Medical Services Insurance Regulation

Medical Services Insurance Regulation, M.R. 49/93 The Health Services Insurance Act , C.C.S.M. c. H35 Regulation 49/93 Registered March 19, 1993 bilingual version (HTML) Table of Contents Section DEFINITIONS 1 Definitions ENTITLEMENT TO INSURED MEDICAL SERVICES 2 Entitlement to insured medical services INSURED MEDICAL SERVICES IN MANITOBA 3 Amount payable for medical services in Manitoba 4 Payment to doctor 5 Payment for opted-out doctor 6 Assignment of benefits INSURED MEDICAL SERVICES OUTSIDE MANITOBA 7 Amount payable for services outside Manitoba 7.1 Services provided outside Canada pursuant to agreement 8 Payment conditional on receipt or account 8.1 Assignment of benefits 9 Coming into force DEFINITIONS Definitions 1 In this regulation, "Act" means The Health Services Insurance Act ; («  Loi  ») "insured medical services" means all personal health care services provided to an insured person by a medical practitioner that are medically required and are not excluded under the Excluded Services Regulation made under the Act; (« soins médicaux assurés ») "family registrant" means a person who has registered with the minister in his or her own name and on behalf of one or more of his or her resident dependants; (« chef de famille ») ENTITLEMENT TO INSURED MEDICAL SERVICES Entitlement to insured medical services 2 An insured person is entitled as a benefit under the Act to payment of insured medical services paid by the minister in accordance with this regulation. INSURED MEDICAL SERVICES IN MANITOBA Amount payable for medical services in Manitoba 3 Where an insured medical service is provided in Manitoba, the benefit payable is the amount prescribed in the Payments for Insured Medical Services Regulation under the Act. Payment to doctor 4(1) Payment for an insured medical service provided in Manitoba shall be made to the medical practitioner who provides the service except where payment of benefits is made directly to an insured person under section 5. 4(2) A medical practitioner who provides an insured medical service to an insured person, and who has not made an election under subsection 91(1) of the Act, shall submit to the minister (a) a claim for the service within six months from the date on which the service was provided in the form and manner required by the minister; and (b) such further information respecting the service in a form and manner as may be required by the minister. 4(3) The minister may extend the time referred to in subsection (2) if in the minister's opinion there are extenuating circumstances that prevented the filing of the claim within the six month period. Payment for opted-out doctor 5(1) An insured person is entitled to be paid directly for insured medical services provided by a medical practitioner who has made an election under subsection 91(1) of the Act. 5(2) A medical practitioner who has made an election under subsection 91(1) of the Act shall either (a) send to the minister on behalf of the insured person a claim in respect of the insured medical service provided, in a form required by the minister, which shall contain the amount charged to the insured person; or (b) furnish the insured person with the necessary information, including the amount charged for the insured medical service provided, on a claim form required by the minister, to enable the insured person to submit a claim under subsection (3). 5(3) Where an insured person submits a claim in respect of an insured medical service provided by a medical practitioner who has made an election under subsection 91(1) of the Act, the claim shall be submitted to the minister within six months from the date on which the service was provided, in such form as the minister may require. 5(4) The minister may extend the time referred to in subsection (3) if in the minister's opinion there are extenuating circumstances that prevented the filing of the claim within the six month period. 5(5) Where an insured person is a dependant, payment under this section may be made to the family registrant. Assignment of benefits 6(1) In this section, "teaching unit" means a group of medical practitioners engaged in the practice of medicine providing in-patient, emergency and diagnostic services in conjunction with the teaching of medical learning in units, (a) that are within an institution that is affiliated with the University of Manitoba for the purpose of providing those services; (b) that are designated as teaching units by the executive of the Faculty of Medicine of the University of Manitoba; (c) that are established as a result of an agreement between the University of Manitoba and the institution; and (d) in which the services are provided by medical practitioners who are appointed jointly by the University of Manitoba and the institution. 6(2) Subject to subsections (3) and (4), an insured person shall not assign benefits payable to him or her by the minister. 6(3) An insured person may assign the benefits to which he or she is entitled to a medical practitioner who has made an election under subsection 91(1) of the Act if, (a) the medical practitioner is attached to and practicing within a teaching unit; and (b) the insured person makes a request for medical services by presenting himself or herself to the teaching unit for medical treatment. 6(4) Where the insured person is a child, the assignment to a medical practitioner under subsection (3) may be made by the child's parent or guardian. 6(5) An assignment under subsection (3) or (4) shall be in the form as may be required by the minister, and payment by the minister to the medical practitioner under an assignment shall constitute payment in full of all fees that he or she may charge to or collect from the insured person in respect of medical services provided to the insured person. INSURED MEDICAL SERVICES OUTSIDE MANITOBA Amount payable for services outside Manitoba 7(1) Where insured medical services are provided outside of Manitoba but within Canada, the benefit payable is the amount that is approved by the health care insurance plan of the province in which the services are provided, except that where there is an agreement that apportions cost between the respective health care insurance plans in a different manner, then payment shall be made in accordance with the agreement. 7(2) Except in the circumstances provided for in section 7.1, where insured medical services are provided outside of Canada, the benefit payable is an amount up to but not exceeding the amount prescribed in the Payments for Insured Medical Services Regulation under the Act if the insured medical services, (a) are required because of an accident or sudden attack of illness; (b) could not in the opinion of the minister be adequately provided in Manitoba or elsewhere in Canada and are provided as a result of a referral outside of Canada by a medical practitioner practising in Manitoba who is a specialist in the appropriate field of practice; (c) are provided to a person named in an out of province certificate; (d) are provided to an insured person, including insured dependants, if any, temporarily employed outside Manitoba; or (e) are provided to an insured person and his or her dependants, if any, temporarily absent for the purpose of furthering his or her education. M.R. 169/96; 48/2003 7(3) No payment shall be made unless the requirements in subsection (2) have been met. 7(4) Upon receipt of an application in a form and manner as the minister may require, the minister may pay amounts greater than the amounts otherwise payable in respect of services that meet the requirement set out in clause (2)⁠(b) if the minister considers it fair and reasonable to do so having regard to the insured services provided and the financial circumstances of the insured person. 7(5) Rather than making payment directly to an insured person for insured medical services provided outside Manitoba, the minister may pay the medical practitioner who provided the insured services if the insured person has not paid the fees for the services provided. Services provided outside Canada pursuant to agreement 7.1 Where (a) insured medical services are provided outside of Canada by a medical practitioner who frequently renders medical services to insured persons; and (b) an agreement has been entered into by the minister with that medical practitioner under subsection 89(2) of the Act; the benefit payable is the amount provided for in the agreement. M.R. 169/96 Payment conditional on receipt or account 8(1) It is a condition of payment for insured medical services provided outside of Manitoba that within six months from the date upon which the services were provided the insured person submit to the minister an itemized receipt or account that shows the insured services provided and the fees paid or payable. 8(2) The minister may extend the time referred to in subsection (1) if in the minister's opinion there are extenuating circumstances that prevented the filing of the claim within the six month period. Assignment of benefits 8.1 An insured person may assign any benefit that the person is entitled to receive for insured medical services provided outside Canada if the assignment is made to a person or organization with whom the government has entered into an agreement governing payment of such benefits. M.R. 207/94 Coming into force 9 This regulation comes into force on March 31, 1993.