A-28, r. 1 - Regulation respecting the application of the Hospital Insurance Act

Updated to 1 September 2012

This document has official status.

chapter A-28, r. 1

Regulation respecting the application of the Hospital Insurance Act

Hospital Insurance Act

(chapter A-28, s. 8).

In this Regulation, only the indexing of the tariffs in section 10 has been revised. (1 January 2011)

1. Definitions: In this Regulation,

(a)  “beneficiary” means every person benefiting from the services of a hospital centre;

(b)  “hospital centre” means a hospital centre within the meaning of subparagraph h of section 1 of the Act respecting health services and social services (chapter S-5);

(c)  “hospital centre for short-term care” or “hospital centre for long-term care” means any hospital centre for short-term care or hospital centre for long-term care within the meaning of the Organization and Management of Institutions Regulation (chapter S-5, r. 5);

(d)  “private hospital centre” means a private hospital centre that has made a contract or agreement with the Minister within the meaning of sections 176 or 177 of the Act respecting health services and social services;

(e)  “private room” means room containing 1 bed with an area of not less than 9.25 m2, intended for the lodging of beneficiaries;

(f)  “semi-private room” means room containing 2 beds with an area of not less than 14.75 m2, intended for the lodging of beneficiaries;

(f.1)  “spouse” means

(1)  the man or woman with whom a person is married and cohabits;

(2)  the man or woman of the opposite or the same sex with whom a person cohabits in a conjugal relationship, where they have been so cohabiting for at least 1 year or where

(a)  a child has been born of their union;

(b)  they have adopted a child together; or

(c)  one of them has adopted the other’s child;

(g)  “board of directors” means the board of directors of a hospital centre, constituted in accordance with the Act respecting health services and social services;

(h)  “executive director” means the executive director of a hospital centre, appointed in accordance with section 104 of the Act respecting health services and social services;

(i)  “agreement” means an agreement concluded in accordance with section 6 of the Act;

(j)  “federal hospital” means a hospital or hospital centre owned or operated by the Canadian Government;

(k)  “Act” means the Hospital Insurance Act (chapter A-28);

(l)  “Minister” means the Minister of Health and Social Services;

(l.1)  “agency” means a health and social services agency referred to in the Act respecting health services and social services (chapter S-4.2);

(m)  “resident” means a resident or temporary resident of Québec within the meaning of sections 5 to 8 of the Health Insurance Act (chapter A-29) and of Division II of the Regulation respecting eligibility and registration of persons in respect of the Régie de l’assurance maladie du Québec (chapter A-29, r. 1);

(n)  “ward” means all premises intended for accommodating beneficiaries other than a private or semi-private room;

(o)  “dependent person” means any dependent person within the meaning of section 1.1 of the Regulation respecting eligibility and registration of persons in respect of the Régie de l’assurance maladie du Québec.

In this Regulation, where the expression “board of directors” is used in connection with a private institution, it means “proprietor”.

R.R.Q., 1981, c. A-28, r. 1, s. 1; O.C. 1523-83, s. 1; O.C. 1768-84, s. 1; O.C. 1100-90, s. 4; O.C. 696-91, ss. 1, 2, 3 and 4; O.C. 315-93, s. 1; O.C. 1379-95, s. 1; O.C. 973-2001, s. 1.

2. Insured services are provided free of charge by a hospital centre to all residents staying for the period during which such services are medically required, with the exception of contributions payable under section 159 of the Act respecting health services and social services (chapter S-5).

R.R.Q., 1981, c. A-28, r. 1, s. 2; O.C. 1490-82, s. 1; O.C. 696-91, s. 1; O.C. 315-93, s. 2.

3. Insured services shall include the following services when they are required from a medical or dental standpoint and, in the latter case, to the extent that they are insured services for the purposes of subparagraph b of the first paragraph of section 3 of the Health Insurance Act (chapter A-29) or for the purposes of the second paragraph of section 3 of that Act:

(a)  for beneficiaries who are in-patients at a hospital centre:

i.  lodging and meals;

ii.  necessary nursing care;

iii.  diagnostic services for the purpose of maintaining health, preventing disease and assisting in the treatment of any injury, disease or disability;

iv.  the furnishing of medications, prostheses and ortheses which may be integrated with the human body, the list of which appears in Schedule A, and of biological products and related preparations, on the conditions that, in a physician’s opinion, they are required and that they are administered in a hospital centre;

v.  the use of operating rooms, delivery rooms and anaesthetic facilities, including the necessary equipment and supplies;

vi.  the furnishing of routine surgical supplies;

vii.  the use of radiotherapy facilities;

viii.  the use of physiotherapy facilities;

ix.  the services rendered by hospital centre staff;

(b)  for beneficiaries who are outpatients at a hospital centre:

i.  clinical services for psychiatric care provided during the day or at night;

ii.  electroshock therapy, insulin therapy and behavior therapy;

iii.  emergency care;

iv.  minor surgery care;

v.  radiotherapy;

vi.  diagnostic services;

vii.  physiotherapy, ergotherapy and inhalation therapy;

viii.  audiology and speech therapy;

ix.  orthoptics;

x.  the services or examinations which a resident must undergo in order to obtain employment, which he must undergo during his employment or which are required by an employer or his representative, provided that such examinations or services are required by an Act of Québec other than the Act respecting collective agreement decrees (chapter D-2).

The services covered by the first paragraph shall also be insured services when they are required:

(a)  for the purposes of mechanical, hormonal or chemical contraception;

(b)  for the purposes of surgical sterilization, namely a tubal ligation or vasectomy;

(c)  for the reanastomosis of the uterine tubes or the vas deferens;

(d)  for the extraction of a tooth or the excision of a root where, for that purpose, the beneficiary’s state of health necessitates hospital services.

R.R.Q., 1981, c. A-28, r. 1, s. 3; O.C. 1490-82, s. 2; O.C. 1321-84, s. 1; O.C. 197-86, s. 1; O.C. 1257-87, s. 1; O.C. 1981-88, s. 1; O.C. 668-91, s. 1; O.C. 696-91, ss. 1 and 5.

4. Excluded services: Insured services shall not include the services to which residents are entitled free of charge under one or other of the following Acts:

(a)  Acts of the Parliament of Canada:

i.  the Government Employees Compensation Act (R.S.C. 1985, c. G-5);

ii.  the National Defence Act (R.S.C. 1985, c. N-5);

iii.  the Royal Canadian Mounted Police Act (R.S.C. 1985, c. R-10);

iv.  the Pension Act (R.S.C. 1985, c. P-6);

v.  the Merchant Seamen Compensation Act (R.S.C. 1985, c. M-6);

vi.  the Veterans Rehabilitation Act (R.S.C. 1970, c. V-5);

vii.  the Aeronautics Act (R.S.C. 1985, c. A-2);

viii.  the Civilian War Pensions and Allowances Act (R.S.C. 1985, c. C-31);

(b)  Acts of the National Assembly:

i.  the Act respecting industrial accidents and occupational diseases (chapter A-3.001) or any other Act of Québec which requires the providing of services other than those prescribed in subparagraph x of paragraph b of section 3;

(c)  other Acts:

i.  any Act enacted by a government other than that of Canada or Québec under whose provisions the resident is entitled to a total or partial refund.

R.R.Q., 1981, c. A-28, r. 1, s. 4; S.Q. 1985, c. 6, s. 477.

5. The admission and discharge of a person in a hospital centre shall be carried out in accordance with the Act respecting health services and social services (chapter S-4.2) and the regulations made thereunder.

R.R.Q., 1981, c. A-28, r. 1, s. 5.

6. Report to Minister: A hospital centre shall, upon request, forward a written report to the Minister on a beneficiary’s condition, stating in particular the reasons and necessity for providing certain services to such person.

Where services that are not medically required are provided, the hospital centre shall charge the cost thereof to the beneficiary.

R.R.Q., 1981, c. A-28, r. 1, s. 6; O.C. 696-91, s. 1.

7. Twenty per cent of the beds in every hospital centre for short-term care must be situated in wards.

R.R.Q., 1981, c. A-28, r. 1, s. 7; O.C. 696-91, s. 6.

8. All premises intended for lodging beneficiaries in a hospital centre shall be designated by the board of directors as a private room, semi-private room or a ward. The Minister must be notified of every change in designation.

R.R.Q., 1981, c. A-28, r. 1, s. 8; O.C. 696-91, s. 1.

9. A hospital centre may only charge resident beneficiaries of short-term care the tariff prescribed in this Regulation for the use of a private or semi-private room.

R.R.Q., 1981, c. A-28, r. 1, s. 9; O.C. 1100-90, s. 5; O.C. 696-91, s. 7.

10. Tariff: A hospital centre for short-term care shall charge $90.88 per day for a private room. That tariff is amended in the following manner:

(a)  for a private room with an area of 9.75 to 11.50 m2, with telephone, washbasin or toilet either private or shared with another room: $112.52 per day;

(b)  for a private room with an area of not less than 11.50 m2, with telephone, washbasin and toilet either private or shared with another room: $134.15 per day;

(c)  for a private room with an area of not less than 11.50 m2, with telephone and full bathroom shared with another room: $157.24 per day;

(d)  for a private room with an area of not less than 11.50 m2, with telephone and full private bathroom: $180.32 per day;

(e)  for a private room with telephone, private bathroom and adjoining sitting room: $225.02 per day.

A hospital centre for short-term care shall charge a beneficiary $56.24 per day for a semi-private room. That tariff is amended in the following manner:

(a)  for a room with two of the following facilities: telephone, washbasin or toilet either private or shared with another room: $62.03 per day;

(b)  for a room with telephone, washbasin and toilet either private or shared with another room: $67.80 per day;

(c)  for a room with telephone and full bathroom: $79.35 per day.

Where a room lacks a facility enabling it to be classified at a given price, its rate shall be that prescribed for the category immediately below it.

The tariff prescribed by this section must be posted up in each private or semi-private room. However, it does not apply to rooms in long-term care units of a hospital centre for short-term care.

From 1 January 2001, that tariff shall be indexed at the beginning of each year in accordance with the Pension Index established under section 117 of the Act respecting the Québec Pension Plan (chapter R-9).

R.R.Q., 1981, c. A-28, r. 1, s. 10; O.C. 1036-82, s. 1; O.C. 1314-83, s. 1; Erratum, 1983 G.O. 2, 3089; O.C. 113-90, s. 1; O.C. 1100-90, s. 6; O.C. 696-91, ss. 1, 8 and 9; O.C. 744-91, s. 1; O.C. 812-97, s. 1; O.C. 544-2000, s. 1.

11. Basic facilities: Private or semi-private rooms in a hospital centre shall be equipped with minimum basic facilities comprising an electric bell system, a table and bedside lamp for each bed, an armchair and a wall cupboard or dresser for each occupant.

R.R.Q., 1981, c. A-28, r. 1, s. 11.

12. Additional equipment: The tariffs prescribed in section 10 do not include rental of a television set or any other additional equipment for which a hospital centre may bill the beneficiary by adding to the real cost administration fees not exceeding 20%.

R.R.Q., 1981, c. A-28, r. 1, s. 12; O.C. 696-91, s. 1.

13. Emergency: Where the condition of a person who has requested admission to a ward necessitates immediate attention and where there are no vacancies in a ward, the hospital centre shall admit this person to a private or semi-private room until such vacancy occurs. In such case, the hospital centre may not claim any amount whatsoever from such person for use of the room.

Where the condition of a person lodging in a ward is such that, in the professional judgment of his attending physician, it is necessary to transfer this person to a private or semi-private room for health reasons or for his own safety or that of others, the hospital centre shall transfer him to such room for the period during which his stay therein is medically necessary. In such case, the hospital centre may not claim any amount whatsoever from this person for use of the room.

Where a person has requested admission to a private or semi-private room and such room is assigned to him and reserved in his name, he must pay the tariff prescribed therefor even if his stay in such room, coronary unit or intensive care unit becomes medically necessary.

R.R.Q., 1981, c. A-28, r. 1, s. 13; O.C. 1100-90, s. 7.

14. Where a resident receives insured services in a hospital centre situated in Canada but outside Québec, the Minister shall reimburse the cost of those services to the resident or, as the case may be, to the hospital centre or the public authority responsible therefor, according to the tariff in force.

Notwithstanding the foregoing, where services requiring hospitalization are to be provided to a resident by a hospital centre not covered by a reciprocal billing agreement entered into by Québec with another province and where the agency of the resident’s territory keeps a computerized register of availability of the services provided on its territory, a certificate of non-availability of the services in question shall first be obtained by the hospital centre from the agency. In the absence of a certificate, the Minister shall reimburse a maximum amount of $450 per day of hospitalization.

The second paragraph does not apply if the services are provided in an emergency.

R.R.Q., 1981, c. A-28, r. 1, s. 14; O.C. 1379-95, s. 2.

15. Where a resident receives insured services in a general hospital situated outside Canada, the Minister shall, upon presentation of a detailed claim, reimburse to the resident or to the hospital centre the following amounts:

(a)  the price of the services, where necessitated by sudden illness or an emergency, up to the amount of $100 per day if there was hospitalization, including day surgery, or up to the amount of $50 per visit for out patient treatment, including associated diagnostic or therapeutic services in both cases;

(a.1)  for a hemodialysis treatment, the price of the service, up to the amount of $220 per treatment including medications;

(b)  the price of the services, where they were authorized in advance by the Minister upon request in writing signed by 2 physicians having expert knowledge in the field of the illness of the person on whose behalf the authorization is requested. The request must be accompanied by a summary of the medical record of the person and must comprise the following:

i.  a description of the specialized services;

ii.  certification that the required specialized services are available in Canada;

iii.  the name and address of the hospital centre recommended for provision of the specialized services required.

R.R.Q., 1981, c. A-28, r. 1, s. 15; O.C. 1180-82, s. 1; O.C. 498-92, s. 1; O.C. 1042-96, s. 1.

15.1. Despite section 15, in the case of a resident or his spouse and his dependants:

(a)  staying outside of Canada as a student from Québec enrolled in a program at an educational institution outside of Canada;

(b)  staying outside of Canada as a full-time unremunerated trainee at a university, an establishment affiliated with a university, a research institute or an international or government organization;

(c)  who is a Québec civil servant on duty outside of Canada; or

(d)  employed by a non-profit organization with headquarters in Canada and working abroad within the framework of a program of international aid or cooperation approved by the Minister of Health and Social Services;

the Minister, upon presentation of an itemized claim form, shall reimburse that resident or the hospital centre, the cost of the services the resident received at a hospital centre outside of Canada where those services became necessary because of sudden illness or of an emergency situation.

Where the services are not services rendered following a sudden illness or an emergency situation, the Minister, upon presentation of a detailed claim form, shall reimburse the resident a maximum of 75% of the cost of the services.

O.C. 1490-82, s. 3; O.C. 1523-83, s. 2; O.C. 696-91, s. 10; O.C. 315-93, s. 3.

16. The reimbursements prescribed in sections 14 and 15 are made only with respect to services provided by a recognized institution accredited as hospital or hospital centre by the competent authorities to which such institution is responsible; no reimbursement shall be made for a stay in a nursing home, spa or other similar shelter.

R.R.Q., 1981, c. A-28, r. 1, s. 16.

17. (Revoked).

R.R.Q., 1981, c. A-28, r. 1, s. 17; O.C. 1768-84, s. 2; O.C. 1100-90, s. 8.

18. The Minister shall make payments to the Federal hospitals situated in Québec for insured services provided to residents in accordance with the terms and conditions of any agreement concluded to this effect.

R.R.Q., 1981, c. A-28, r. 1, s. 18.

19. Every private hospital centre shall provide the services listed in paragraph a of section 3, with the exception of those stipulated in subparagraphs vii and viii. If it does not have the necessary facilities to provide all the services prescribed in subparagraph iii of paragraph a of section 3, it must take measures to ensure that these services are furnished elsewhere, at its own expense, and must assume the transportation costs therefor.

R.R.Q., 1981, c. A-28, r. 1, s. 19.

SCHEDULE A

(s. 3)

PROSTHESES AND ORTHOPAEDIC APPLIANCES WHICH MAY BE INTEGRATED IN THE HUMAN BODY

A: Prostheses and orthopaedic appliances of the visual system:

1. Replacement pin of the eyeball.

2. Replacement material for floor of the orbit.

3. Springs for muscles involved in paralyses of the seventh nerve.

4. Rhino-conjunctival tube.

5. Organic, metallic or synthetic implants for the correction of cornea detachment.

6. Replacement oils of the vitreous.

7. Keratoprostheses.

8. Anterior chamber lenses.

9. Cemented lenses.

B: Prostheses and orthopaedic appliances of the auditory system:

1. Replacement prostheses of the ossicles.

2. Replacement prostheses of the anvil.

3. Replacement prostheses of the malleus.

4. Replacement prostheses of the stirrup bone.

5. Replacement prostheses of the eardrum.

6. Transtympanic prostheses.

7. Transmission electrodes for the inner ear with or without an incorporated receiving set.

C: Prostheses and orthopaedic appliances of the cardiovascular system:

1. Endocavitary pacemaker.

2. Extracavitary pacemaker electrodes.

3. Carotidian stimulator.

4. Cardiac and aortic valves.

5. Vascular building material.

6. Vascular replacement material.

D: Prostheses and orthopaedic appliances of the respiratory system:

1. For reconstruction:

(a) of the nose;

(b) of the larynx;

(c) of the pharynx;

(d) of the naso frontal duct;

(e) of the trachea.

2. For filling in collapse therapy.

E: Prostheses and orthopaedic appliances of the digestive system:

1. Replacement material for excretory ducts.

F: Prostheses and orthopaedic appliances of the urogenital system:

1. Replacement pin for testicle.

2. Penal-ortho-prostheses.

G: Mammary prostheses and orthopaedic appliances:

1. Of mammary reconstruction.

H: Prostheses and orthopaedic appliances of the skeletal system:

1. Glenohumeral prostheses.

2. Cephalic humeral prostheses.

3. Trochlear prostheses.

4. Humero-cubital prostheses.

5. Humero-cubito-radial prostheses.

6. Cephalic radial prostheses.

7. Cubito-radio-carpal prostheses.

8. Carpal prostheses.

9. Metacarpal prostheses.

10. Metacarpophalangeal prostheses.

11. Phalangeal prostheses.

12. Interphalangeal prostheses.

13. Acetabular prostheses.

14. Acetabulo-femoral prostheses.

15. Partial or complete distal femoral prostheses.

16. Femoro-tibio-peroneal prostheses.

17. Peroneo-astragalar tibio prostheses.

18. Astragalo-metatarsal prostheses.

19. Metatarso-tarsal prostheses.

20. Tarso-tarsal prostheses.

21. Intertarsal prostheses.

22. Anterior vertebral retention prostheses.

23. Posterior vertebral retention prostheses.

24. Mandibular prostheses.

25. Maxillary reconstruction prostheses.

26. Skull table prostheses.

27. Trepanation fasteners.

28. Replacement material for facial surface.

I: Prostheses of the nervous system:

1. Decompression valves for hydrocephalus.

2. Building tubes for encephalo rhachidian septum.

3. Building tubes for rhachidian septum.

4. Neuro-stimulator electrodes.

5. Anastomosis coatings.

J: Prostheses and orthopaedic appliances of various uses:

1. Traction or holding support nails.

2. Traction or holding support screws.

3. Traction or holding support wires.

4. Retention lattices.

5. Retention plates.

6. Holding plates.

7. Osseous cements.

R.R.Q., 1981, c. A-28, r. 1, Sch. A.

FORM A

(Revoked)

R.R.Q., 1981, c. A-28, r. 1, Form A; O.C. 1100-90, s. 8.

FORM B

(Revoked)

R.R.Q., 1981, c. A-28, r. 1, Form B; O.C. 1100-90, s. 8.

REFERENCES

R.R.Q., 1981, c. A-28, r. 1

O.C. 1036-82, 1982 G.O. 2, 1527; Suppl. 80

O.C. 1180-82, 1982 G.O. 2, 1677; Suppl. 81

O.C. 1490-82, 1982 G.O. 2, 1809; Suppl. 82

O.C. 1314-83, 1983 G.O. 2, 2256 and 3089

O.C. 1523-83, 1983 G.O. 2, 3146

O.C. 1321-84, 1984 G.O. 2, 2039

O.C. 1768-84, 1984 G.O. 2, 3279

S.Q. 1985, c. 6, s. 477

O.C. 197-86, 1986 G.O. 2, 298

O.C. 1257-87, 1987 G.O. 2, 3201

O.C. 1981-88, 1989 G.O. 2, 43

O.C. 113-90, 1990 G.O. 2, 450

O.C. 1100-90, 1990 G.O. 2, 2294

O.C. 668-91, 1991 G.O. 2, 1720

O.C. 696-91, 1991 G.O. 2, 1756

O.C. 744-91, 1991 G.O. 2, 1769

O.C. 498-92, 1992 G.O. 2, 1928

S.Q. 1992, c. 21, s. 375

O.C. 315-93, 1993 G.O. 2, 1889

O.C. 1379-95, 1995 G.O. 2, 3051

O.C. 1042-96, 1996 G.O. 2, 3902

O.C. 812-97, 1997 G.O. 2, 3338

O.C. 544-2000, 2000 G.O. 2, 2205

O.C. 973-2001, 2001 G.O. 2, 4880

S.Q. 2005, c. 32, s. 309