A-29, r. 4 - Regulation respecting devices which compensate for a physical deficiency and are insured under the Health Insurance Act

À jour au 1^er janvier 2019

Ce document a valeur officielle.

chapter A-29, r. 4

Regulation respecting devices which compensate for a physical deficiency and are insured under the Health Insurance Act

Health Insurance Act

(chapter A-29, ss. 3 and 69).

TITLE ONE PROSTHESES, ORTHOSES, ORTHOPEDIC DEVICES AND OTHER EQUIPMENT

1. Any service, device or other equipment referred to in this Title that is furnished to an insured person within the meaning of the Health Insurance Act (chapter A-29) in the cases, conditions and circumstances prescribed in this Title is determined to be insured for the purposes of the fifth paragraph of section 3 of the Act.

The Régie de l’assurance maladie du Québec, established under the Act respecting the Régie de l’assurance maladie du Québec (chapter R-5), assumes the cost of such service as well as the cost of the purchase, replacement, fitting or repair of such a device or such equipment.

O.C. 612-94, s. 1.

1.1. For the purposes of this Title, the word “Tariff” designates the Tariff for insured devices which compensate for a motor deficiency and related services (chapter A-29, r. 9), made by the Board under section 72.1 of the Health Insurance Act (chapter A-29).

Decision 001-2009, s. 2.

CHAPTER I SERVICES, DEVICES AND OTHER EQUIPMENT INSURED

2. For the purposes of this Title, a prosthesis, orthosis or orthopedic device constitutes a device. There are 2 types of orthopedic devices: ambulation aids and standing aids.

O.C. 612-94, s. 2; O.C. 1334-98, s. 1.

3. A device has components that are constituent parts of the device and it may be fitted. A device may also have a supplement which is an accessory that is required both to improve the functioning of the device and to enable it to be used permanently.

O.C. 612-94, s. 3.

4. A device is insured where

(1)  it appears on one of the lists in the Tariff; and

(2)  it is manufactured with all of the basic components and supplements appearing in the description of the device under the heading “Basic Component(s) and Supplement(s)” in the Tariff.

Notwithstanding the foregoing, a device for which “S.C.” appears under the purchase price or replacement price heading in the Tariff may constitute an insured device for an insured person if it is shown, by means of an evaluation conducted by the person referred to in section 31, that, owing to a specific disability, the insured person is unable to use any of the other insured devices appearing on a list in Part I of the Tariff, and if the device is manufactured with all of the basic components appearing in the description of a similar device found in Part I of the Tariff.

O.C. 612-94, s. 4; O.C. 150-2000, s. 1; Decision 001-2009, s. 3.

5. Notwithstanding subparagraph 2 of the first paragraph of section 4, an optional component may be substituted for a basic component of a device where the former appears in the description of the device under the heading “Component(s) and Supplement(s) Available” or on an exclusive list of components in the Tariff.

O.C. 612-94, s. 5; Decision 001-2009, s. 4.

6. The adjustments that may be made to a device are insured only if they are listed in the description of the device under the heading “Adjustment(s) Available” in the Tariff.

O.C. 612-94, s. 6; Decision 001-2009, s. 4.

7. Supplements to a device are insured only if they are listed in the description of the device under the heading “Basic Component(s) and Supplement(s)” or “Component(s) and Supplement(s) Available” or on an exclusive list of supplements in the Tariff.

O.C. 612-94, s. 7; Decision 001-2009, s. 4.

8. To be insured, a device, component, adjustment or supplement shall be manufactured with materials of a suitable quality and of such a nature that the cost does not exceed the price fixed in the Tariff for that device, component, adjustment or supplement. Such device, component, adjustment or supplement shall also be safe and esthetically pleasing.

O.C. 612-94, s. 8; Decision 001-2009, s. 5.

9. The replacement of an insured device is insured during its minimum duration period where the written prescription from a physician referred to in this Title certifies that such a replacement is necessary following a significant change in the insured person’s physical condition or where it is shown, by means of an evaluation conducted by a person referred to in section 30 or 31, as the case may be, that an insured person under the age of 19 has grown.

The minimum duration period for a device, which runs from the time of the final installation, is determined as follows:

(1)  5 years for a lower-limb prosthesis;

(2)  6 years for an upper-limb prosthesis;

(3)  1 year for prosthetic finger or partial hand restoration;

(4)  6 months for a prosthetic glove for an upper-limb prosthesis; and

(5)  2 years for an orthosis;

(6)  10 years for a cane, crutch or children’s depth-adjustable, height-adjustable, 4-wheeled walker with thoracic support; and

(7)  5 years for a walker.

The final installation of a device occurs at the end of the period required for the necessary fittings during its manufacture, when the insured person, once those fittings have been completed, takes final receipt of the device.

O.C. 612-94, s. 9; O.C. 1334-98, s. 2.

10. Fittings and repairs of an insured device, component, adjustment or supplement are insured.

O.C. 612-94, s. 10.

11. Notwithstanding section 10, fittings and repairs are insured only if the device has been used solely for the purposes for which it was designed and intended and in a responsible manner.

Furthermore, where it becomes necessary to replace a device under the provisions of this Title, only urgent and necessary fittings and repairs are insured for that device in order to allow minimal functioning of the device until the insured person takes initial receipt of his new device.

O.C. 612-94, s. 11; O.C. 1334-98, s. 3.

12. Notwithstanding section 10, fittings and repairs of a device, component or adjustment are insured only where the estimate of the cost of one or all of such services does not exceed 80% of the cost of purchase or previous replacement of the device, component or adjustment, as the case may be.

In addition, only those services are insured in such a case. Where such is not the case, only the replacement of the device is insured in accordance with the provisions of this Title.

Notwithstanding the second paragraph, the replacement is insured only if the device, component, adjustment or supplement has been used solely for the purposes for which it was designed and intended.

Notwithstanding the second paragraph, for a 2-year period from the event of damage or irreparable breakage, the replacement of a device, component, adjustment or supplement is not insured if the only reason for the replacement is that the device, component, adjustment or supplement was used negligently or was lost, stolen or destroyed. That 2-year period shall cease when the minimum duration period of the device expires and shall not be extended beyond that expiry.

If, before the expiry of either period, the insured person, at his own expense and in accordance with this Title, replaces a broken or damaged device, component, adjustment or supplement with an insured device, component, adjustment or supplement, fittings and repairs of the new device, component, adjustment or supplement are insured, subject to the relevant provisions of this Title.

O.C. 612-94, s. 12; O.C. 1334-98, s. 4.

13. Any device appearing on the list in Division II of Part II of the Tariff that is no longer used by an insured person owing to the person’s death or that has been replaced owing to a change in the person’s physical condition must be returned to an institution that operates a rehabilitation centre offering technical aid services for persons with motricity impairment and that holds a permit issued by the Minister under section 437 of the Act respecting health services and social services (chapter S-4.2) or section 136 of the Act respecting health services and social services for Cree Native persons (chapter S-5).

Furthermore, a children’s depth-adjustable, height-adjustable, 4-wheeled walker with thoracic support shall be returned to such an institution or laboratory where it is no longer used by the insured person.

For that purpose, such an institution or laboratory shall verify annually that such a device or walker is used by the insured person in accordance with the provisions of this Title.

The word “institution” has the same meaning as the meaning assigned by the Health Insurance Act (chapter A-29), the Act respecting health services and social services or the Act respecting health services and social services for Cree Native persons to the extent that it applies to the territory of the Cree Board of Health and Social Services of James Bay, in accordance with the law or laws that apply.

O.C. 612-94, s. 13; O.C. 1334-98, s. 5; Decision 001-2009, s. 6; O.C. 1092-2011, s. 1.

CHAPTER II SERVICES, DEVICES OR OTHER EQUIPMENT INSURED FOR AN INSURED PERSON

14. A device is insured only if the physical deficiency and, where applicable, the deformity for which it is intended to compensate and, also where applicable, the activities and living environment of an insured person to whom the device is furnished are taken into account in its manufacture.

O.C. 612-94, s. 14.

15. Only an orthosis that is furnished to an insured person on the written prescription of a physician referred to in this Title whose contents meet the requirements of section 28 is insured where the insured person must wear the orthosis on a daily basis for at least the following length of time:

(1)  6 months for a lower-limb orthosis;

(2)  1 month for an upper-limb orthosis; and

(3)  3 months for a trunk orthosis.

Notwithstanding the foregoing, an orthosis that is furnished to an insured person under the age of 19 shall remain an insured orthosis even if it has not been determined that he is required to wear it daily for the full length of time stated in the first paragraph, provided the insured person is required to wear the orthosis to correct a deformity.

O.C. 612-94, s. 15.

15.1. An ambulation aid is insured only where it is furnished to an insured person on the written prescription of a physician referred to in the Tariff whose contents meet the requirements of section 28 and where the insured person must use such aid on a daily basis for at least 12 months.

Notwithstanding any provision to the contrary, an ambulation aid is insured only in respect of an insured person whose inability to walk cannot be compensated for, if he requires a cane, by a cane on the list in the Tariff or, if he requires a crutch, by a cane or crutch on the list in the Tariff or, if he requires a walker or a children’s depth-adjustable, height-adjustable, 4-wheeled walker with thoracic support, by a cane, a crutch, a walker or a children’s depth-adjustable, height-adjustable, 4-wheeled walker with thoracic support on the list in the Tariff.

O.C. 1334-98, s. 6; Decision 001-2009, s. 7.

16. Only one device that is furnished for each specific function of a limb and only one device that is furnished for each specific function of a segment of a limb are insured.

Notwithstanding the foregoing and subject to section 15, an additional device, an additional component or an additional supplement in the case where the latter is also listed as a device is insured if it is shown, by means of an evaluation conducted by at least one person referred to in section 30 or 31, as the case may be, that the use of such a device, component or supplement is required to carry out specific activities pertaining essentially to recognized studies or to professional activities.

Recognized studies are those pursued by a student registered in a program leading to a diploma, certificate or other attestation of studies recognized by the Minister of Education, Recreation and Sports or the Minister of Higher Education, Research, Science and Technology.

O.C. 612-94, s. 16; O.C. 1334-98, s. 7; S.Q. 2013, c. 28, s. 205.

17. For each insured person, 6 socks or 6 socks and 6 sheaths per 12-month period are insured for each limb fitted with one or more prostheses. Each sock or each sock and sheath shall be a supplement, within the meaning of section 3, for a prosthesis fitted on a limb.

For the same insured person, 3 suspension linings with or without nylon on the inside per 12-month period are insured for each limb fitted with one or more prostheses.

In addition, for the same insured person, 4 latex or elastic suspension linings per 12-month period are insured for each limb fitted with one or more prostheses.

Each suspension lining must be, within the meaning of section 3, a component of a prosthesis fitted on a limb.

O.C. 612-94, s. 17; O.C. 150-2000, s. 2.

CHAPTER III COSTS ASSUMED BY THE BOARD

18. The cost of purchase, replacement, fitting or repair of a device or of one or a combination of its components, adjustments or supplements assumed by the Board is the price fixed for each device, for each component, adjustment, supplement or combination thereof, or for the fitting or repair appearing on the list in the Tariff.

O.C. 612-94, s. 18; Decision 001-2009, s. 8.

19. (Revoked).

O.C. 612-94, s. 19; Decision 001-2009, s. 9.

20. Where, in accordance with section 5, an optional component is substituted for a basic component at the time of purchase or replacement of an insured device, the cost of the device assumed by the Board is determined by adding the price fixed in the Tariff for the optional component to the price of purchase or replacement of the device.

O.C. 612-94, s. 20; Decision 001-2009, s. 10.

21. (Revoked).

O.C. 612-94, s. 21; Decision 001-2009, s. 11.

22. In respect of canes and height-adjustable axillary crutches, the Board assumes, per 12-month period, the cost of replacement of not more than 1 set of ice tips with 4 or 5 prongs and safety tips, and not more than 2 pairs of axillary pads and handrest covers, if any.

O.C. 612-94, s. 22; O.C. 1334-98, s. 8; Decision 001-2009, s. 12.

23. Where the reference “S.C.” in the Tariff appears in place of the purchase or replacement price of a device that is determined to be insured or of one or a combination of its components, the total cost assumed by the Board is determined as follows:

(1)  the rate fixed in the Tariff per quarter hour or fraction thereof for manufacturing time beyond the time usually required for a similar device or component, as the case may be, specified on a list appearing in the Tariff; and

(2)  the cost price of the materials required in addition to those generally used, as the case may be, for a similar device or component specified on a list appearing in the Tariff is added to the cost arising from the application of subparagraph 1.

The Board does not assume the replacement cost of a component for which the reference “N/A” appears in the Tariff in place of the replacement price.

The Board does not assume the cost of a component for which the reference “N/A” appears in the Tariff in place of the component price when the device is purchased or replaced.

O.C. 612-94, s. 23; O.C. 150-2000, s. 3; Decision 2001-11-14, s. 1; Decision 2003-06-11, s. 1; Decision 2004-04-14, s. 1; Decision 2005-04-13, s. 1; Decision 003-2006, s. 1; Decision 001-2007, s. 1; Decision 002-2008, s. 1; Decision 001-2009, s. 13.

24. Where the cost of an insured repair or fitting of a device or of one or a combination of components, adjustments or supplements is undetermined because no price has been entered on the list in the Tariff, the total cost assumed by the Board is determined as follows:

(1)  the rate fixed in the Tariff per quarter hour or fraction thereof for the time required for fitting or repair, or both, where applicable;

(2)  the rate fixed in the Tariff per quarter hour or fraction thereof for the time required to make an adjustment; and

(3)  the cost price of the materials is added to the cost arising from the application of paragraphs 1 and 2.

O.C. 612-94, s. 24; O.C. 1334-98, s. 9; Decision 2001-11-14, s. 1; Decision 2003-06-11, s. 1; Decision 2004-04-14, s. 1; Decision 2005-04-13, s. 1; Decision 003-2006, s. 1; Decision 001-2007, s. 1; Decision 002-2008, s. 1; Decision 001-2009, s. 14.

25. Where, prior to the final installation, the insured person’s physical condition changes to such an extent that the rehabilitation phase must be stopped or where the insured person dies, the total cost assumed by the Board for an insured device that is partially or totally manufactured is determined as follows:

(1)  the rate fixed in the Tariff per quarter hour or fraction thereof for manufacturing time; and

(2)  the cost price of the materials is added to the cost arising from the application of subparagraph 1 and the cost price of the materials that can be recovered by the institution that operates the centre that manufactured it or, if such is the case, by a laboratory is subtracted from that total.

The words “centre” and “laboratory” have the same meaning, in each case, as the meaning assigned by the Health Insurance Act (chapter A-29).

O.C. 612-94, s. 25; Decision 2001-11-14, s. 1; Decision 2003-06-11, s. 1; Decision 2004-04-14, s. 1; Decision 2005-04-13, s. 1; Decision 003-2006, s. 1; Decision 001-2007, s. 1; Decision 002-2008, s. 1; Decision 001-2009, s. 15.

25.0.1. (Revoked).

Decision 2001-11-14, s. 2; Decision 2003-06-11, s. 2.

25.1. Where a children’s depth-adjustable, height-adjustable, 4-wheeled walker with thoracic support is furnished to an insured person and has already been returned to an institution or laboratory in accordance with the second paragraph of section 13, the total cost assumed by the Board for all of the following services is the price fixed in the Tariff:

(1)  the recovery of the walker, the safety check and cleaning, after it has been returned, providing it to another insured person; and

(2)  administrative and inventory management services.

Furthermore, the Board shall assume the purchase or replacement cost of such a walker only if no other walker, which had already been paid for by the Board or by the Office des personnes handicapées du Québec, was recovered by an institution or laboratory and none is available for the insured person. For that purpose, subject to section 12, the institution or laboratory must repair the walker or have it repaired as soon as it has been recovered to make it available for the insured person.

O.C. 1334-98, s. 10; Decision 2001-11-14, s. 3; Decision 2004-04-14, s. 2; Decision 2005-04-13, s. 2; Decision 003-2006, s. 2; Decision 001-2007, s. 2; Decision 002-2008, s. 2; Decision 001-2009, s. 16.

CHAPTER IV TERMS AND CONDITIONS FOR ALLOCATION

26. The Board assumes the cost of purchase or replacement of an insured device where a written medical prescription indicates the need to furnish an insured person with such a device in accordance with section 28.

The written medical prescription shall be produced by one of the following persons:

(1)  a physician specializing in orthopedics, physiatry, neurology, rheumatology, in geriatrics or neurosurgery; or

(2)  a general practitioner or a physician specializing in pediatrics who holds specific privileges for that purpose in a hospital or in a rehabilitation centre that offers technical aid services for persons with motricity impairment and is operated by an institution holding a permit issued by the Minister under section 437 of the Act respecting health services and social services (chapter S-4.2) or section 136 of the Act respecting health services and social services for Cree Native persons (chapter S-5), or whose designation by the agency has been approved by the Minister of Health and Social Services in accordance with section 29.

Notwithstanding the foregoing, the written medical prescription may also, in the case of a lower-limb prosthesis, be produced by a physician specializing in general surgery who practises in a hospital and, in the case of a lower-limb or upper-limb orthosis, by a physician specializing in plastic surgery.

The expressions “hospital” and “rehabilitation centre for persons with motricity impairment” have the same meaning, in each case, as the meaning assigned by the Health Insurance Act (chapter A-29), the Act respecting health services and social services or the Act respecting health services and social services for Cree Native persons to the extent that it applies to the territory of the Cree Board of Health and Social Services of James Bay, in accordance with the law or laws that apply.

O.C. 612-94, s. 26; O.C. 1334-98, s. 11; O.C. 999-2002, s. 1; O.C. 1092-2011, s. 2.

27. In addition to the condition set forth in section 26, the Board assumes the cost of purchase or replacement of an insured device

(1)  in the case of a device that appears on one of the lists in Part I of the Tariff where it is furnished to an insured person in Québec by an institution in a hospital or in a rehabilitation centre offering technical aid services for persons with motricity impairment or by a laboratory, provided that the institution that operates the hospital or rehabilitation centre or the laboratory, as the case may be, holds a permit issued by the Minister under section 437 of the Act respecting health services and social services (chapter S-4.2), section 136 of the Act respecting health services and social services for Cree Native persons (chapter S-5) or section 31 of the Act respecting medical laboratories and organ and tissue conservation (chapter L-0.2), or where it is furnished to an insured person outside Québec by an institution or laboratory recognized under section 13 of the Health Insurance Act (chapter A-29); and

(2)  in the case of a device that appears on one of the lists in Part II of the Tariff where it is furnished to an insured person in Québec by an institution in a hospital or in a rehabilitation centre offering technical aid services for persons with motricity impairment, provided that the institution that operates the hospital or the rehabilitation centre holds a permit issued by the Minister under section 437 of the Act respecting health services and social services or section 136 of the Act respecting health services and social services for Cree Native persons, or where it is furnished to an insured person outside Québec by an institution recognized under section 13 of the Health Insurance Act.

Notwithstanding the condition set forth in subparagraph 1 of the first paragraph, the Board only assumes the cost of purchase or replacement of an insured device that appears on one of the lists in Part I of the Tariff where the reference “S.C.” appears in place of the purchase or replacement price, provided that a person from a centre referred to in subparagraph 2 of the first paragraph or a person designated by such a centre attests in writing that the device will be furnished in the course of a rehabilitation process at the centre.

The Board assumes the cost of fitting or repair of a device or of one or a combination of its components, adjustments or supplements, or the cost of purchase or replacement of one or a combination of components, adjustments or supplements for an insured device under the conditions set forth in the first paragraph, or in the first and second paragraphs, as the case may be.

O.C. 612-94, s. 27; O.C. 150-2000, s. 4; Decision 001-2009, s. 17; O.C. 1092-2011, s. 3.

28. For the purposes of section 26, the written medical prescription shall, at a minimum, confirm the insured person’s physical deficiency and disability, and it shall also state the need for a device.

Furthermore, for the purposes of section 15, the written medical prescription shall also certify the deformity, where applicable, and the need for the insured person to wear the prescribed orthosis on a daily basis for a medically required duration that must be stated in the prescription.

Furthermore, for the purposes of section 15.1, the written medical prescription shall also certify that the insured person must use an ambulation aid on a daily basis for medical reasons and for the duration shown on the prescription.

O.C. 612-94, s. 28; O.C. 1334-98, s. 12.

29. In regions where there is no hospital or rehabilitation centre offering technical aid services for persons with motricity impairment, an institution that operates a rehabilitation centre for persons with motricity impairment or a hospital in which there is a practising general practitioner who is empowered to attest to the needs of persons with motricity impairment and who holds specific privileges for that purpose, or in which there is a physician specializing in pediatrics who meets the same requirements, may receive a designation by the agency that is approved by the Minister of Health and Social Services pursuant to sections 347 and 377 and subparagraphs 1 to 3 and 7 of the second paragraph of section 431 of the Act respecting health services and social services (chapter S-4.2), for the purposes of subparagraph 2 of the second paragraph of section 26.

O.C. 612-94, s. 29; O.C. 1092-2011, s. 4.

30. The Board also assumes the cost of purchase, replacement, fitting or repair of an insured device or of one or a combination of its components, adjustments or supplements that is furnished to an insured person in Québec by an institution in the hospital or rehabilitation centre for persons with a physical deficiency operated by the latter or by a laboratory under subparagraph 1 of the first paragraph of section 27, on the following additional conditions:

(1)  the technical specifications of the device have been set forth in writing by one of the following persons at the centre: a prosthesist, an orthosist or an orthotics-prosthetics technician, an occupational therapist or a physiotherapist, the latter 2 having been designated by the centre; one of those persons shall have met with the insured person for that purpose; and

(2)  in the case of a laboratory, the technical specifications of the device have been set forth in writing by one of the following persons at the laboratory: a prosthesist, an orthosist or an orthotics-prosthetics technician; one of those persons shall have met with the insured person for that purpose;

(3)  in respect of an ambulation aid, whether it is furnished to an insured person in Québec by an institution or a laboratory, a full assessment of the person’s needs certifying in writing that a specific aid is required has been carried out by a physiotherapist or occupational therapist in a centre operated by an institution referred to in the fourth paragraph where a rehabilitation program may have been drawn up and implemented for the insured person; moreover, the physiotherapist or occupational therapist has certified that the person is undergoing or has undergone rehabilitation and that the aid is nevertheless required to ensure the person’s ability to walk. In that respect, the insured person must have met with a prosthesist, an orthosist, an orthotics-prosthetics technician with the laboratory which provided the ambulation aid in Québec or, where the aid is provided by an institution, one of the latter specialists, a physiotherapist or an occupational therapist.

An orthotics-prosthetics technician is a person who holds a Diploma of College Studies in orthotics and prosthetics technology (1984) or in orthopedic ortheses and prostheses techniques (1993).

An orthosist or prosthesist is a person who holds a diploma in orthotics or prosthetics awarded before 1 July 1982 by an educational establishment recognized by the Minister of Education, Recreation and Sports or who has received a laboratory permit in orthopedic prosthetics or orthotics under the Act respecting medical laboratories and organ and tissue conservation (chapter L-0.2).

Notwithstanding section 13, for the purposes of subparagraph 3 of the first paragraph, the institution referred to in this paragraph is a public institution within the meaning of the Act respecting health services and social services (chapter S-4.2) or the Act respecting health services and social services for Cree Native persons (chapter S-5) or is a private institution referred to in both sections 99 and 475 of the Act respecting health services and social services or referred to in both sections 12 and 177 of the Act respecting health services and social services for Cree Native persons.

O.C. 612-94, s. 30; O.C. 1334-98, s. 13; O.C. 1047-2000, s. 1.

31. The Board also assumes the cost of purchase, replacement, fitting or repair of an insured device or of one or a combination of its components, adjustments or supplements that are furnished to an insured person in Québec by an institution in the hospital or rehabilitation centre for physically impaired persons operated by the latter under subparagraph 2 of the first paragraph of section 27, provided that the following additional conditions are met: the technical specifications of the device have been set forth in writing by one of the following persons at the centre: a prosthesist, an orthosist or an orthotics-prosthetics technician, an occupational therapist or a physiotherapist, the latter 2 having been designated by the centre; such person shall have met with the insured person for that purpose.

O.C. 612-94, s. 31.

32. The Board assumes the purchase or replacement cost of a device or of one or a combination of its components specified in section 23 only if the following items are sent to the Board in writing:

(1)  the additional manufacturing time required in accordance with section 23; and

(2)  the list of additional materials used in accordance with section 23 and their cost price.

O.C. 612-94, s. 32.

33. The Board assumes the repair or fitting cost referred to in section 24, where it exceeds $80, only if the following items are sent to the Board in writing:

(1)  the duration of the repair, fitting or replacement of one or a combination of components, adjustments or supplements; and

(2)  the list of materials used and their cost price.

O.C. 612-94, s. 33; Decision 2001-11-14, s. 4; Decision 2003-06-11, s. 3.

34.1. The Board assumes the cost of purchase or replacement of a device referred to in the second paragraph of section 27 provided that the written attestation prescribed therein is sent to the Board, jointly prepared and signed by each of the members of a multidisciplinary rehabilitation team that includes at least a physiotherapist or occupational therapist, designated by the centre referred to in the second paragraph of section 27, an orthotist, a prosthesist or a orthotics-prosthetics technician from the centre and the physician designated by the centre as a member of the team.

When replacing such a device, where the insured person’s condition has not changed, the attestation may establish that the insured device is not furnished in the course of a rehabilitation process since rehabilitation is not required.

O.C. 150-2000, s. 5.

34.2. The Board assumes the cost of a service as well as the cost of the purchase, replacement, fitting or repair of a device or other equipment referred to in this Title only if the institution or laboratory sends to the Board, using the form provided by the Board, the following information, which may vary depending on the medium used or depending on whether the reference “S.C.” appears in place of the purchase or replacement price or the case involves a claim for payment:

(1)  the health insurance number, the expiration date indicated on the health insurance card and the information required by the Board to identify the insured person who benefited from the property or service;

(2)  the name, permit number and dispenser number of the institution or laboratory, and the prescriber number and the reference number of the claim concerning a device, component or supplement for which the reference “S.C.” appears in place of its purchase or replacement price or of the claim for payment;

(3)  a description of the insured person’s physical deficiency and disability, and the information provided for, as the case may be, in sections 4, 23 and 27;

(4)  the code of the good or service, side of the body, type, the number of units, the amount claimed, the serial number, the date on which the property was allocated or the service rendered and, in the case of a repair, fitting, replacement or adjustment, the reason therefor, the date of taking possession, the reference code for the property and the manufacturer’s authorization number;

(5)  a statement of the labour costs, including the duration of the work and a list of the materials;

(6)  a statement by the insured person confirming that the person received the property or service described and authorizing the Board to make the payment;

(7)  the necessary information for identifying the recipient of the payment; and

(8)  a statement by the person in charge of the institution or laboratory confirming that the information provided is accurate and complete.

O.C. 1092-2011, s. 5.

CHAPTER V

(Revoked)

O.C. 612-94, c. V of Title One; O.C. 1334-98, ss. 41 and 42; O.C. 150-2000, s. 6; Decision 2001-11-14, s. 11; Decision 004-2005, s. 1; Decision 003-2006, s. 3; Decision 001-2007, s. 3; Decision 002-2008, s. 3; Decision 001-2009, s. 18.

TITLE TWO LOCOMOTOR AND POSTURE ASSISTS

35. Any service, device or other equipment referred to in this Title that is furnished to an insured person within the meaning of the Health Insurance Act (chapter A-29) in the cases, conditions and circumstances prescribed in this Title is determined to be insured for the purposes of the fifth paragraph of section 3 of the Act.

The Régie de l’assurance maladie du Québec assumes the cost of such service as well as the cost of the purchase, replacement, fitting or repair of such a device or such equipment.

O.C. 612-94, s. 35.

35.1. For the purposes of this Title, the word “Tariff” designates the Tariff for insured devices which compensate for a motor deficiency and related services (chapter A-29, r. 9), made by the Board under section 72.1 of the Health Insurance Act (chapter A-29).

Decision 001-2009, s. 19.

CHAPTER I SERVICES, DEVICES AND OTHER EQUIPMENT INSURED

36. For the purposes of this Title, a locomotor assist or a posture assist constitutes a device.

There are 2 types of assists: locomotor assists and posture assists. The first type includes wheel chairs, positioning bases as well as strollers and orthomobiles. The second type includes upper-limb posture assists and technical posture assists.

O.C. 612-94, s. 36.

37. A device has components that are constituent parts of the device. It may also have a supplement which is an accessory that is required both to improve the functioning of the device and to enable it to be used permanently.

O.C. 612-94, s. 37.

38. A device is insured where

(1)  it appears on one of the lists in the Tariff; and

(2)  it is manufactured with all of the basic components appearing in the description of the device under the heading “Basic Component(s)” in the Tariff.

Notwithstanding the foregoing, a device which does not meet the requirements set forth in subparagraph 1 or 2 of the first paragraph may constitute an insured device for an insured person if it is shown, by means of an evaluation conducted by the persons referred to in section 72, that, owing to a specific disability, the insured person is unable to use any of the devices appearing on a list in the Tariff and meeting the requirements set forth in subparagraph 2 of the first paragraph.

The same applies with respect to a component of a device for an insured person where it is shown, by means of such an evaluation, that, owing to a specific disability, it would serve no purpose to allocate to the insured person a component appearing on a list in the Tariff and meeting the requirements set forth in subparagraph 2 of the first paragraph or to allocate the device without such component.

O.C. 612-94, s. 38; O.C. 1334-98, s. 14; Decision 001-2009, s. 20.

39. Notwithstanding subparagraph 2 of the first paragraph of section 38, an optional component may be substituted for a basic component where the former appears in the description of the device under the heading “Basic and Optional Component(s)” or on an exclusive list of components in the Tariff.

O.C. 612-94, s. 39; O.C. 1334-98, s. 15; Decision 001-2009, s. 21.

40. A supplement to a device is insured only if it is listed in the description of the device under the heading “Supplement(s) Available” or on an exclusive list of supplements in the Tariff.

O.C. 612-94, s. 40; Decision 001-2009, s. 21.

41. To be insured, a device, component or supplement shall be manufactured with materials of a suitable quality and of such a nature that the cost does not exceed the price fixed in the Tariff for that device, component or supplement. Such device, component, adjustment or supplement shall also be safe and esthetically pleasing.

O.C. 612-94, s. 41; Decision 001-2009, s. 22.

42. The replacement of an insured device is insured in the following cases:

(1)  upon the expiry of its minimum duration period if the device no longer functions under normal conditions of use;

(2)  during its minimum duration period where the written prescription from a physician referred to in this Title certifies that such a replacement is necessary following a change in the insured person’s physical condition or where it is noted, in the technical specifications prepared by an occupational therapist or a physiotherapist referred to in section 72, that an insured person under the age of 19 has grown and, in the latter case, where one of those persons also certifies that the device cannot be adjusted; and

(3)  (subparagraph revoked).

The minimum duration period for a locomotor assist, which runs from the time of the final installation, is 5 years.

The final installation of a device occurs at the end of the period required for the necessary fittings during its manufacture, when the insured person, once those fittings have been completed, takes final receipt of the device.

O.C. 612-94, s. 42; O.C. 1334-98, s. 16.

43. Fitting, adaptation and repair services for an insured device, component or supplement are insured.

Notwithstanding the foregoing, fitting or repair services for a wheel chair or a component referred to in section 38 are insured only for an insured person referred to in section 51 or 53, as the case may be.

Furthermore, adaptation services for a device are insured only if they are to install a ventilator or a compressor, where the device is a powered wheel chair and such service is furnished to an insured person referred to in section 53 with a written medical prescription for that service.

In addition, fitting and repair services for a device, component or supplement no longer appearing on a list in the Tariff but for which the Board previously assumed the purchase or replacement cost are also insured services, but only in respect of an insured person who is still referred to in section 51 or 53, as the case may be, at the time the fitting or repair service is furnished.

Finally, fitting and repair services for a 3-wheeled scooter or a 4-wheeled scooter, any of the components or supplements that have already been furnished to any insured person within the meaning of the Health Insurance Act (chapter A-29) by the Office des personnes handicapées du Québec on 12 November 1998 and for which the aforementioned Office has assumed the cost are insured services.

O.C. 612-94, s. 43; O.C. 1334-98, s. 17; Decision 001-2009, s. 23.

44. Notwithstanding section 43, fitting and repair services are insured only if the device has been used solely for the purposes for which it was designed and intended and in a responsible manner.

Furthermore, where the Board has authorized a device to be replaced, only urgent and necessary fitting and repair services are insured for that device in order to allow minimal functioning of the device until the insured person takes initial receipt of his new device.

O.C. 612-94, s. 44; O.C. 1334-98, s. 18.

45. Notwithstanding section 43, fitting and repair services for a device or component and the replacement of a component are insured only where the estimate of the cost at a given time of one or all of such services does not exceed 80% of the cost of purchase or previous replacement of the device.

Where such is not the case, only the replacement of the device is insured in accordance with the provisions of this Title.

O.C. 612-94, s. 45; O.C. 1334-98, s. 19.

46. (Revoked).

O.C. 612-94, s. 46; O.C. 1334-98, s. 20.

47. Notwithstanding the second paragraph of section 45, the replacement of a device or component and the replacement of a supplement is insured only if it has been used for the purposes for which it was designed and intended.

Notwithstanding the second paragraph of section 45, for a 2-year period from the event of damage or irreparable breakage, the replacement of a device, component or supplement is not insured if the only reason for the replacement is that the device, component or supplement was used negligently or was lost, stolen or destroyed.

That 2-year period shall cease to run when the minimum duration period of the device expires and shall not be extended beyond that expiry.

If, before the end of either of those periods, the insured person, at his own expense and in accordance with this Title, replaces a broken or damaged device, component or supplement with an insured device, component or supplement, fittings and repairs of the new device, component or supplement are insured, subject to the relevant provisions of this Title.

O.C. 612-94, s. 47; O.C. 1334-98, s. 21.

48. (Revoked).

O.C. 612-94, s. 48; O.C. 1334-98, s. 22.

CHAPTER II SERVICES, DEVICES AND OTHER EQUIPMENT INSURED FOR AN INSURED PERSON

49. Notwithstanding section 38, a device is insured only if it is designed for the physical deficiency and, where applicable, the deformity for which it is intended to compensate and, also where applicable, for the activities and living environment of the insured person to whom the device is furnished.

O.C. 612-94, s. 49.

50. Only one device is insured for each insured person; fitting services and repair services are also insured for that one device.

Notwithstanding the first paragraph and subject to advance authorization by the Board, an additional locomotor and posture assist, other than a powered wheel chair, including its components and supplements, or an additional component of such a device is insured where the device is required for specific activities pertaining essentially to recognized studies or professional activities.

Recognized studies are those pursued by a student registered in a program leading to a diploma, certificate or other attestation of studies recognized by the Minister of Education, Recreation and Sports or the Minister of Higher Education, Research, Science and Technology.

Fitting and repair services for such an additional device, its components or supplements or for such an additional component are also insured.

Subject to the second paragraph, only one of the following devices is also insured for any one insured person: a wheel chair or a stroller appearing on a list in this Title.

O.C. 612-94, s. 50; O.C. 1334-98, s. 23; S.Q. 2013, c. 28, s. 205.

51. Notwithstanding section 38, a manual wheel chair, a lightweight manual wheel chair or any of their components or supplements appearing on a list in the Tariff are insured only if they are furnished in the following cases:

(1)  to a hemiplegic insured person with a posture or balance disorder;

(2)  to a paraplegic insured person;

(3)  to a quadriplegic insured person whose injury is located at a level other than levels C3-C4, C4-C5 or C5-C6;

(4)  to an insured person who has sustained a bilateral femoral or bilateral coxofemoral amputation or a bilateral hemipelvectomy;

(5)  to an insured person with a permanent loss of function of the lower limbs, in cases of spastic disorders, ataxy and athetosis; or

(6)  to an insured person with functional disorders that permanently prevent the use of the lower limbs;

(7)  to an insured person with a degenerative deficiency of the musculoskeletal system, who already has a device allocated under section 53 and who requires a manual wheel chair or a lightweight manual wheel chair to maintain his residual abilities, which allow him nonetheless to use such a wheel chair independently.

For an insured person referred to in subparagraph 7 of the first paragraph, and notwithstanding section 38 and the first paragraph, only a manual wheel chair or a lightweight manual wheel chair having been returned to an institution in accordance with the second paragraph of section 57 is insured.

Notwithstanding section 38 and the first paragraph, where such insured person already owns a manual wheel chair or a lightweight manual wheel chair for which the Board has already assumed the purchase or replacement cost, that wheel chair is insured without having been returned to an institution.

Only fitting and repair services for such wheel chairs and their components or supplements furnished in the same cases are insured.

In addition, where an insured person referred to in subparagraph 7 of the first paragraph agrees to have the Board assume responsibility for a manual wheel chair or a lightweight manual wheel chair belonging to him on 12 November 1998 but for which the Board has not assumed the purchase or replacement cost, fitting and repair services for such wheel chair and its components or supplements are insured.

The Board shall assume responsibility only for a wheel chair that is similar to a wheel chair appearing on a list in Subdivision I or II of Division I of Part I of the Tariff, that complies with the requirements of section 41 and that meets the requirements of the first paragraph of section 45.

O.C. 612-94, s. 51; O.C. 1334-98, s. 24; Decision 001-2009, s. 24.

52. Notwithstanding sections 38 and 51, a manual wheel chair, a lightweight manual wheel chair or any of their components or supplements appearing on a list in the Tariff is not insured if it is furnished to an insured person residing in a residential and long-term care centre or in a private institution under agreement referred to in the Act respecting health services and social services (chapter S-4.2) or, if such is the case, in a long-term care hospital or private institution under agreement referred to in the Act respecting health services and social services for Cree Native persons (chapter S-5) to the extent that the latter Act applies to the territory of the Cree Board of Health and Social Services of James Bay.

Notwithstanding the foregoing, a manual wheel chair or any of its components or supplements is insured, even if furnished to such an insured person, if it is shown, by means of an evaluation conducted by the persons referred to in section 72, that none of the wheel chairs on hand at such a private institution under agreement or at the public institution operating such a residential centre or such a hospital, as the case may be, can be used independently by the insured person owing to a specific disability and that the insured person will be able to maintain or develop his ability to move about only if he can independently use a manual wheel chair.

The expression “public institution” has the same meaning as that assigned by the Act respecting health services and social services. A “private institution under agreement” is an institution referred to in section 477 of the same Act.

O.C. 612-94, s. 52; Decision 001-2009, s. 25.

53. Notwithstanding section 38, a powered wheel chair or any of its components or supplements appearing on a list in the Tariff is insured only if it is furnished in the following cases:

(1)  to a quadriplegic insured person whose injury is located at levels C3-C4, C4-C5 or C5-C6; or

(2)  to an insured person with a permanent loss of function of both upper limbs and at least one lower limb;

(3)  to an insured person who has been suffering for more than 6 months from a severe cardiovascular or cardiorespiratory insufficiency associated with a physical deficiency within the meaning of this Title, who already has a device allocated under section 51, who is still able to use a powered wheel chair and who requires such wheel chair because, by reason of that insufficiency and that deficiency, and notwithstanding optimal medical treatment, he is now unable to use a manual wheel chair or a lightweight manual wheel chair independently.

For an insured person referred to in subparagraph 3 of the first paragraph, and notwithstanding section 38 and the first paragraph, only a powered wheel chair having been returned to an institution in accordance with the second paragraph of section 57 is insured.

Only fitting and repair services for a powered wheel chair and its components or supplements furnished in the same cases are insured.

Furthermore, where an insured person referred to in subparagraph 3 of the first paragraph agrees to have the Board assume responsibility for a powered wheel chair belonging to him on 12 November 1998 but for which the Board has not assumed the purchase or replacement cost, fitting and repair services for such wheel chair and its components or supplements are insured.

The Board shall assume responsibility only for a wheel chair that is similar to a wheel chair appearing on a list in Subdivision III of Division I of Part I of the Tariff, that complies with the requirements of section 41 and that meets the requirements of the first paragraph of section 45.

For the purposes of subparagraph 3 of the first paragraph, a severe cardiorespiratory insufficiency is that of Group B of the respiratory impairment classification used by Retraite Québec, as determined when the insured person is under optimal treatment and the insufficiency has been present for more than 6 months.

Furthermore, for the purposes of subparagraph 3 of the first paragraph, a severe cardiovascular insufficiency is that of Class III of the functional cardiovascular impairment classification used by the New York Heart Association, as determined when the insured person is under optimal treatment and the insufficiency has been present for more than 6 months.

O.C. 612-94, s. 53; O.C. 1334-98, s. 25; Decision 001-2009, s. 26.

54. Notwithstanding section 38, a “Buggy Major”-type stroller or any of its components or supplements appearing on a list in the Tariff is insured only if the device is furnished in the following cases:

(1)  to an insured person who is under 3 years of age but over 1 year with a permanent and severe disability who requires a personalized technical posture assist; or

(2)  to an insured person who is 3 years of age or over but whose weight does not exceed 63 kg.

Only fitting and repair services for a “Buggy Major”-type stroller and its components or supplements furnished in the same cases are insured.

O.C. 612-94, s. 54; Decision 001-2009, s. 27.

55. Notwithstanding section 38, a device appearing on a list in Division II or III of Part I of Tariff, or one of its components or supplements, is insured only if the device is furnished to an insured person who requires a personalized technical posture assist.

Only fitting and repair services for these devices alone and for their components or supplements furnished in the same case are insured.

O.C. 612-94, s. 55; O.C. 1334-98, s. 26; Decision 001-2009, s. 28.

56. Notwithstanding section 38, a posture assist appearing on a list in the Tariff is insured only if it is furnished to an insured person who is referred to in section 51 or 53 and who owns an insured wheel chair or to whom a non-insured wheel chair is furnished by an institution referred to in section 52 and in which the insured persony resides.

The first paragraph does not apply to the possession of the wheel chair in the case of a personalized technical posture assist in the situation referred to in the first paragraph of section 55.

O.C. 612-94, s. 56; O.C. 1334-98, s. 27; Decision 001-2009, s. 29.

57. A locomotor assist furnished to an insured person is insured only if the insured person has returned to an institution any locomotor assist he may have in his possession and for which the Board previously assumed the cost, except where the latter device becomes the additional device granted under the second paragraph of section 50 or subparagraph 7 of the first paragraph of section 51.

Furthermore, a device that is no longer used by an insured person owing to the person’s death or a change in the person’s physical condition must be returned to an institution that operates a rehabilitation centre offering technical aid services for persons with motricity impairment and that holds a permit issued by the Minister under section 437 of the Act respecting health services and social services (chapter S-4.2) or section 136 of the Act respecting health services and social services for Cree Native persons (chapter S-5).

The word “institution” has the same meaning as that assigned by the Health Insurance Act (chapter A-29), the Act respecting health services and social services or the Act respecting health services and social services for Cree Native persons to the extent that it applies to the territory of the Cree Board of Health and Social Services of James Bay, in accordance with the law or laws that apply.

O.C. 612-94, s. 57; O.C. 1334-98, s. 28; O.C. 1092-2011, s. 6.

CHAPTER III COSTS ASSUMED BY THE BOARD

58. The cost of purchase, replacement, fitting or repair of a device or of one or a combination of its components or supplements assumed by the Board is the price fixed for each device or for each component or supplement or combination thereof, or a fitting or repair appearing on the list in the Tariff.

O.C. 612-94, s. 58; O.C. 1334-98, s. 29; Decision 001-2009, s. 30.

59. (Revoked).

O.C. 612-94, s. 59; Decision 001-2009, s. 31.

60. Where, in accordance with section 39, any basic component of an insured device is substituted for another at the time of purchase or replacement of the device, the cost of the device assumed by the Board is determined in the following manner: the price fixed in the Tariff for the substituted basic component is subtracted from the purchase or replacement price of the device, and the price fixed in the Tariff for the optional component is then added to the difference.

O.C. 612-94, s. 60; Decision 001-2009, s. 32.

61. (Revoked).

O.C. 612-94, s. 61; Decision 001-2009, s. 33.

62. Where the reference “S.C.” appears in place of the purchase or replacement price of a device that is determined to be insured or of one or a combination of its components or supplements, the total cost assumed by the Board is determined as follows:

(1)  the rate fixed in the Tariff per quarter hour or fraction thereof for manufacturing time; and

(2)  the cost price of the materials is added to the cost arising from the application of paragraph 1.

O.C. 612-94, s. 62; Decision 2001-11-14, s. 5; Decision 2003-06-11, s. 4; Decision 2004-04-14, s. 3; Decision 2005-04-13, s. 3; Decision 003-2006, s. 4; Decision 001-2007, s. 4; Decision 002-2008, s. 5; Decision 001-2009, s. 34.

63. Where the cost of an insured repair, adaptation or fitting of a device or of one or a combination of its components or supplements is undetermined because no price has been entered on the relevant list, the total cost assumed by the Board is determined as follows:

(1)  the rate fixed in the Tariff per quarter hour or fraction thereof for the time required for fitting or repair, or both, as the case may be, taking into account, up to a maximum of 4 quarter hours, the time devoted exclusively to travelling, under the circumstances set forth in the second paragraph;

(2)  the rate fixed in the Tariff per quarter hour or fraction thereof for the time required for replacing one or a combination of components or supplements, where applicable; and

(3)  the cost price of the materials is added to the cost arising from the application of subparagraph 1 and, where applicable, subparagraph 2.

Travelling time is taken into account where the insured wheel chair has broken down due to a defect or problem in the electrical or mechanical system and requires adjustment or repair work to restore it to proper working order.

O.C. 612-94, s. 63; O.C. 1334-98, s. 30; Decision 2001-11-14, s. 5; Decision 2003-06-11, s. 4; Decision 2004-04-14, s. 3; Decision 2005-04-13, s. 3; Decision 003-2006, s. 4; Decision 001-2007, s. 4; Decision 002-2008, s. 5; Decision 001-2009, s. 34.

64. Where, prior to the final installation, the insured person’s physical condition changes to such an extent that the rehabilitation phase must be stopped or where the insured person dies, the total cost assumed by the Board for a posture assist that is partially or totally manufactured is determined as follows:

(1)  the rate fixed in the Tariff per quarter hour or fraction thereof for manufacturing time; and

(2)  the cost price of the materials is added to the cost arising from the application of paragraph 1 and the cost price of the materials that can be recovered by an institution operating a centre is subtracted from that total.

O.C. 612-94, s. 64; O.C. 1334-98, s. 31; Decision 2001-11-14, s. 5; Decision 2003-06-11, s. 4; Decision 2004-04-14, s. 3; Decision 2005-04-13, s. 3; Decision 003-2006, s. 4; Decision 001-2007, s. 4; Decision 002-2008, s. 5; Decision 001-2009, s. 34.

64.1. (Revoked).

Decision 2001-11-14, s. 6; Decision 2003-06-11, s. 5.

65. Where an insured person dies before taking final receipt of a wheel chair or a stroller, the total cost assumed by the Board for the device is as follows:

(1)  the lump sum fixed in the Tariff for a powered wheel chair;

(2)  the lump sum fixed in the Tariff for a manual wheel chair or a lightweight manual wheel chair;

(3)  the lump sum fixed in the Tariff for a stroller.

O.C. 612-94, s. 65; O.C. 1334-98, s. 32; Decision 2001-11-14, s. 7; Decision 2003-06-11, s. 6; Decision 2004-04-14, s. 4; Decision 2005-04-13, s. 4; Decision 003-2006, s. 5; Decision 001-2007, s. 5; Decision 002-2008, s. 6; Decision 001-2009, s. 35.

66. At the time of purchase or replacement of an insured powered wheel chair, the total cost assumed by the Board is the price fixed in the Tariff for the following services combined:

(1)  the cost of services required for taking measurements, assembling and adjusting the wheel chair, and for training the insured person; and

(2)  administration and inventory management services.

At the time of purchase or replacement of an insured manual wheel chair or lightweight manual wheel chair, the total cost assumed by the Board for all such services is the price fixed in the Tariff.

Where a wheel chair having already been returned to an institution in accordance with section 57 is again furnished to an insured person, the total cost assumed by the Board for all such services is the price fixed in the Tariff, depending on whether the wheel chair is a powered wheel chair or any other type of wheel chair.

Where a device must be adjusted to the growth of an insured person less than 19 years old, the total cost assumed by the Board for all the services referred to in the first paragraph is the lump sum fixed in the Tariff.

O.C. 612-94, s. 66; O.C. 961-94, s. 1; O.C. 1334-98, s. 33; Decision 2001-11-14, s. 8; Decision 2003-06-11, s. 7; Decision 2004-04-14, s. 5; Decision 2005-04-13, s. 5; Decision 003-2006, s. 6; Decision 001-2007, s. 6; Decision 002-2008, s. 7; Decision 001-2009, s. 36.

67. At the time of purchase or replacement of an insured “Buggy Major”-type stroller, the total cost assumed by the Board is the price fixed in the Tariff for the following services combined:

(1)  the services required for taking measurements and adjusting the stroller; and

(2)  administration and inventory management services.

O.C. 612-94, s. 67; Decision 2001-11-14, s. 9; Decision 2004-04-14, s. 6; Decision 2005-04-13, s. 6; Decision 003-2006, s. 7; Decision 001-2007, s. 7; Decision 002-2008, s. 8; Decision 001-2009, s. 37.

CHAPTER IV TERMS AND CONDITIONS FOR ALLOCATION

68. The Board assumes the cost of purchase, fitting, replacement or repair of a device that is determined to be insured or of one or a combination of its components or supplements, where a written medical prescription indicates the need, in accordance with section 70, to furnish an insured person with such a device, component or supplement, or such service.

The written medical prescription shall be produced by one of the following persons:

(1)  a physician specializing in orthopedics, physiatry, neurology, rheumatology, in geriatrics or neurosurgery; or

(2)  a general practitioner or a physician specializing in pediatrics who holds specific privileges for that purpose in a hospital or in a rehabilitation centre that offers technical aid services for persons with motricity impairment and is operated by an institution holding a permit issued by the Minister under section 437 of the Act respecting health services and social services (chapter S-4.2) or section 136 of the Act respecting health services and social services for Cree Native persons (chapter S-5), or whose designation by the agency has been approved by the Minister of Health and Social Services in accordance with section 71;

(3)  a physician specializing in cardiology or pneumology, in respect of an insured person referred to in subparagraph 3 of the first paragraph of section 53.

Notwithstanding the foregoing, a prescription is not required where the insured person’s physical condition has not changed and where a fitting, preventive adjustment or repair is to be made to extend the use of a device, or where the device is to be replaced in accordance with the original medical prescription.

The expressions “hospital” and “rehabilitation centre for persons with motricity impairment” have the same meaning, in each case, as the meaning assigned by the Health Insurance Act (chapter A-29), the Act respecting health services and social services (chapter S-4.2) or the Act respecting health services and social services for Cree Native persons (chapter S-5) to the extent that it applies to the territory of the Cree Board of Health and Social Services of James Bay, in accordance with the law or laws that apply.

O.C. 612-94, s. 68; O.C. 1334-98, s. 34; O.C. 999-2002, s. 1; O.C. 1092-2011, s. 7.

69. In addition to the condition set forth in section 68, the Board assumes the cost of purchase, adjustment, replacement or repair of a device that is determined to be insured or of one or a combination of its components or supplements, where the device, component or supplement, or the service, is furnished to an insured person in Québec by an institution in a hospital or a rehabilitation centre offering technical aid services for persons with motricity impairment, provided that the institution that operates the hospital or the rehabilitation centre holds a permit issued by the Minister under section 437 of the Act respecting health services and social services (chapter S-4.2) or section 136 of the Act respecting health services and social services for Cree Native persons (chapter S-5), or where it is furnished to an insured person outside Québec by an institution that is recognized under section 13 of the Health Insurance Act (chapter A-29).

O.C. 612-94, s. 69; O.C. 1334-98, s. 35; O.C. 1092-2011, s. 8.

70. For the purposes of the first and second paragraphs of section 68, the written medical prescription shall, at a minimum, confirm the insured person’s physical deficiency and disability, and it shall also state the need for a device.

Furthermore, for the purposes of subparagraph 7 of the first paragraph of section 51, the written medical prescription shall also confirm that the insured person has a degenerative deficiency of the musculoskeletal system, that his residual abilities are such that he can still independently use the manual wheel chair that may be allocated to him and that such wheel chair is required to maintain those residual abilities.

For the purposes of subparagraph 3 of the first paragraph of section 53, the written medical prescription shall also confirm that the insured person has a severe insufficiency defined in the fifth or sixth paragraph of section 53, as determined in the circumstances provided for in that section, and shall confirm that the insufficiency is associated with a physical deficiency within the meaning of this Title, that the insured person is able to use a powered wheel chair independently and that, owing to the confirmed insufficiency associated with the physical deficiency, and notwithstanding optimal medical treatment, he is unable to use a manual wheel chair or a lightweight manual wheel chair independently.

O.C. 612-94, s. 70; O.C. 1334-98, s. 36.

71. In regions where there is no hospital or rehabilitation centre offering technical aid services for persons with motricity impairment, an institution that operates a rehabilitation centre for persons with motricity impairment or a hospital in which there is a practising general practitioner or a practising physician specializing in pediatrics who is empowered to attest to the needs of persons with motricity impairment and who holds specific privileges in that rehabilitation centre or hospital for that purpose may receive a designation by the agency that is approved by the Minister of Health and Social Services pursuant to sections 347 and 377 and subparagraphs 1 to 3 and 7 of the second paragraph of section 431 of the Act respecting health services and social services (chapter S-4.2), for the purposes of subparagraph 2 of the second paragraph of section 68.

O.C. 612-94, s. 71; O.C. 1092-2011, s. 9.

72. The Board also assumes the purchase or replacement cost of a device and the fitting and repair cost of a device, other than a wheel chair, or of one or a combination of its components or supplements that is insured and furnished to an insured person in Québec by an institution in the hospital or rehabilitation centre for persons with a physical deficiency operated by the latter under section 69, on the condition that the identification of the insured person’s functional needs and disabilities to be compensated for has been made in writing by a physician referred to in the second paragraph of section 68 or in section 71 and by an occupational therapist or a physiotherapist designated by the centre. The physician and the occupational therapist or the physiotherapist shall have met with the insured person for that purpose.

O.C. 612-94, s. 72; O.C. 1334-98, s. 37.

73. The Board assumes the purchase or replacement cost of a device referred to in section 62 only if the following items are sent to the Board in writing:

(1)  the time required to manufacture the device; and

(2)  the list of materials used and their cost price.

O.C. 612-94, s. 73.

74. The Board assumes the repair or fitting cost referred to in section 63, where it exceeds $80, only if the following items are sent to the Board in writing:

(1)  the duration of the repair, fitting or replacement of one or a combination of components or supplements; and

(2)  the list of materials used and their cost price.

O.C. 612-94, s. 74; Decision 2001-11-14, s. 10; Decision 2003-06-11, s. 8.

75. The Board assumes the purchase or replacement cost of a device in the cases referred to in section 64 only if the following items are sent to the Board in writing:

(1)  a written prescription from a physician referred to in the second paragraph of section 68 certifying a change in the insured person’s physical condition; and

(2)  the manufacturing time, the list of materials used and their cost price.

O.C. 612-94, s. 75.

75.1. The Board assumes the cost of a service as well as the cost of the purchase, replacement, adjustment, repair or adaptation of a device, component or supplement referred to in this Title only if the institution sends to the Board, using the form provided by the Board, the following information, which may vary depending on the medium used or depending on whether the reference “S.C.” appears in place of the purchase or replacement price or the case involves a request for prior authorization or a claim for payment:

(1)  the health insurance number, the expiration date entered on the health insurance card and the information required by the Board in order to identify the insured person who received the property or service;

(2)  the name, the permit number and the dispenser number of the institution, and the prescriber number and the reference number of the claim for payment for a device, component or supplement for which the reference “S.C.” appears in place of its purchase or replacement price, of the request for prior authorization or of the claim for payment;

(3)  a description of the insured person’s physical deficiency and disability, and the information provided for in section 62;

(4)  the code for the good or service, side of the body, type, the number of units, the amount claimed, the serial number, the date on which the property was allocated or the service rendered and, in the case of a repair, fitting, replacement or adjustment, the reason therefor, the date of taking possession, the reference code for the property and the manufacturer’s authorization number;

(5)  a statement of the labour costs, including the duration of the work and a list of the materials;

(6)  a statement by the insured person confirming that the person received the property or service described and authorizing the Board to make payment;

(7)  the necessary information for identifying the recipient of the payment; and

(8)  a statement by the person in charge of the institution confirming that the information provided is accurate and complete.

O.C. 1092-2011, s. 10.

76. The Board assumes the purchase cost of a device, component or supplement whose name is followed by an asterisk on the list appearing in the Tariff only if it has given its prior authorization to the institution requesting it.

O.C. 612-94, s. 76; O.C. 1334-98, s. 38; Decision 001-2009, s. 38.

CHAPTER V

(Revoked)

O.C. 612-94, c. V of Title Two; O.C. 961-94, s. 2; O.C. 829-95, s. 1; O.C. 1495-95, s. 1; O.C. 1636-96, s. 1; O.C. 668-97, s. 1; O.C. 20-98, s. 1; O.C. 1334-98, s. 43; O.C. 574-99, s. 1; O.C. 864-99, s. 1; O.C. 1329-99, ss. 1 to 4; O.C. 1330-99, s. 1; Decision 2001-05-16, s. 1; Decision 001-2003, s. 1; Decision 003-2005, s. 1; Decision 002-2008, s. 4; Decision 001-2009, s. 39.

76.1. Subject to the last paragraph of section 43, repairs, fittings and the replacement of a device with an insured device that belongs to an insured person on 12 November 1998, shall remain insured only if all the provisions of these Titles are complied with from that date.

O.C. 1334-98, s. 39.

77. This Regulation replaces sections 45 to 48 of The Regulation respecting the application of the Health Insurance Act (R.R.Q., 1981, c. A-29, r. 1) as well as Schedule A to that Regulation.

O.C. 612-94, s. 77.

78. (Omitted).

O.C. 612-94, s. 78.

REFERENCES

O.C. 612-94, 1994 G.O. 2, 1589

O.C. 961-94, 1994 G.O. 2, 2229

O.C. 829-95, 1995 G.O. 2, 1757

O.C. 1495-95, 1995 G.O. 2, 3212

O.C. 1636-96, 1997 G.O. 2, 127

O.C. 668-97, 1997 G.O. 2, 1973

O.C. 20-98, 1998 G.O. 2, 345

O.C. 1334-98, 1998 G.O. 2, 4291

O.C. 574-99, 1999 G.O. 2, 1394

O.C. 864-99, 1999 G.O. 2, 2307

O.C. 1329-99, 1999 G.O. 2, 4511

O.C. 1330-99, 1999 G.O. 2, 4513

S.Q. 1999, c. 89, s. 53

O.C. 150-2000, 2000 G.O.2, 990

O.C. 1047-2000, 2000 G.O. 2, 4544

Decision 2001-05-16, 2001 G.O. 2, 2311

Decision 2001-11-14, 2002 G.O. 2, 17

O.C. 999-2002, 2002 G.O. 2, 4729

Decision 001-2003, 2003 G.O. 2, 1699

Decision 2003-06-11, 2003 G.O. 2, 1991

Decision 2004-04-14, 2004 G.O. 2, 1360

Decision 2005-04-13, 2005 G.O. 2, 1110

Decision 003-2005, 2005 G.O. 2, 1254

Decision 004-2005, 2005 G.O. 2, 4537

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

Decision 003-2006, 2006 G.O. 2, 3262

Decision 001-2007, 2007 G.O. 2, 3505

Decision 002-2008, 2008 G.O. 2, 1670

Decision 001-2009, 2009 G.O. 2, 578

O.C. 1092-2011, 2011 G.O. 2, 3101

S.Q. 2013, c. 28, s. 205

S.Q. 2015, c. 20, s. 61