In the Canadian health system, feeding and eating disorders are diagnosed by medical professionals (physicians and nurse practitioners) or psychologists. These diagnoses are guided by the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association. The manual is revised periodically with input from international working groups of clinicians and researchers. The fifth edition of the manual, the DSM-5, was published in 2013, with revisions to the feeding and eating disorders section intended to be inclusive of a wider range of disordered eating, to aid in the identification of males affected, and to facilitate earlier identification of eating disorders.
These formal categories of eating disorders and their definitions are summarized on the pages linked below. We include a few categories which are not formally recognized but which represent real distress that people may experience in relation to food, eating, or body weight or shape.
It is important to remember that you can’t tell whether or not someone has an eating disorder just by looking at them. People of all body types experience eating disorders. Moreover, people of all ages, genders, classes, racial backgrounds, ethnicities, and abilities experience eating disorders. Similarly, you can’t rely on an affected person’s size or weight to identify which type of eating disorder they have. Learn more about the difference between disordered eating and an eating disorder.
Anorexia nervosa is a mental illness characterised by behaviours that interfere with maintaining an adequate weight.
Biological, social, genetic, and psychological factors play a role in increasing the risk of its onset.
Bulimia nervosa is a mental illness characterised by periods of food restriction followed by binge eating, with recurrent compensating behaviours to “purge” the body of the food.
Biological, social, genetic, and psychological factors play a role in increasing the risk of its onset.
Avoidant/restrictive food intake disorder (ARFID) involves limitations in the amount and/or types of food consumed, but unlike anorexia, ARFID does not involve any distress about body shape or size, or fears of fatness.
ARFID is a mental illness which can severely compromise growth, development, and health.
Binge eating disorder is a mental illness that can seriously affect psychological and physical health. It is characterized by recurrent episodes of eating large quantities of food then experiencing shame, distress or guilt afterwards.
Other Specified Feeding and Eating Disorders refers to atypical presentations of anorexia nervosa, bulimia nervosa, and binge eating disorder, among other eating disorders.
These eating disorders are equally serious and as potentially life-threatening as the more typical presentations.
Including pica, rumination disorder and unspecified feeding or eating disorder
Definitions and Treatment Information
This is an informal definition for a behaviour pattern that can seriously impact someone’s life but is not a diagnosable eating disorder included in the DSM. You will not find insurance-covered treatment for it unless you also have another diagnosable eating disorder.
Anorexia athletica is a condition where people over-exercise to the point that fulfilling their exercise goals takes on more importance than almost anything else. Exercise is used to control body shape and weight and to provide a sense of power, control, and self-respect. It is not a clinically recognized diagnosis in the same way that anorexia nervosa and bulimia nervosa are, but compulsive exercising can have serious health consequences.
This is an informal definition for a behaviour pattern that can seriously impact someone’s life but is not a diagnosable eating disorder included in the DSM. You will not find insurance-covered treatment for it unless you also have another diagnosable eating disorder.
People with nocturnal sleep-related eating disorder may binge eat, or consume strange combinations of food, raw foods and even non-food items in the period between sleep and wakefulness. Upon waking up, the person has little or no memory of doing this.
Nocturnal sleep-related eating disorder is found across ages and genders. Because it occurs while a person is unconscious (as in sleep-walking), it may be best to consider it a sleep disorder rather than an eating disorder.
This is an informal definition for a behaviour pattern that can seriously impact someone’s life but is not a diagnosable eating disorder included in the DSM. You will not find insurance-covered treatment for it unless you also have another diagnosable eating disorder.
Body dysmorphic disorder (BDD) is characterised by preoccupation with one or more perceived flaws in one’s physical appearance that are unobservable or viewed as minor to others. Individuals with BDD experience persistent thoughts about their appearance that cause significant distress and engage in repetitive behaviours driven by a compulsion to correct or hide their perceived flaw(s).
Muscle dysmorphia (MD) is a form of BDD that is characterised by the belief that one's body is too small or not muscular enough. Individuals with MD experience persistent thoughts about their perceived lack of muscularity that cause significant distress. They may engage in dysfunctional movement or exercise, or use steroids or supplements, to correct or hide their perceived flaw(s).
BDD and MD fall under the umbrella of obsessive-compulsive and related disorders.
The Body Mass Index (BMI) was originally designed in the 1800s as a way to show the various proportions of the human build. By the 1970s, the use of BMI had been adopted as a quick and inexpensive system for epidemiologists to classify participants based on body mass in public health studies. In 1986, the National Institute of Health started encouraging its use for defining “obesity”. BMI is calculated by dividing an individual’s body weight in kilograms by their height in squared meters. It is a measure of total body mass. It does not calculate a person's body fat, nor does it take into consideration a person's natural set point range.
The assumption that "obesity" directly causes disability and death has led to the widespread belief that the higher one's BMI, the higher one's health risk. However, there is no consistent or reliable data that shows that losing weight and lowering one’s BMI actually decreases risk of disease or increases life expectancy.
The current guidelines that define a "normal" BMI were lowered based on recommendations set by the Obesity Task Force in 1998; however these recommendations were not supported by research evidence. It is important to note that weight gain, or increases in BMI, over time may be normal and healthy. Not everyone labeled "overweight" or "obese" is unhealthy, and not everyone labeled "normal" is healthy. Since this tool does not reveal an individual's level of fitness, nutrition status, quality of life, or any of the many other aspects of health, it is not effective for assessing how healthy they are.
Disordered eating refers to thoughts, attitudes, and behaviours around food, eating, and body image that can interfere with an affected person's daily life.
Examples of psychological signs:
Examples of behavioural signs:
The label of “obesity” is problematically defined and can be stigmatizing for the individuals it is associated with. The World Health Organization defines "obesity" as a BMI of 30 and above. Please see Body Mass Index (BMI) for information on its limitations. It is assumed that all people who are “obese”, as per BMI standards, have a higher risk of death. However, an association between "obesity" and increased mortality is actually clustered in the BMI range of 35 and above, which is higher than where most people's BMI falls. In addition, government statistics have indicated that "obesity" rates leveled off between 1999 and 2003 and have stabilized while life expectancy continues to increase. Therefore, we can conclude that claims about "obesity crises" are exaggerations.
One of the more harmful effects of labelling people "obese" is the widespread practice of recommending weight loss. Attempts to lose weight have been associated with lean tissue loss, increased risk of food preoccupation and eating disorders, and other psychological consequences. Often people use “diets” in an effort to lose weight despite a large amount of research showing that dieting predicts weight gain; in fact, two-thirds of those who lose weight through dieting often regain all the weight, if not more, within 1 to 5 years.
There are many factors beyond their diet, physical activity, and genetics that influence a person's weight. Therefore it should not be assumed a person labeled "obese" is unhealthy. Most health indicators can actually be improved by changing health behaviours (such as engaging in enjoyable physical activity, eating based on internal cues, and quitting smoking) and addressing other needs (such as social connectedness) that are not being properly met, regardless of weight loss.
The World Health Organization defines "overweight" as a BMI 25-30. Please see Body Mass Index (BMI) for information on its limitations. It’s assumed that people above a certain BMI have a higher risk of death. However, an association between "obesity" and increased mortality is actually clustered in the BMI range of 35 and above, which is higher than where most people's BMI falls. A BMI in the "overweight" category may actually be protective against the risk of death.
The use of the label “overweight” as a health indicator is concerning in a way that similar to that of the term “obesity”. Please see Obesity for more information on its limitations.
Counsellors are mental health clinicians who perform counselling, including advising, educating, and coaching. This is sometimes called “talk therapy”. Many counsellors hold master’s degrees, and may be registered with a professional association like the Canadian Counselling and Psychotherapy Association.
A dietitian has comprehensive training in food and nutrition, and helps individuals translate the science of nutrition into terms and ideas that the individual can apply to one’s own life and dietary habits. In Canada, dietitians are regulated by provincial colleges.
A family doctor is usually your first point of contact in the health care system. They are medical doctors who work with individuals and their families. If you do not have a family doctor, a walk-in clinic can sometimes offer similar services.
Occupational therapists are registered health care professionals who have been trained to offer interventions if a barrier is preventing an individual from participating in activities or life. They work in a variety of clinical settings.
A nurse is a health practitioner who has undergone rigorous training and is registered by their provincial regulatory body. They provide health care in a variety of settings.
A nurse practitioner is a registered nurse who has completed additional advanced university education. Nurse practitioners work in a variety of settings.
Nutritionists offer advice on food and nutrition to individuals. Their qualifications may vary because, in Canada, they are not regulated by a provincial body. Some registered dietitans may also use the term nutritionist.
A psychiatrist is a medical doctor who has had further training in the diagnosis and treatment of mental illnesses. They can prescribe medication to individuals living with mental illnesses.
A psychologist has undergone extensive training, and often has a master’s degree or PhD. They can offer counselling and a variety of specialized treatments and interventions for mental illnesses. In Canada, psychologists are regulated by provincial bodies. Psychologists work in a variety of settings, including hospitals, community-based care settings, and private practice.
A psychotherapist is a mental health practitioner who uses one or a variety of techniques of the various branches of psychotherapy. Psychotherapists help individuals to understand and process their problems, and are usually registered by a regulatory college.
Social workers usually have master’s degrees, and are regulated at the provincial level in Canada. Their focus is on helping people to develop their skills and ability to resolve problems using the individual’s own skills or community resources.
You may also find these Tips for Choosing a Professional Help (PDF) helpful.
CBT is based on the assumption that thoughts, emotions, and behaviours are interconnected and can be restructured to support new, healthier thoughts and actions.
DBT is based on the assumption that self-destructive behaviours are caused by the inability to manage and regulate intense emotion. DBT combines cognitive behavioural techniques with mindfulness and acceptance strategies.
In EFT, individuals learn how to manage their maladaptive emotions, as opposed to controlling what they eat as an outlet for the emotions
In FBT, parents of children and younger teens are empowered to take responsibility for managing their child’s eating disorder symptoms, with the goal of restoring their child’s health.
There are three phases.
o Phase one: parents are supported to re-establish normal eating patterns, deciding what their child will eat for meals and snacks, ensuring adequate nourishment, and interrupting problematic behaviours like exercising to control weight or purging.
o Phase two: control of eating is carefully handed back to the child or teen (age-appropriately).
o Phase three: treatment focuses working through underlying issues and helping the child establish a healthy, non eating-disordered, identity.
In EFFT, emotion coaching is integrated into a Maudsley model. A parent or caregiver helps their child to identify and process emotions that come up in the process of eating disorder recovery, allowing the young person to feel the compassion and understanding of their parent. The parent also learns to recognize when their own actions are being controlled by maladaptive emotions. New and healthier choices and directions can then be taken.
Group members are all going through similar struggles and come together to support and empower each other.
You may also find these Tips for Choosing a Provider (PDF) helpful.
Day treatment programs are a form of outpatient care. The patient usually spends a number of hours at the program, and eats meals there while continuing to live at home. In Canada, these are often hospital-based programs. Day programs are staffed by multidisclipinary teams that generally include psychiatrists, nurse practitioners/ nurses, psychologists, dietitians, social workers, child/youth counsellors, and educators.
Adolescents who are medically stable but for whom outpatient treatment is insufficient to reduce their eating disorder symptoms may require a day program. This typically involves attending a clinic 5 days per week from breakfast through dinner time.
Inpatient care is, in Canada, a form of hospital-based care for individuals whose eating disorder symptoms require intensive medical interventions or monitoring. It is intended to be relatively short-term with the goal of stabilizing the person’s physical health so that they can continue treatment.
Inpatient eating disorder treatment includes medical monitoring, re-feeding/nutrition restoration, and/or symptom interruption. A typical week’s schedule will consist of staff-supervised meals and snacks. In addition, an inpatient program may offer academic programming; increasingly, family-based meal support is being integrated into inpatient programs.
Inpatient eating disorder units are staffed by multidisclipinary teams that generally include psychiatrists, nurse practitioners/ nurses, psychologists, dietitians, social workers, child/youth counsellors, and educators.
Children who are experiencing or at high risk of medical complications need to be hospitalized so they can receive 24-hour care. They may be placed in a general hospital setting for medical stabilization or, where available, in a specialized eating disorder unit.
Individuals who are medically stable may be treated on an outpatient basis (e.g., attending weekly therapy appointments).
Most families, with professional help, are able to restore their children’s health at this level of care. The recommended firstline treatment for youth with eating disorders is an outpatient approach known as Family-Based Treatment or the Maudsley Model (see Types of Therapy).
For individuals who are medically stable but for whom outpatient or day treatment has been unsuccessful, residential treatment may be indicated. 24-hour care is provided, with aspects of inpatient care incorporated into some sites.
In Canada, the following providers offer residential treatment:
British Columbia
Alberta
Saskatchewan
Ontario
Québec
You may also find these Tips for Choosing a Provider (PDF) helpful.
For some eating disorder treatment programs, including most provincially-funded hospital-based care, you will require a referral from a medical doctor in order to access care. Each program usually has their own referral form which the doctor will have to complete. There may be medical tests required in order to complete the referral, which your doctor can order.
Some providers, especially those in private practice, may accept or even request a referral from another service provider -- in this instance, meaning a provider other than a medical doctor.
Some programs or providers may have an intake process to access their services. This might involve meeting with an intake coordinator or submission of completed forms.
Most providers in private practice accept clients through self-referral. This means that the potential client can reach out to the provider and express interest in working with the provider. The provider may still ask for an intake form to gather information about your history with an eating disorder and current needs.
In all provinces, to obtain provincial health insurance coverage for out-of-province and out-of-country eating disorder treatment, a similar process must be followed. Note that government-funded treatment facilities are relatively scarce in Canada and they are often unable to accommodate out-of-province clients.
The process across Canada usually involves the following steps:
1. The client must be assessed and referred in writing by an appropriate eating disorders specialist.
2. A letter of request and/or the necessary application forms from a physician specializing in eating disorders must be sent to the Ministry of Health in the client’s home province.
The letter of request/application must include the following:
3. The request will receive approval or denial by the corresponding provincial government panel. If denied there are appeal processes that can be followed in each province.
Source:https://www.alberta.ca/ahcip-out-of-country-health-funding.aspx
For More Information:
Alberta Health Care Insurance Plan
Telephone Edmonton area: 780-415-8744
Toll Free (elsewhere in Alberta): dial 310-0000, then 780-415-8744
Fax 780-415-0963
E-mail (for general information or non-personal questions about insurance coverage ONLY) health.ahcipmail@gov.ab.ca
Chair, Out-of-Country Health Services Committee
PO Box 1360, Station Main
Edmonton AB T5J 2N3
Out-of-Province
Under the Alberta Health Care Insurance Plan (AHCIP) and the Hospitals Act, eligible Alberta residents are provided coverage for insured physician and hospital services in Alberta and elsewhere in Canada. Alberta Health limits some coverage outside the province and covers only limited physician and hospital expenses outside Canada.
Out-of-Province Claim Form: https://formsmgmt.gov.ab.ca/Public/AHC0693.xdp
Out-of-Country
Applicant Conditions
Application Process
Online Application: https://cfr.forms.gov.ab.ca/Form/AHC2176.pdf (note: this PDF file can only be opened using Adobe Acrobat - it will not open in a web browser)
Applications must include the following documents/information:
a) A letter of referral/support, or a completed Application Form, including the following information:
b) The reason for seeking funding for out-of-country health services and a minimum of one of the following to support that reason:
c) A recent health history/summary of the patient that is relevant to the health service for which funding is requested, prepared by an Alberta physician or dentist and which must include:
Approval
Once the OOCHSC chair has determined that an application is complete, the OOCHSC has 60 days to assess the application and make a decision. If the application is urgent for medical reasons, the physician or dentist must state this on the application, along with the reasons for the urgency and the timeframe within which it is recommended that the health services/ treatment be initiated.
The OOCHSC will send a written copy of its decision with reasons to the applicant and the patient on whose behalf the application was made, within 10 days of making its decision.
Appeal Process
Decisions made by the OOCHSC can be appealed. Appeals may be submitted by the Alberta physician or dentist who submitted the application for the Alberta resident, or by the Alberta resident. All appeals must be submitted in writing to the Out-of-Country Health Services Appeal Panel within 60 days of the appellant receiving the OOCHSC decision letter. The appeal letter must be sent either:
By mail to:
Out-of-Country Health Services Appeal Panel
PO Box 1360, Station Main
Edmonton, AB T5J 2N3
Or by fax to:
780-644-1445
Attention: Chair, Out-of-Country Health Services Appeal Panel
For More Information:
Out-of-Province
BC will fund the cost of physician and acute care hospital services in other Canadian provinces and territories (except Quebec) provided the service meets the following criteria:
a) It is medically required;
b) It is provided by a medical practitioner or oral surgeon entitled to practice in the province or territory where the service is rendered; and
c) It would be a benefit if performed in BC unless otherwise stipulated by the terms of the reciprocal agreement.
Out-of-Country
a) Generally, eating disorder treatment services are not eligible for out of country funding because treatment services are available in BC. Exceptions may be funded pursuant to these Guidelines.
b) Applications for out of country funding for treatment of eating disorders outside of Canada require the following information to be submitted by the appropriate specialist involved in the beneficiary's care:
(i) a written recommendation based on an assessment by the Director of the St. Paul’s Hospital Eating Disorders Program (located at St. Paul's Hospital in Vancouver) following assessment and referral from a BC tertiary eating disorder program (for adults, St. Paul's Hospital Eating Disorders Program, for children, B.C. Children's Hospital Eating Disorders Program);
(ii) Details of the referring physician’s attempts to locate appropriate medical care within Canada;
(iii) A written treatment plan and transfer protocol (a written plan detailing date and manner of return of the beneficiary to BC following the provision of out of country medical care)
(iv) Proof of accreditation of the proposed facility; and
(v) Approximate length of stay for the treatment plan and an undertaking by the out of country treating physician to provide MSP and the referring specialist with monthly follow-up reports on the outcomes of the treatment program.
c) If funding is approved under this provision, payment will be at the negotiated U&C* or
contract rate.
* "usual and customary rate" (U&C) is the preferred customer rate that MSB will negotiate in advance ofthe provision of out of country medical services during the pre-approval process. It is a preferred rate received by large insurance providers.
Application and Review Process for Funding of Out of Country Medical Care
Printable Application Form:https://www2.gov.bc.ca/assets/gov/health/forms/2810fil.pdf
In relation to an application for elective out of country medical care, MSB may consider:
a) Whether the treatment is recommended by the medical profession in BC and/or elsewhere in Canada;
b) If the treatment is experimental or developmental, Health Canada's position with respect to the efficacy of the treatment including if a drug or device has been approved by Health Canada for the proposed use;
c) If a procedure offered in the United States is beyond Phase III clinical trials and approved by the Centers for Medicare & Medicaid Services; and
d) Whether all avenues for treatment within the Canadian healthcare system have been exhausted.
The Application and Approval Process
INTRODUCTION
Prior approval of provincial coverage for elective out of country medical care is the responsibility of Out of Country Claims Branch, HIBC, and the Medical Services Branch, Ministry of Health Services. In order to consider provincial coverage for elective out of country medical care, an application for prior approval must be received by HIBC. In cases where out of country funding is appropriate, the preapproval process enables the province to negotiate a reasonable and fair compensation rate from out of country service providers prior to the provision of the service.
APPLICATION BY APPROPRIATE SPECIALIST
Applications for prior approval of funding for medically necessary out of country services must be submitted to HIBC by an appropriate specialist actively involved in the beneficiary's care in BC. An appropriate specialist is one with the most knowledge in the proposed service and/or specialty that will be provided out of country.
DOCUMENTATION
It is the responsibility of the appropriate medical specialist making application on behalf of the beneficiary to submit all supporting documentation, including, when appropriate or required, a written recommendation from the tertiary care centre or appropriate agency responsible for standards of care in BC regarding the proposed out of country medical care.
APPLICATIONS
Only complete applications will be considered. Incomplete or abandoned applications are not eligible for review by an authority delegated by the MSC. An incomplete application is one that does not include a recommendation from the appropriate attending medical specialist and/or does not include the required documentation or written recommendation from a tertiary care centre or the appropriate agency responsible for the medical standard of care in BC.
If additional information is requested during the course of reviewing an application, the information must be received within 45 days of the request, or on an agreed date. If the information is not received, the application for out of country funding will be considered abandoned.
SUMMARY OF THE DECISION PROCESS
Stage 1 - Consideration and decision by Medical Services Branch
The completed application for funding approval and any supporting documentation is considered by MSB or its designate, Health Insurance BC, and a decision is made as to whether or not funding for out of country care will be provided.
Stage 2 - Administrative Review by Medical Services Branch
If the decision made by MSB is to deny the application for funding, the beneficiary may request an administrative review of the denial. To request the administrative review, the beneficiary must supply MSB with additional relevant information from the appropriate specialist.
The request for an administrative review must be made by the beneficiary within six months after the date of the initial determination made by MSB.
Stage 3 - Formal Review by Medical Services Commission
If, after the administrative review is concluded, the application for funding is denied again, the beneficiary may request that the MSC formally review the decision of MSB. The question for the MSC to determine in the formal review is whether MSB properly applied the Out of Province and Out of Country Medical Care Guidelines for Funding Approval.
The formal review is conducted by an MSC Review Panel, which consists of three members -- one representative from each of the Ministry of Health Services, the British Columbia Medical Association and the general public.
Source: https://www.gov.mb.ca/health/mhsip/out-of-province-coverage.html
For More Information:
Out-of-Province
You may be eligible for help with costs related to getting medical care in another province when an appropriate physician (specialist) recommends that you need a necessary, specific medical service (i.e., care or treatment) and that it is not available in Manitoba.
For further details, see" https://www.gov.mb.ca/health/mhsip/out-of-province-coverage.html#section-three
Approval process
If treatment is not available in Manitoba, documentation from a specialist is needed to obtain coverage for out-of-province care:
Out-of-Country
Manitoba Health will pay for care or treatment in the United States only if all Canadian medical resources have been exhausted. In some cases, documentation that you have seen other Canadian specialists may be required before your request for referral outside the country will be considered.
Costs covered outside of Canada
For medical and hospital services provided in the U.S., Manitoba Health will cover:
If your costs for medical and hospital services exceed these coverage limits, it is your responsibility to pay the difference, unless you qualify for special assistance based on financial hardship.
Travel Costs
If your out-of-province referral is approved, you may be reimbursed for reasonable transportation costs. Accommodations, meals, taxis, ambulance and other expenses are not covered.
For more information abut travel subsidies for out-of-province medical referrals, see:
https://www.gov.mb.ca/health/mhsip/out-of-province-coverage.html#section-three
Escorts
Travel costs for an escort may also be reimbursed if the escort is required for your well-being and safety during travel. If an escort is required, your specialist must notify Manitoba Health by including that information in his or her initial letter of request.
Billing
If you have already paid a doctor or hospital bill, you must include in your request for reimbursement the original receipt showing the amount you paid. If you do not include a receipt, Manitoba Health will pay the doctor or hospital directly.
Source: https://www2.gnb.ca/content/gnb/en/departments/health/Medicare.html
For More Information:
Out-of-Province
If you require insured physician services anywhere in Canada, except Quebec, simply present your valid New Brunswick Medicare card to the physician. New Brunswick has agreements with all Canadian provinces and territories, except Quebec, which allow physicians to bill their own health plan for providing insured physician services to New Brunswickers.
However, physicians in other provinces or territories may bill a New Brunswick resident for services excluded from the agreements, such as genetic screening and procedures still in the experimental or developmental phase. These claims can be submitted to New Brunswick Medicare for consideration, but reimbursement is not guaranteed.
In the province of Quebec, the physician may bill the patient directly or choose to bill New Brunswick Medicare. If you receive a bill from a physician in Quebec, submit a claim to New Brunswick Medicare for consideration. If reimbursement applies, it will be calculated at the Quebec rate only, which could be less than the amount billed by the physician.
If you require insured hospital services elsewhere in Canada, New Brunswick Medicare will pay the standard rate. However, certain insured hospital services may be billed directly to you. These claims can be submitted to New Brunswick Medicare for consideration, but reimbursement is not guaranteed.
It is mandatory for physicians to request prior approval from New Brunswick Medicare before referring a patient out-of-province for addiction or psychiatric treatment, unless the treatment is provided in a general hospital. The approval must be sought through the province’s Addiction Services or Mental Health Services.
Please note that you must present a valid New Brunswick Medicare card to receive insured physician and hospital services in other Canadian provinces or territories.
Travel and accommodation fees are not covered by New Brunswick Medicare for out-of-province services.
Out-of-Country
Prior approval
New Brunswick Medicare covers out-of-country services not available in Canada on a prior approval basis only. This involves having a written request submitted to New Brunswick Medicare by a New Brunswick specialist which identifies a specific, medically necessary and scientifically acceptable service unavailable in New Brunswick or elsewhere in Canada.
Appeals
You may appeal to the Insured Services Appeal Committee if you do not agree with a decision made by New Brunswick Medicare about your case or the case of an immediate family member. This includes decisions about eligibility, refusal of a claim for entitled services or the amount paid on a claim. The Committee is made up of three members from the general public. It meets three to four times a year based on the number of cases it receives. It then reviews each case and presents recommendations to the Minister of Health and Wellness who makes the final decision regarding an appeal.
Appeals, with all background information, should be addressed to:
Insured Services Appeal Committee
c/o New Brunswick Medicare
Department of Health and Wellness
PO Box 5100
Fredericton, NB E3B 5G8
Client Advocate Services
Client Advocate Services was established to: inform patients of their rights when dealing with New Brunswick Medicare; provide help and guidance on matters of dispute or disagreement; ensure the Medical Services Payment Act is appropriately applied; and ensure the process of the different sections of the Act is respected. Examples of issues that can be brought to the attention of the Client Advocate Services include: non-payment of services and eligibility issues.
Contact:
Client Advocate Services
New Brunswick Medicare
Department of Health and Wellness
P.O. Box 5100
Fredericton, NB E3B 5G8
Phone: (506) 453-4227
Fax: (506) 453-2726
Source: http://www.health.gov.nl.ca/health/mcp/outofprovincecoverage.html
For More Information:
Out-of-Province / Out-of-Country
Application Form: http://www.health.gov.nl.ca/health/mcp/forms/out_of_province_claim.pdf
With certain exceptions, claims for insured medical services obtained outside Newfoundland or Canada are paid at Medical Care Plan (MCP) rates, which are the rates paid to Newfoundland and Labrador physicians
A) Rates Payable - Services Available in Newfoundland and Labrador
Claims for insured medical services obtained outside Canada, that are available in Newfoundland and Labrador, are paid at Medical Care Plan (MCP) rates, which are the rates paid to Newfoundland and Labrador physicians. When the amount billed exceeds the amount payable, payment of the difference is the patient’s responsibility.
B) Rates Payable - Services Available in Canada but not in Newfoundland and Labrador
Insured medical services obtained outside of Canada which are not available in Newfoundland and Labrador but are available in another province are payable at the rates established by the medical care plan in that province. When the amount billed exceeds the amount payable, payment of the difference is the patient’s responsibility.
C) Rates Payable - Services Not Available in Canada
If you are planning to have insured medical treatment which you think may not be available in Canada, and if you wish to claim reimbursement of related medical costs through Medical Care Plan (MCP), you must ask your physician to request prior approval from Medical Care Plan (MCP) before obtaining such treatment in another country. By doing so you will be made aware in advance of the rate at which your medical bills will be reimbursed.
If you are granted prior approval based on the unavailability of the services in Canada, the Medical Care Plan will provide coverage for medically necessary physician services. Payment will be in the currency of the country where the services are received provided the rates are deemed to be fair and reasonable as determined by the Department of Health and Community Services. Prior approval is mandatory to receive payment at rates higher than those published in the Medical Care Plan (MCP) or other provincial physician fee schedules. If a patient opts to travel outside the country for medical service/treatment and prior approval has not been granted, payment will be in accordance with the established rates outlined in A) or B) above, and any balance remaining is the responsibility of the patient.
Claim Submission Requirements
If you have been treated by a physician in Canada who is not participating in the interprovincial arrangement, or have obtained services which are excluded firm the agreement, it will be necessary for you to submit an Out-of-Province Claim Form. This claim may be submitted on your behalf by the physician, in which case you will be asked to sign the form.
If the physician elects not to submit a claim on your behalf or you obtain medical services outside Canada, you should obtain letterhead billing which contains an itemized statement of the charges and services. This information is required so that we may substantiate and assess your claim. You will then be required to submit an Out-of-Province Claim Form, accompanied by the letterhead billing.
Medical Travel Assistance
The Medical Transportation Assistance Program provides financial assistance to beneficiaries of the Medical Care Plan (MCP) who incur substantial out-of-pocket travel costs to access specialized insured medical services which are not available in their immediate area of residence and/or within the Province.
Claimable expenses include airfare, accommodations purchased from a registered accommodations provider, such as a hostel, hotel, motel and/or registered apartment, scheduled busing services, and taxis when used in conjunction with commercial air travel. When a patient/family is out of pocket for the cost of registered accommodations, there is a provision for claiming a meal allowance for each night of medically required purchased accommodations. Accommodations and/or meals provided by family/friends are not claimable expenses under the Program.
Claims can be made for Economy Airfare, Private Vehicle Usage and Registered Accommodations
For forms and detailed information on criteria:
https://www.gov.nl.ca/exec/las/medical-transportation-assistance-program-mtap/
Source: http://novascotia.ca/DHW
For More Information:
Out-of-Province:
Nova Scotians who are referred outside the province to receive medical or clinical treatment are eligible for coverage under the province’s out-of-province services plan.
This type of funding can apply to a breadth of treatments, including eating disorders.
The province has a process in place to consider funding out-of-province treatments:
Out-of-Country:
If you are a Nova Scotia resident and require medically necessary treatment unavailable in Canada, your referring Nova Scotia specialist must submit a request to the MSI Medical Consultant for prior approval. For travel and accommodation assistance, prior approval is required from the Nova Scotia Department of Health and Wellness before accessing out-of-country treatment.
Travel and Accommodation Assistance Policy:
Nova Scotians who are approved to travel out-of-province for medical care are eligible for some financial support under the province's travel and accommodation assistance policy.
Patients will need to have their specialist seek approval from MSI. It needs to be a medically insured treatment and it has to be a service that is not available in Nova Scotia.
Insured services are generally those determined by experts to have proven medical benefits for patients. This does not include cosmetic procedures, procedures still being researched, or drug therapy.
Travel and Accommodation Assistance forms and information:
https://novascotia.ca/dhw/Travel-and-Accommodation-Assistance
Source:
https://www.ontario.ca/page/ohip-coverage-while-outside-canada#section-8
For More Information:
Out-of-Province / Out-of-Country
Prior approval from the Ministry of Health and Long-Term Care is required in order for patients to receive funding for OHIP-insured hospital and medical services out-of-country (OOC). Written approval must be received from the ministry before OOC health services are rendered.
Physicians seeking out-of-country treatment on behalf of patients must complete and submit a Prior Approval Application to the ministry before funding will be considered. Application forms and instructions can be found at: https://forms.mgcs.gov.on.ca/dataset/on00314
Completed application forms may be mailed to the ministry at the address provided on the application form, or sent by fax to: 1-866-221-3536 or 613-536-3181.
Specialist Confirmation
Requests for prior approval for funding of out-of-country health services require written confirmation from an Ontario physician who is a specialist in the type of service for which funding is requested. The specialist must confirm that the service is:
General practitioners (GPs) may submit applications that include confirmation from a specialist.
Approval
When a patient's application for OOC Prior Approval has been processed by the ministry a decision letter will be sent to you and a copy sent to your physician. The ministry's decision letter will clearly outline what service(s) have been approved, the facility where the service(s) are to be provided and the approved cost of the service(s).
The decision letter is based on the medical documentation that was provided with the application. If a patient's circumstances change, the physician may submit a new prior approval application to the ministry requesting new treatment and/or services as well as the proposed OOC physician/facility for consideration.
Services Not Eligible for Out-of-Country Funding
In the case of prior approvals, the ministry only covers costs for prior approved medical services. Expenses incurred for non-medical services such as travel, accommodation and meals (except where included as part of insured hospital services) are not insured services of OHIP.
For More Information:
Out-of-Province / Out-of-Country
Residents seeking government funding for non-emergency (that is, not for sudden illness) out-of-province medical or hospital services are required to obtain prior approval from Health PEI. The cost of such out-of-province services may be fully covered providing that your physician submits an application on your behalf to Health PEI.
Applications may be approved in the following circumstances:
province
Approval for a service will cover a period of no more than 12 consecutive months.
If you do not receive prior approval from Health PEI for a non-emergency medical and/or hospital service to be obtained out-of-province, you will be held responsible for the total cost of the services rendered.
Out-of-Province Travel Support Programs
If you are a PEI Resident with a valid PEI Health card and have received prior approval from Health PEI for out-of-province medical services, you may be eligible for travel assistance.
Travel Support forms and information: https://www.princeedwardisland.ca/en/information/health-pei/out-province-travel-support-programs
Appealing a Medical Insurance Decision
For information/questions about a decision or other matter relating to the administration of Health PEI, residents need to contact Health PEI, Appeals Division.
Contact Information
Medicare Office
Appeals Division
126 Douses Road
Montague, PE C0A 1R0
Toll Free: 1-800-321-5492
Fax: 902-838-0940
Source: http://www.ramq.gouv.qc.ca/en/Pages/home.aspx
For More Information:
Out-of-Province / Out-of-Country
The Health Insurance Plan covers a wide range of essential medical services. However, in exceptional cases, some services may not be available in Québec. In such cases, and as a last resort, it is possible to request the Régie's authorization to receive healthcare outside Québec.
How to Proceed
The Régie must be provided with the following:
The Régie's Decision
The Régie will evaluate the request and inform the insured person and that person's medical specialists of its decision.
If the Régie grants an authorization, it will pay the full cost of:
Application for Review
If you disagree with the decision of the Regie you can apply for a review. You have six months, from the date the Régie’s letter of decision is deposited in your mailbox or handed to you in person, to apply for a review of your file. Under the Health Insurance Act, the Régie has 90 days to render its decision following an application for review. If, after you’ve filed your application, you wish to provide supporting documents or comments, the 90-day time limit will run from the date the Régie receives the documents. Moreover, if the Régie deems that it needs additional documents or information, it may extend the time limit by another 90 days.Finally, if the Régie does not meet the deadlines, you may wait for its new decision, or contest the previous decision before the Tribunal administratif du Québec (TAQ).
If you believe that the decision rendered in follow-up to your application for review does not respect your rights, you have 60 days (from the date the decision is delivered to your address) to contest it before the Tribunal administratif du Québec.
For more information on the review process:
http://www.ramq.gouv.qc.ca/en/regie/Pages/application-for-review.aspx
Online application for review form:
https://www.ramq.gouv.qc.ca/sites/default/files/documents/form-demande-revision-4185-en_2.pdf
For More Information:
Out-of-Province
Prior approval is required for services related to alcohol and drug, mental health, and problem gambling issues. Requests for out-of-province assessment and/or treatment are only accepted from Regional Health Authorities or the Physician Support Program of the Saskatchewan Medical Association. Once a request is submitted, it is reviewed by the Ministry of Health according to the out-of-province policy. If approved, the Ministry will pay the full cost of the assessment or treatment service. The cost of travel, accommodation, and meals are not eligible for coverage or
reimbursement.
Please note that you will not be reimbursed for the cost of services accessed without prior approval.
Out-of-Country
If a specialist physician refers you outside Canada for treatment not available in Saskatchewan or another province, they must ask for prior approval, in writing, from the Medical Services Plan of Saskatchewan Health. The request must:
Referring specialists may call 306-787-3299 for further details about the prior approval process.
If the treatment is approved, Saskatchewan Health will pay the full cost of treatment at a rate that the Ministry considers to be fair and reasonable after taking into account the locality in which the insured service is being provided
Health Services Review Committee (HSRC)
This committee reviews government decisions made on requests for out-of-province and out-of-country medical coverage, ensuring legislation, policy and guidelines are followed appropriately.
Reviews for denied coverage can be requested if the requested coverage is for insured out-of-province or out-of-country medical services (physician and hospital care) or community care programs (mental health, alcohol and drug, problem gambling, home care and rehabilitative services).
The Ministry will inform eligible applicants of their right to request a review by the HSRC.
Applications Process
Eligible applicants must submit a written application to the HSRC within 90 days after the date the Ministry made its coverage decision.
Online application form is available to download under "Apply for Review": https://www.saskatchewan.ca/residents/health/prescription-drug-plans-and-health-coverage/health-benefits-coverage/out-of-province-and-out-of-canada-coverage#health-services-review-committee
Send the completed application to:
Health Services Review Committee
TC Douglas Building
3475 Albert Street
Regina, SK S4S 6X6
Phone : 306-787-1910
Fax: 306-787-3761
You may submit to the HSRC additional information that was not previously provided to the Ministry in its coverage decision. This information will be forwarded to the Ministry to reconsider its decision. If the additional information does not result in a change in the Ministry’s coverage decision, the HSRC will schedule a meeting to review your request.
The Ministry has 30 days from receiving your application to inform you of the date that the HSRC will consider your application. In cases of clinical urgency, the committee may be convened to conduct a review with a quicker turnaround time. The committee will consider whether the legislation, policies and guidelines governing out-of province and out-of country coverage were followed by the Ministry in making its coverage decision. Following the review, the committee will provide you with its recommendation as soon as possible.
If the committee turns down your request you may contact the Provincial Ombudsman. The Ombudsman not only reviews whether the Ministry followed policy appropriately, but also assesses the fairness and equity of the decision. Note: The Provincial Ombudsman is not able to review past Ministry decisions; it only has the authority to make recommendations.
Out-of-Territory / Out-of-Country
Specialized eating disorder services are not available in the territories. Residents should be referred to the nearest provincial centre where treatment is available by an appropriate physician. Those seeking funding for treatment at an out-of-country facility must obtain prior approval from their territory’s health and social services department. The process is similar to that of the provincial ones whereby the physician must submit an explanation as to why the procedure is required outside the country which is reviewed by a team. The criteria considered include the urgency, wait times at Canadian hospitals, and the type of treatment requested.
Yukon Territory
https://yukon.ca/en/department-health-social-services
Toll-free telephone (in Yukon) 1-800-661-0408 + 4 digit extension
E-mail: hss@gov.yk.ca
Mail:
Health and Social Services
Government of Yukon
Box 2703
Whitehorse, YK Y1A 2C6
Northwest Territories
https://www.hss.gov.nt.ca/en/services/nwt-health-care-plan
Telephone: 867-777-7400
Toll-free: 1-800-661-0830
Fax: 867-777-3197
E-mail hsa@gov.nt.ca
Mail:
Health Services Administration
Department of Health and Social Services
Bag #9
Inuvik, NT X0E 0T0
Nunavut
https://gov.nu.ca/en/health
Telephone: 867-975-5766
Fax: 867-975-5705
Mail:
Department of Health
PO Box 1000, Station 1000
Iqaluit, NU X0A 0H0
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Access the document here.
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