Health and Dental Services Cost Assistance Act

t HEALTH AND DENTAL SERVICES COST ASSISTANCE ACT PLEASE NOTE This document, prepared by the Legislative Counsel Office, is an office consolidation of this Act, current to April 23, 2024. It is intended for information and reference purposes only. This document is not the official version of the Act. The Act and the amendments as printed under the authority of the King’s Printer for the province should be consulted to determine the authoritative statement of the law. For more information concerning the history of this Act, please see the Table of Public Acts on the Prince Edward Island Government web site (www.princeedwardisland.ca). If you find any errors or omissions in this consolidation, please contact: Legislative Counsel Office Tel: (902) 368-4292 Email: legislation@gov.pe.ca Health and Dental Services Cost Assistance Act Table of Contents HEALTH AND DENTAL SERVICES COST ASSISTANCE ACT Table of Contents Section Page INTERPRETATION 5 1. Definitions................................................................................................................................................ 5 ADMINISTRATION 6 2. Minister responsible for administration ................................................................................................... 6 THE PLAN AND PROGRAMS 6 3. Plan established ........................................................................................................................................ 6 4. Payor of last resort ................................................................................................................................... 6 5. Eligibility criteria ..................................................................................................................................... 7 6. Not eligible for benefits ........................................................................................................................... 7 7. Application for enrollment in program .................................................................................................... 7 8. Payment of benefit ................................................................................................................................... 8 9. Powers of administrator ........................................................................................................................... 8 AUDIT OF PARTICIPATING HEALTH PROFESSIONALS 9 10. Record ...................................................................................................................................................... 9 11. Appointment of auditor ............................................................................................................................ 9 12. Report to Minister .................................................................................................................................... 9 REVIEW 10 13. Request for review ................................................................................................................................. 10 GENERAL 11 14. Minister’s duty on overpayment ............................................................................................................ 11 15. Prohibitions ............................................................................................................................................ 11 16. Offence and penalty ............................................................................................................................... 11 17. Officers and directors of corporation ..................................................................................................... 12 18. Limitation of liability ............................................................................................................................. 12 19. Regulations ............................................................................................................................................ 12 20. and 21 (These sections make consequential amendments to other Acts. The amendments have been incorporated into those Acts.) ........................................................................................................ 13 c t Current to: April 23, 2024 Page 3 Health and Dental Services Cost Assistance Act Section 1 HEALTH AND DENTAL SERVICES COST ASSISTANCE ACT CHAPTER H-1.21 Interpretation 1. Definitions In this Act (a) “administrator” means a person appointed or contracted pursuant to section 3 to administer and operate a program, except where otherwise specified; (b) “applicant” means a person by whom, or on whose behalf, an application is made for enrollment in a program; (c) “benefit” means (i) a prescribed health or dental service, (ii) a prescribed supply, product, drug or expense associated with the prescribed health or dental service, or (iii) the payment of the cost or part of the cost of a benefit set out in subclause (i) or (ii), as provided in the regulations; (d) “claim” means a claim for the payment of a benefit under a program, except where otherwise specified; (e) “co-payment” means the prescribed amount that an eligible person is required to pay toward the cost of a benefit; (f) “eligible person” means a person who is eligible for benefits under a program in accordance with the regulations; (g) “health number” means a health number as defined in the Provincial Health Number Act R.S.P.E.I. 1988, Cap. P-27.01; (h) “Minister” means the Minister of Health and Wellness; (i) “participating health professional” means a person who is (i) authorized by the laws of the jurisdiction in which the person practices a health profession to practice that health profession, and (ii) authorized by the Minister, pursuant to an agreement, to provide benefits in support of a program; (j) “Plan” means the Plan established in section 3 of this Act; (k) “program” means a program of benefits established under the Plan, except where otherwise specified; (l) “resident” means a resident as defined in the regulations under the Health Services Payment Act R.S.P.E.I. 1988, Cap. H-2, but does not include persons who are resident pursuant to a temporary resident visa, study permit, work permit or other similar visa or permit issued by the Government of Canada; c t Current to: April 23, 2024 Page 5 Section 2 Health and Dental Services Cost Assistance Act (m) “third-party insurance” means a contract or plan of insurance between a person and an insurer for the payment of benefits. 2020,c.66,s.1; 2024,c.49,s.1. Administration 2. Minister responsible for administration (1) The Minister is responsible for the administration of this Act. Delegation of Minister’s powers and duties (2) Subject to subsection 13(6), the Minister may delegate any power, duty or function of the Minister under this Act or the regulations to any person the Minister considers appropriate. 2020,c.66,s.2. The Plan and Programs 3. Plan established (1) There is hereby established a Plan to provide benefits in a cost-effective manner to eligible persons. Programs may be established (2) The Minister may recommend that the Lieutenant Governor in Council establish programs by regulation. Administrator (3) The Minister shall appoint or enter into an agreement with a person to administer and operate a program. Agreement with health professional (4) The Minister may enter into an agreement with a health professional or a body representing a group of health professionals to provide for matters including (a) the provision of a benefit by a participating health professional to an eligible person under a program; (b) the payment of a benefit to a participating health professional on behalf of an eligible person under a program; (c) any fees to be paid to a participating health professional for providing a benefit in support of a program; and (d) the information to be provided to the Minister by a participating health professional for the purpose of administering the Plan and the programs. 2020,c.66,s.3. 4. Payor of last resort (1) Where, in respect of a benefit, an eligible person is covered by third-party insurance or a prescribed benefit plan or program not established under this Act, the Plan shall be the payor of last resort. Co-payment (2) The Minister may require an eligible person to contribute to the cost of a benefit under the Plan at a rate of co-payment prescribed by the regulations. 2020,c.66,s.4; 2024,c.49,s.2. Page 6 Current to: April 23, 2024 t c Health and Dental Services Cost Assistance Act Section 5 5. Eligibility criteria (1) Subject to subsection (2), the Lieutenant Governor in Council may prescribe eligibility criteria for a program, which may vary for each program. Residency required (2) A person shall be a resident of the province to be eligible for a benefit under the Plan. Initial and ongoing eligibility (3) Eligibility for the purposes of this Act and the regulations shall include initial and ongoing eligibility. 2020,c.66,s.5. 6. Not eligible for benefits Except where otherwise provided in regulations, a person is not eligible for a benefit under the Plan if the person is entitled to the benefit (a) under the Workers Compensation Act R.S.P.E.I. 1988, Cap. W-7.1; (b) from the Royal Canadian Mounted Police; (c) from the Department of National Defence; (d) from Veterans Affairs Canada; (e) under the Non-Insured Health Benefits Program for First Nations and Inuit; (f) under any other enactment or Act of the Parliament of Canada; or (g) under any statute of any jurisdiction either within or outside of Canada. 2020,c.66,s.6; 2024,c.49,s.3. 7. Application for enrollment in program (1) A resident may apply to the administrator of a program in the form approved by the administrator and in accordance with the regulations for enrollment in the program. Request for information (2) The administrator of a program may request and an applicant, and any other person whose information is required under the regulations, shall provide in a timely manner any information required to determine the applicant’s eligibility for enrollment in the program. Verification of information (3) The administrator of a program may seek verification from third parties, including the Canada Revenue Agency, of information provided by an applicant or other person, as the administrator considers necessary. Determination of application (4) The eligibility of an applicant for enrollment in a program shall be determined by the administrator of the program in accordance with the regulations based on the information provided by the applicant and any other information available or provided to the administrator by any other person for that purpose. Application or participation considered consent (5) The application for or participation in a program by a person, including the use of a health number for the purpose of obtaining a benefit under a program, shall be considered to be consent by the person for third parties to release to the administrator of the program information required by the administrator c t Current to: April 23, 2024 Page 7 Section 8 Health and Dental Services Cost Assistance Act (a) to determine the person's eligibility for the program; (b) for conducting audits of the person’s participation in the program; (c) for planning, delivering or funding programs, allocating resources and evaluating or monitoring programs; and (d) detecting, monitoring and preventing fraud or any unauthorized receipt of benefits. Notice of decision (6) The administrator of a program shall give notice to the applicant in writing of a decision in respect of an application for enrollment in a program and, where the application is not approved, the reasons for that decision and the applicant’s right to request a review of the decision by the Minister in accordance with section 13. 2020,c.66,s.7. 8. Payment of benefit (1) The administrator of a program shall pay a benefit to or on behalf of an eligible person under the program in accordance with the regulations. Claim (2) To obtain payment of a benefit under a program, an eligible person or a participating health professional, as the case may be, shall submit a claim to the administrator of the program, in the form and containing the information required by the administrator. Additional particulars and information (3) An eligible person or participating health professional who submits a claim shall, on the administrator’s request, provide to the administrator sufficient particulars of the claim and supporting documentation to enable the administrator to assess the claim in accordance with this Act and the regulations. Assessment and approval (4) All claims are subject to assessment and approval by the administrator of the program. Prescribed rules (5) The rules, terms, restrictions and conditions under which a benefit may be paid, including the amount of any co-payment required or the person to whom a benefit may be paid, shall be determined in accordance with the regulations. Assumption of responsibility for payment (6) Nothing in this Act or the regulations shall be construed so as to prevent an eligible person from assuming responsibility for the payment of a cost that would otherwise be covered as a benefit under this Act and the regulations. 2020,c.66,s.8. 9. Powers of administrator The administrator of a program may, in accordance with the regulations, (a) restrict, refuse, suspend, vary or discontinue the provision of a benefit under the program to or on behalf of a person; (b) reassess or adjust a claim under the program; (c) require a person or participating health professional to reimburse the Plan, as directed by the Minister, in whole or in part, for any benefit; and (d) take any steps permitted by this Act or the regulations to recover the cost of any benefit inadvertently or improperly provided or paid. 2020,c.66,s.9. Page 8 Current to: April 23, 2024 t c Health and Dental Services Cost Assistance Act Section 10 Audit of Participating Health Professionals 10. Record A participating health professional shall maintain a record of a claim made by the participating health professional for not less than 10 years from the date of the provision of the benefit to which the claim relates. 2020,c.66,s.10. 11. Appointment of auditor (1) The Minister may appoint a person as an auditor for the purposes of this section. Assistant to auditor (2) The Minister may designate a person to accompany an auditor for the purpose of providing assistance in conducting an audit. Audit of participating health professional (3) In order to ensure compliance with a program, the Plan and this Act and the regulations, an auditor may conduct an audit of a participating health professional. Access to premises and records (4) Where reasonably necessary for the purposes of this section, an auditor may, at all reasonable times, without a warrant, enter a participating health professional’s business premises to inspect the records in the custody or control of a participating health professional that the auditor considers necessary to complete the audit in the manner required by this Act and the regulations. Examining and copying records (5) An inspection under subsection (4) may include examining and copying records, including electronic records, in any manner that the auditor considers appropriate, including photocopying, scanning and electronic copying of data. Insurance records (6) An inspection under subsection (4) may include an examination of records relating to an eligible person’s insurer and any records of payment to that insurer or other method of obtaining benefits. Duty to provide information (7) A participating health professional shall provide the information required by an auditor under this section to determine compliance with a program, the Plan and this Act and the regulations and that information may be provided in person or by mail, facsimile or electronic transmission. 2020,c.66,s.11. 12. Report to Minister (1) At the conclusion of an audit, or at any time when requested to do so by the Minister, an auditor shall report to the Minister the auditor’s findings with respect to the audit. Overpayment is debt to Government (2) Where, following an audit, the Minister determines that a payment has been made to a person or a participating health professional in excess of the amount that was required to be paid under the Plan, the excess amount is a debt due to the Government. c t Current to: April 23, 2024 Page 9 Section 13 Health and Dental Services Cost Assistance Act Notice to regulatory body (3) The Minister may, during or after an audit, with respect to the activities of a participating health professional, notify and provide information to the regulatory body for that health profession respecting the findings or results of the audit. Duty to report offence (4) Where, as a result of an audit under this Act, the Minister has reasonable grounds to believe that an offence has been committed contrary to the Criminal Code (Canada), the Minister shall provide the information in the possession of the Minister in respect of the offence to the appropriate law enforcement authority. 2020,c.66,s.12. Review 13. Request for review (1) A person who is aggrieved by (a) a decision of an administrator in respect of enrollment in a program or a claim; (b) a determination that a payment in excess of the amount that was required to be paid under the Plan has been made to the person; or (c) a decision or determination under the regulations, may request that the Minister review the decision or determination by filing a request with the Minister, in the form required by the Minister, within 30 days of receipt of notice of the decision or determination. Further information or records (2) The Minister may require the person requesting a review to provide further information or records for the purpose of the review. Review within 30 days of request (3) Subject to subsection (4), within 30 days of receiving a request for a review under subsection (1), the Minister shall review the matter. Extension of time (4) Where information or records requested by the Minister under subsection (2) have not been provided before the deadline for a review under subsection (3), the Minister shall, within 30 days of receipt of the information, records or documents, review the matter. Decision on review (5) Within 30 days following a review under this section, the Minister (a) may (i) confirm, vary or rescind the decision or determination under review, (ii) refer the matter, or any issue, back to the administrator who made the decision or determination for further consideration, or (iii) provide any direction that the Minister considers appropriate; and (b) shall notify, in writing, the person who requested the review of the Minister’s decision and the reasons for it. Page 10 Current to: April 23, 2024 t c Health and Dental Services Cost Assistance Act Section 14 Delegation of review powers and duties (6) The Minister may delegate the Minister’s powers and duties under this section to an employee of the Government. 2020,c.66,s.13. General 14. Minister’s duty on overpayment (1) Where it has been determined that a payment in excess of the amount that was required to be paid under the Plan has been made to a person or a participating health professional, the Minister shall, in writing, notify the person or participating health professional (a) of the amount paid in excess and the manner in which the amount was calculated; (b) that the excess amount is a debt due to the Government; (c) that the amount may be recovered; and (d) of the person’s or participating health professional’s right to request a review of the determination under section 13. Interest on overpayment (2) The Minister may charge interest on an amount paid in excess of the amount that was required to be paid under the Plan in accordance with the Judicature Act R.S.P.E.I. 1988, Cap. J-2.1. 2020,c.66,s.14. 15. Prohibitions No person shall (a) apply for or obtain a benefit under the Plan that the person is not entitled to under the Plan; (b) apply for or obtain a benefit under the Plan on behalf of another person, unless the person has reasonable grounds to believe that the other person is entitled to the benefit under the Plan; (c) provide false or misleading information or records pursuant to a requirement of this Act or the regulations to provide information or records; (d) fail to provide information or records as required by this Act or the regulations; or (e) aid or abet another person in applying for or obtaining a benefit under the Plan to which that other person is not entitled. 2020,c.66,s.15. 16. Offence and penalty (1) A person who contravenes or fails to comply with a provision of this Act or the regulations is guilty of an offence and liable on summary conviction (a) in the case of an individual, to a fine of not less than $2,000 and not more than $10,000 or to imprisonment for a term of not more than 12 months, or to both; and (b) in the case of a corporation, to a fine of not less than $20,000 and not more than $50,000. Continued contravention (2) Where a contravention of or failure to comply with any provision of this Act or the regulations continues for more than one day, the offender is guilty of a separate offence for each day that the contravention or noncompliance continues. 2020,c.66,s.16. c t Current to: April 23, 2024 Page 11 Section 17 Health and Dental Services Cost Assistance Act 17. Officers and directors of corporation (1) Every officer, director or representative of a corporation who directs, authorizes, assents to, acquiesces in, or participates in the commission of an offence by that corporation is also guilty of the offence and is liable, on summary conviction, to a fine not exceeding $20,000, or to imprisonment for a term not exceeding 12 months, or both. Application (2) Subsection (1) applies whether or not the corporation has been prosecuted or convicted of the offence. 2020,c.66,s.17. 18. Limitation of liability No action or proceeding shall be brought against the Minister, an administrator, an auditor or any other person acting or assisting a person acting under the authority of this Act or the regulations for anything done or not done, in good faith, (a) in the performance or intended performance of a duty imposed under this Act or the regulations; or (b) in the exercise or intended exercise of a power conferred under this Act or the regulations. 2020,c.66,s.18. 19. Regulations The Lieutenant Governor in Council may make regulations (a) prescribing benefits; (b) establishing programs; (b.1) prescribing a benefit plan or program not established under this Act for the purpose of subsection 4(1); (c) prescribing eligibility criteria for programs and the enrollment of eligible persons; (d) prescribing factors that make a person ineligible; (e) respecting the application process for enrollment in a program and the information and supporting documents to be provided by an applicant; (f) requiring persons to report changes in their status as eligible persons, and providing for applications to vary enrollment in a program accordingly where appropriate; (g) respecting the circumstances and conditions under which an administrator shall determine whether a person’s eligibility shall be reassessed, changed or revoked; (h) respecting the rules, terms, restrictions and conditions under which benefits may be paid; (i) respecting the process for making a claim; (j) prescribing the method of determining the amount of any co-payment required under a program; (k) respecting co-ordination of benefits under a program; (l) respecting the manner in which benefits may be restricted, refused, suspended, varied or discontinued by an administrator; (m) respecting the manner of assessment, reassessment and readjustment of claims and the reimbursement and recovery of benefit payments made inadvertently or improperly; (n) respecting audits of participating health professionals; (o) respecting reviews conducted under section 13; Page 12 Current to: April 23, 2024 t c Health and Dental Services Cost Assistance Act Section 20 (p) respecting the service of documents and the provision of information for the purposes of the Act, including specifying when and in what circumstances service may be deemed to be effected; (q) defining any word or phrase used but not defined in this Act; and (r) respecting other matters the Lieutenant Governor in Council considers necessary to give effect to the purposes of this Act. 2020,c.66,s.19; 2024,c.49,s.4. 20. and 21 (These sections make consequential amendments to other Acts. The amendments have been incorporated into those Acts.) c t Current to: April 23, 2024 Page 13