any mat ter under this

section or

section 22.2.

(16) Nothing in this

section or

section 22.2 operates (

a) to abrogate or restrict any other remedy the Com mission has under this Act or at law, or (

b) to abrogate or restrict any disciplinary proceedings that may be taken against the practitioner con cerned in respect of anything ,that is the subject of proceedings under this

section under The Medical Profession Act, The Dental Association Act, The Optomet'l"Y Act, The Chiropractic Profession Act or The Podiatry Act, as the case may be. 22.2

(1) Where a practitioner becom'es liable to the Commission under

section 22.1, the Commission may, with or without the consent of the practitioner, make an order directing that, the Commission will not pay benefits in respect of services provided by the practitioner after a date specified in the order.

(2) An order under subsection (1) (

a) may be for a stated period or of indefinite duration; (

b) shall specify the basic health services to which it relates; (

c) shall ,specify, as to any service referred to in clause (b), whether no benefits are to be paid by the Com mission in respect of it, or the portion of the bene fits that are to be paid.

(3) A copy of an order under this

section shall be serv~d on the practitioner against whom it is made, and except .Ill the case where it was made with his consent, the pracbt- 5

ioner may, within 30 days aflter the date on which he receiv ed the copy of the order, apply to the Supreme Court of Alberta by originating notice of motion, to have the order rescinded or varied.

(4) After the hearing of the application, the Court may direct the Comm,ission (

a) to rescind its order, if it considers the Commission had no reasonable justifica,tion for making it, or (

b) to vary its order in the manner specified by the Cou~t.

(5) Where an order of the Commission is in effect under this section, the practitioner against whom it is made shall not charge or be entitled to recover, as fees or benefits, for services pro\nided by him, 6 (

a) any amount for his services, where the order directs that no benefits are payable for those services, or (

b) any amount in excess of the percentage specified in the order, where the order specifies that only a portion of the benefits are to be paid for those services. 6. Se.ction 25 is amended (

a) by adding the following subsecUon after subsection (1):

(1.1) A member of the Commission or an em ployee of the Commission authorized by a member may disclose or communicate information pertruin ing to the date on which bas,ic health serviees were provided and the general nature of those services, the name and address of the person who provided the service, the benefits paid by the Commission for that service and the person to whom they were paid, Ithe name and address of the person to whom the services were provided and any other information pertaining to the nature of the basic health services provided, to' the Pro\nincial Cancer Hospitals Board, The Workmen's Compensation Board, the Alberta Hospital Services Commiss,ion, or the Division of Social Hygiene of the Department of Health and Social Development, if (

a) a member or officer of the Board or Commis sion, or an officer of the Division, as the case may be, makes a written request therefor, (

b) the information required ris necessary and rele vant to a matter being dealt with by the Board or the Division, and (

c) the disclosure or cO'mmunicatiO'n is consented to by the persO'n to' whO'm ,the services were pro vided, his sO'licitO'r, persO'nal representative or

6 6. (

a) Seltf-exp1an:atory (b), (

c) and (d). The definitil{)ltl of "prrofessional ,a:ssociation" is chang:ed to "disciplinary body" in order Ito distinguish it from the PTOPOSed derfinitiion of "prrofess~ona1 associa tion" in secti'On 22.1 (1) see

section 5 'Of ,this Bill. The amendments to subsections (4) and (5) are a consequence of the change.

guardian, the committee of his estate, his trus tee on bankruptcy or other legal representative. (

b) as to subsection (4) by striking out the words "to the professional association" and by substitut ing the 'words "to a disciplinary body of the College or association, as the case may be,", (

c) as to subse,ction (5) by striking out the words "may disclose to a professional association" and by sub stituting the words "may disclose to a disciplinary body", (

d) by striking out subsection (6) and by SUbstituting the following:

(6) In subsections (4) and (5), "disciplinary body" means (

a) the council of the College or a discipline com mittee under The Medical Profession Act, or (

b) the hoard of direc,torsof The Alberta Dental Association or the discipline committee of that Association, or (

c) the Council of Management of The Alberta Op tometric Association or the dis1cipline commit tee of that Association, or (

d) the council of the Alberta Chiropractic Asso eiation, or (

e) the Council of Management of the Alberta Podiatry Association.

Section 32 is amended by adding the following subsec tion after subse,cUon (1):

(1.1) Where an order is made by the Commission against a practitioner pursuant to

section 22.2, any bill or account or receipt issued by or on behalf of the practitioner, shall, in the case of any charge for a basic health service to which the order relates and which is provided at a time w hen the order is in effect, (

a) be in an amount not exceeding tJ1at allowed by the order, and (

b) clearly show that the charges are subject to an order of the Commission under

section 22.2 and that the amount so charged is not in excess of that allowed by the order.

Section 35 is amended by adding the following sub

section after subsection (2):

(3) Where the Commission registers any person. under this

section it may make the registration effective as of the 7

7. See

section 5 of this Bill and the proposed

section 22.2. The proposed subsection (1.1) is related to the requirement that prac titioners not be entitled to charge for fees in excess of what is allowed under a fee prorating order under

section 22.2. 8.

Section 35(1) presently reads: 35. (1) ·Where (

a) a claim for benefits is made under this Act by or on behalf of a resident who is not registered with the Commission, or (

b) insured services (within the meaning of

Part 3 of The Alberta Hospitals Act) are provided to a resident who is not registered with the Commission, the Commission may register that resident upon being furnished with evidence satisfactory to it that he is a resident of Alberta. The new subsection (3) will allow the Commission in these cases to backda,te the registration. Thus any waiting period prescribed by regulation will begin to run from the prior date. 7

date as of the 'Claim for benefits is received by the Commis sion or the dat'e on which the person is admitted to an approved hospital, as the case may be. 9. The following

section is added aft,er

section 41: 41.1

(1) A person who is expressly authorized to do so by the Commission may, (

a) with the consent of the practitioner or group of practitioners concerned, examine and audit any books and accounts maintained by or on behalf of a praotitioner or group of practitioners, or (

b) with the consent of the patient concerned or his legal representative, the practitioner and the coun cil of the College or professional association of which ,the practitioner is a member, examine patient records maintained by a practitioner, and in the course of an examination or audit made with such consent may take extracts from, or make copies of, all or any part of those books and accounts or patient records.

(2) Where any practitioner does not give or refuses to give any consent under subsection (1) after the Commission has requested that consent, the Commission may withhold the payment of benefits to that practitioner in respect of claims made by him on behalf of residents until the consent is given.

(3) In this section, "legal repr'esentative" means, w~th referenee to a patient, his solicitor, personal representatIve or guardian, the committee or guardian of his e~tate or other legal representative of that patient. 8

9. 41.1 Inspection and examination of books and accounts or patient records 'Of a practitioner, subject t'O his consent and, in the case of patient records, the consent of the patient and the profes sional as'SQciation concerned. Lack 'Of consent 'On the practitioner's part may lead rto' the Commission wilthhJolding the payment of claims to him until the consent is given. 8

PART 2 THE HEALTH INSURANCE PREMIUMS ACT !O. The Health Insurance Premiums Act is amended by th~s Part.

Section 4- is amended (

a) as to subsection (1), by striking out the words "Except as otherwise provided in this Act, every resident who is neither," and by substituting the words "Except as otherwise provided in this Act every resident who is registered under The Albertd Health Care Ins'ltrance Act, and who is neither", (

b) as t~ sU.b?ection (1), clause (b), subclau.'w (iii) and subsectwn (3) by striking out the words "Peniten tiaries Act" 7vherever they occur and by substitut ing the words "Penitentiary Act".

Section 10, subsection (3) is amended b1l striking out the words "subsections (4) to (6)" and by substituting the words "subsections (4) to (9)". 18.

(1) Section 22 is amended (

a) as to subsection (2) b1f addinq aft the end thereof the words "and the effect of the provisions of sub section (7)", (

b) bu adding the fdllowing subsections after subsec tion (6):

(7) Notwithstanding anything in subsections (1) and (6), (

a) the spouse 'Of the resident who filed a declar ation may file with the Commission an election to have the ,spouse and the dependants excluded from the declaration; (

b) a dependant of that resident may file with the Comm.jssion an election to have hjmself ex cluded from the declaration, if no election has been filed under clause (a); and an election s:o filed takes effect on the first day of the month next follmving the month in which it is filed.

(8) Where a spouse files an election under sub seetion (7), clause (a), (

a) the declarati'On does not extend to or apply to the spouse and dependants of the resident during the period that the election is in effect; (

b) the resident is liable for the payment of pre mi urns under this Act in respect of the spouse and dependants during the period that the ele0tion i,s in effect. 9

Part 2 of this Bill ,amends

chapter 167 'Of the Revis,ed Statutes of Alberta 1970. II.

Section 4, subsection (1) presently reads: 4.

(1) Except as otherwise provided in this Act, every resident who is neither (

a) a dependant, nor (

b) a member of (

i) the regular forces of the Canadian Forces, or (ii) the Royal Canadian Mounted Police Force, or (iii) a person serving a term of imprisonment in a penitentiary as defined in the Penitentiaries Act (Canada), who has no dependants resident in Alberta, is liable t,1} the Commission for and shall, subject to this Act and the regulations an_d according as to whether he is a person with or with aut dependants, pay t,o the Commiss,ion in advance on behalf of himself and of his dependants, if any, the am'ount of the premium prescribed in the regulations. (

a) Lia'bility for the payment of premiums will be dependent upon registration under The Alberta Health Care Insurance Act. (

b) Corrects references. 12. Consequential to

chapter 46, Statutes of Alberta, 1972, sec tion

Section 10, subsection (3) prf'sently reads:

(3) Section 9, SUbsection (3), clause (

c) and subsections (4) to (6) apply to a designated group to the same extent as though ,it were an employer's group. 13.

Section 22 (1), (5) ,and (6) presently read: 22.

(1) A resident who is not a dependant may, subject to this sec tion, for himself and his dependants, file with the Commission a dec laratlon stating that he elects to remain outside the Alberta Health Care Insurance Plan and the Hospitalization Benefits Plan under

Part 3 of The Alberta Hospitals Act. (?) In this

section "plan year" meaons a 12-month period referred to In subsection (4).

(6) If a resident files a valid declaration under subsection (1), then, notwithstanding anything in this Act, The Alberta Health Care In surance Act or The Alberta Hospitals Act, (

a) neither he nor his dependants are entitled t,o benefits under The Alberta Health Care Insurance Act ,in respect of, basic health services provided to them during the following plan year, (

b) he is' personally and solely liable for the payment to a hospital of the entire cost of insured hospital services prov,ided to him self and his dependants during the next plan year, (

c) neither he nor any of his dependants are entitled to be en rolled by the Commission as members of The Blue Cross Plan pursuant to the Blu.;) Cross agreement, (

d) neither he nor any of his dependants is entitled to apply for or obtain an optional contract issued under the regulations under rart 4 ,of The Alberta Health Care Insurance Act, or to obtain any benefits under such a contract, during the next plan year, and (

e) he is not liable f,or payment of premiums under this Act that become due during the next plan year. Where a resident files a declaration to opt out of the Medicare and Hospitalization Benefits Plans, the resident's spouse will be able in future to elect to exclude herself and their dependants from the declaration. Similarly, a dependant may elect to be ex cluded from the declaration if he assumes payment of his own premiums. 9

(9) Where a dependant files an election under subsection (7), clause (b), (

a) the de'Claration does not extend to or apply to the dependant during the period that the election is in effect; (

b) the dependant is liable for the payment of premiums under this Act in respect of him self unless the resident agrees ,to be liable for the payment of ,those premiums.

(2) This

section applies to declarations under

section 22 of The Health Insurance Premiums Act in effect at the time this

section comes into force and to declarations made there after.

PART 3 COMMENCEMENT 14. This Act com,es into force on the day upon which it is assented to. 10

10 Title: 1972 (17th, 1st) Bill 122, The Health Insurance Statutes Amendment Act, 1972

Document details

Collection	Alberta — Bills
Citation	L17 S1 5103
Type	bill
Volume / chapter	L17 S1 5103
Language	en
Format	json
Source	PROVINCIAL
Identifier	8b4fa695a918694816034ce6e28a8a4af3959765

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