Insured Hospital Services Regulation

(no amdt) ALBERTA REGULATION 290/2025 Alberta Health Care Insurance Act INSURED HOSPITAL SERVICES REGULATION Table of Contents 1 Definitions 2 Residency — full‑time students 3 Residency — temporarily absent from Alberta 4 Registration under Health Insurance Premiums Act 5 Certificate of registration 6 Insured hospital services 7 Non‑insured hospital services 8 Authorized charges 9 Authorized charges for patients requiring facility‑based care 10 Patient transportation 11 Fees for enhanced goods and services 12 Fees charged to non‑entitled persons 13 Payment for out‑of‑province hospital services 14 Continuing provision of out‑of‑province hospital services 15 Payments re diagnostic and laboratory procedures 16 Expiry 17 Coming into force Definitions 1 In this Regulation, (a) “authorized charges” means authorized charges as defined in section 45(c) of the Act; (b) “dependant” means dependant as defined in the Alberta Health Care Insurance Regulation (AR 76/2006); (c) “in‑patient” means a patient referred to in section 45(o)(i) of the Act; (d) “newborn” means (i) an infant newly born in a hospital services facility, or (ii) an infant newly born outside a hospital services facility and admitted to a hospital services facility with the infant’s mother when the infant’s mother is admitted for maternity service, and who remained in the hospital services facility as an in‑patient, but does not include a stillborn infant; (e) “out‑of‑province hospital services” means hospital services or other goods and services provided to a resident in (i) a hospital or health care facility outside Alberta but within Canada, other than the Lloydminster Hospital, or (ii) a hospital or health care facility outside Canada operating under the law of the jurisdiction in which the hospital or health care facility is located; (f) “out‑patient” means a patient referred to in section 45(o)(ii) of the Act; (g) “private room” means a room in a hospital services facility with not more than one bed; (h) “provincial health agency” means (i) a provincial health agency under the Provincial Health Agencies Act , and (ii) with respect to a hospital services facility operator, the provincial health agency established for the health services sector in which the hospital services facility operator provides hospital services; (i) “schedule of fees” means the schedule of fees established by the sector Minister under section 58(2) of the Act; (j) “semi‑private room” means a room in a hospital services facility with 2 beds; (k) “standard ward” means a room in a hospital services facility with more than 2 beds; (l) “temporarily absent from Alberta” has the same meaning as in the Alberta Health Care Insurance Regulation (AR 76/2006). Residency — full‑time students 2 (1) In this section, “accredited educational institute” means an accredited educational institute as defined in the Alberta Health Care Insurance Regulation (AR 76/2006). (2) Subject to subsection (3), the following persons whose ordinary place of residence is outside Canada are deemed to be residents of Alberta for the purposes of Part 2 of the Act and this Regulation: (a) a person who is in full‑time attendance as a student at an accredited educational institute in Alberta; (b) a person who is registered under the Health Insurance Premiums Act as a dependant of a person referred to in clause (a). (3) Subsection (2) applies only if a person referred to in subsection (2)(a) or (b) (a) has been lawfully admitted to Canada, (b) has established residence in Alberta, and (c) intends to remain in Alberta for 12 or more consecutive months. Residency — temporarily absent from Alberta 3 (1) In this section, “sector Minister” means the sector Minister responsible for the health services sector within which the out‑of‑province hospital services would have been provided to a resident had they been provided in Alberta. (2) A resident does not cease to be a resident for the purposes of Part 2 of the Act and this Regulation by reason only of being temporarily absent from Alberta. (3) In determining whether a person is temporarily absent for the purposes of Part 2 of the Act and this Regulation, the sector Minister may extend any period referred to in section 3(1) of the Alberta Health Care Insurance Regulation (AR 76/2006) for a further period that the sector Minister considers proper, if (a) the person provides evidence satisfactory to the sector Minister that the person intends to return to and maintain permanent residence in Alberta after the extended period, or (b) in the opinion of the sector Minister, there are unforeseen and extenuating circumstances. Registration under Health Insurance Premiums Act 4 (1) In this section, “Minister” means the Minister responsible for the Health Insurance Premiums Act . (2) If a resident or a resident’s dependant who is not registered with the Minister under the Health Insurance Premiums Act receives an insured hospital service in a hospital services facility, the hospital services facility operator shall provide the Minister with any information respecting the resident and the resident’s dependants that the Minister requires to register the resident and the resident’s dependants. (3) If the resident or resident’s dependant refuses or is unable to provide sufficient information for the hospital services facility operator to provide the Minister with the information required under subsection (2), the hospital services facility operator shall notify the Minister and provide the Minister with as much information as it can obtain. (4) If the Minister registers a resident and the resident’s dependants under this section, the Minister shall notify the hospital services facility operator of the registration number of the resident or dependant who received the insured hospital service. Certificate of registration 5 (1) On admission to a hospital services facility, proof of registration under the Health Insurance Premiums Act is the responsibility of the patient or person acting on the patient’s behalf. (2) A person registered under the Health Insurance Premiums Act who receives an insured hospital service in a hospital services facility shall present the person’s certificate of registration as defined in the Health Insurance Premiums Act to the appropriate official of the hospital services facility operator. Insured hospital services 6 (1) In this section, (a) “approved program” means an approved program as defined in section 1.9761(c.1) of the Provincial Health Agencies Act ; (b) “specific program” means a specific program as defined in section 1.9761(o) of the Provincial Health Agencies Act . (2) The following goods and services are prescribed as insured hospital services for the purposes of section 52(a)(ii) of the Act: (a) when provided to an in‑patient, (i) semi‑private room or private room accommodation, if the in‑patient’s attending physician is of the opinion that, due to medical necessity, the in‑patient requires such accommodation, (ii) transportation within Alberta, whether by ambulance or other commercial vehicle, in the circumstances described in section 10, and (iii) goods and services provided under an approved program or specific program, unless they are enhanced goods and services; (b) when provided to an out‑patient, any medically necessary goods and services that may be provided on an out‑patient basis, including goods used in a medical procedure but excluding goods provided to a patient for use after discharge from a hospital services facility. Non‑insured hospital services 7 The following goods and services are prescribed as non‑insured hospital services for the purposes of section 54(2)(d) of the Act: (a) services that a resident is entitled to receive under Part 1 of the Act; (b) the health services referred to in section 59(a) of the Act and the goods and services referred to in section 59(b) of the Act; (c) out‑of‑province hospital services provided outside of Canada without the prior approval of the sector Minister, unless the sector Minister directs otherwise, but not including out‑of‑province hospital services provided in an emergency resulting from an acute and unexpected illness, disease, condition or injury that requires medically required treatment without delay outside Canada; (d) examinations required for the use of third parties, unless the sector Minister directs otherwise; (e) laboratory and x‑ray services performed in a facility not approved by the sector Minister. Authorized charges 8 (1) An in‑patient is required to pay authorized charges at the following rates: (a) if the in‑patient is a newborn who is not considered to be in need of hospital services and who, at the request of the Minister responsible for the Child, Youth and Family Enhancement Act by reason of a consideration for adoption, is retained in a hospital services facility up to 15 days from date of birth, at the rate determined by the sector Minister; (b) if the in‑patient requests and receives semi‑private room or private room accommodation, the authorized charges determined by the provincial health agency, subject to section 9; (c) if an in‑patient in a health services sector in an approved hospital is declared to be no longer in need of the hospital services provided by the hospital operator and deemed to be a trespasser under section 1.976995 of the Provincial Health Agencies Act , the applicable fees set out in the schedule of fees. (2) For the purposes of subsection (1)(a), the guardian of the newborn, as determined in accordance with the Family Law Act or Child, Youth and Family Enhancement Act , is required to pay the authorized charges on behalf of the newborn. (3) Notwithstanding subsection (1)(b), if the in‑patient’s attending physician is of the opinion that, due to medical necessity, the in‑patient requires semi‑private room or private room accommodation, the in‑patient is not required to pay the difference between the charges for standard ward accommodation and semi‑private room or private room accommodation. Authorized charges for patients requiring facility‑based care 9 (1) An in‑patient who has been assessed under the Continuing Care Act as requiring facility‑based care is required to pay authorized charges in respect of standard ward, semi‑private room or private room accommodation. (2) The authorized charges for each type of accommodation referred to in subsection (1) must be set at the same amount as the maximum amount of the accommodation charge set under section 9(4) of the Continuing Care Act in respect of the equivalent type of accommodation described in section 8 of the Continuing Care (Ministerial) Regulation (AR 44/2024). (3) The requirement to pay the authorized charges begins on the day the patient is assessed under the Continuing Care Act as requiring facility‑based care. Patient transportation 10 (1) In this section, “type A continuing care home” means a type A continuing care home as defined in the Continuing Care Regulation (AR 21/2024). (2) A charge for the transportation referred to in section 6(2)(a)(ii), resulting from a temporary transfer of a patient (a) from a hospital services facility to another hospital services facility or to a type A continuing care home, or (b) from a type A continuing care home to another type A continuing care home or to a hospital services facility, is the responsibility of the hospital services facility operator or continuing care home operator transferring the patient. (3) A charge for the transportation referred to in section 6(2)(a)(ii), resulting from a permanent transfer within Alberta (a) from a hospital services facility to another hospital services facility or to a type A continuing care home, or (b) from a type A continuing care home to another type A continuing care home or to a hospital services facility, is the responsibility of the hospital services facility operator or continuing care home operator discharging the patient, and a charge shall not be made to the patient. Fees for enhanced goods and services 11 (1) A provincial health agency shall not designate accommodation as enhanced goods and services. (2) For the purposes of section 57(3) of the Act, the amount of the fee that a hospital facility services operator may charge for enhanced goods and services must not exceed the actual cost of the good or service plus a reasonable administrative allowance. (3) For greater certainty, a provincial health agency that is a hospital services facility operator may determine the matters referred to in section 57(2) and (3) of the Act with respect to itself as a hospital services facility operator. Fees charged to non‑entitled persons 12 (1) In this section, “patient day” means the period of service to an in‑patient beginning at midnight on one day and ending on the following midnight, except that (a) the period of service on the day of admission is a patient day, but the period of service on the day of discharge is not a patient day, and (b) where admission and discharge occur on the same day, the period of service is one patient day. (2) A non‑entitled person who is admitted as an in‑patient to a hospital services facility other than the Lloydminster Hospital shall pay to the hospital services facility operator the following fees as set out in the schedule of fees: (a) the patient day standard ward fees for the hospital services facility, in the case of a non‑entitled person who is a resident of Canada; (b) the patient day standard ward fees approved for that purpose in the case of a non‑entitled person who is a non‑resident of Canada. (3) A non‑entitled person who receives goods or services as an out‑patient shall pay to the hospital services facility operator the fees set out in the schedule of fees with respect to the out‑patient goods or services. (4) A non‑entitled person who is provided semi‑private room or private room accommodation shall pay to the hospital services facility operator the following fees: (a) the patient day semi‑private room accommodation rate or the patient day private room accommodation rate in accordance with section 8, in the case of a non‑entitled person who is a resident of Canada; (b) the patient day semi‑private room accommodation rate or the patient day private room accommodation rate in accordance with section 8, in the case of a non‑entitled person who is a non‑resident of Canada. (5) A non‑entitled person who is a newborn and who is retained in a hospital services facility after 30 days shall pay the approved adult rate for the hospital services facility as set out in the schedule of fees. (6) For the purposes of subsection (5), the guardian of the newborn, as determined in accordance with the Family Law Act or Child, Youth and Family Enhancement Act , is required to pay the authorized charges on behalf of the newborn. Payment for out‑of‑province hospital services 13 (1) In this section, “health care insurance plan” means health care insurance plan as defined in the Canada Health Act (Canada). (2) For the purposes of section 62 of the Act, the Government of Alberta shall pay for out‑of‑province hospital services provided to a resident who is (a) temporarily absent from Alberta, or (b) entitled to continuing coverage under Part 1 of the Act by virtue of section 8 of the Alberta Health Care Insurance Regulation (AR 76/2006). (3) If the Government of Alberta is required to pay for out‑of‑province hospital services under section 62 of the Act, it shall make payments as follows: (a) for out‑of‑province hospital services provided within Canada, except those provided in the Lloydminster Hospital, at the rate approved by the health care insurance plan of the province in which the out‑of‑province hospital services are provided, unless the sector Minister has entered into an agreement with the government of that province to apportion the cost between them in a different manner; (b) for out‑of‑province hospital services provided outside Canada, at the lesser of the rates prescribed by the sector Minister and the rates charged by the operator of the hospital or health care facility in which the hospital services were provided. (4) In prescribing the rates under subsection (3)(b), the sector Minister may take into account the size, standard of service and type of hospital or health care facility in which the out‑of‑province hospital services were provided and other factors the sector Minister considers relevant. (5) For the purposes of this section, out‑of‑province hospital services provided to a resident who is admitted to a hospital or health care facility on the same day or during the first visit to the hospital or health care facility are not considered out‑patient services. (6) If a resident has paid the operator of the hospital or health care facility for the out‑of‑province hospital services provided and submits to the sector Minister the information required under subsection (8), the Government of Alberta shall reimburse the resident in accordance with this section. (7) If a resident has not paid the operator of the hospital or health care facility that provided the out‑of‑province hospital services and submits to the sector Minister the information required under subsection (8), the Government of Alberta shall pay the operator of the hospital or health care facility for the out‑of‑province hospital services in accordance with this section. (8) Subject to an agreement referred to in subsection (3)(a), the resident or a person acting on the resident’s behalf shall submit the following information to the sector Minister: (a) a completed application form; (b) a statement of account issued by the hospital or health care facility with respect to the out‑of‑province hospital services; (c) evidence of payment for or receipt of the out‑of‑province hospital services that is satisfactory to the sector Minister; (d) a medical statement that shows the diagnosis and, if surgery was performed, the name of the operation. Continuing provision of out‑of‑province hospital services 14 (1) If out‑of‑province hospital services are provided to a resident in respect of one particular illness or accident for a period of more than 3 months after the date on which the out‑of‑province hospital services were first provided, the resident or a person acting on the resident’s behalf shall, within that 3‑month period, (a) notify the sector Minister of the reasons why continued provision of the out‑of‑province hospital services is necessary, and (b) provide any information requested by the sector Minister. (2) When the sector Minister receives a notification and the requested information under subsection (1), the sector Minister may (a) continue the payment in respect of the out‑of‑province hospital services and prescribe the period during which payment will continue to be made, or (b) terminate the payment in respect of the out‑of‑province hospital services. (3) The sector Minister may terminate the payment at any time after the end of the 3‑month period referred to in subsection (1) if the resident or a person acting on the resident’s behalf fails to (a) notify the sector Minister or provide information in accordance with subsection (1), and (b) make arrangements to return the resident to Alberta as soon as practicable. Payments re diagnostic and laboratory procedures 15 A hospital services facility operator shall make payments in respect of the interpretation of x‑ray, laboratory and other diagnostic procedures only under an agreement with a qualified radiologist or pathologist or other medical personnel recommended by the College of Physicians and Surgeons of Alberta. Expiry 16 For the purpose of ensuring that this Regulation is reviewed for ongoing relevancy and necessity, with the option that it may be repassed in its present or an amended form following a review, this Regulation expires on February 28, 2031. Coming into force 17 This Regulation comes into force on the coming into force of section 1(46) of the Health Statutes Amendment Act, 2025 (No. 2) .