Out-of-Country Health Services Regulation

(Consolidated up to 291/2025) ALBERTA REGULATION 78/2006 Alberta Health Care Insurance Act OUT‑OF‑COUNTRY HEALTH SERVICES REGULATION Table of Contents 1 Interpretation 2 Application 3 OOCHSC continued 4 Members 5 Quorum and voting 6 Functions of OOCHSC 7 Screening of application 8 Review and decision of OOCHSC 9 Payment by Minister 10 Appeal of Chair or OOCHSC decision 11 Appeal Panel 12 Majority decision 13 Appeal Panel reviews of Chair decisions 13.01 Appeal Panel reviews of OOCHSC decisions 13.1 Transitional 14 Expiry Interpretation 1 (1) In this Regulation, (a) “Appeal Panel” means the Out‑of‑Country Health Services Appeal Panel continued under section 11; (a.1) “business day” means a day that is not a Saturday, a Sunday, a holiday or a day when Government of Alberta offices are closed as part of the Government of Alberta’s Christmas closure; (b) “Chair”, except in sections 11 and 12, means the chair of the Out-of-Country Health Services Committee; (c) “dependant” means dependant as defined in the Alberta Health Care Insurance Regulation ; (d) “elective services” means insured health services and insured hospital services that are pre‑authorized, medically required, not available inside Canada and provided in a manner that accords with accepted standards of practice in Alberta of the profession of the practitioner concerned; (d.1) “emergency services” means insured health services and insured hospital services that are provided in the case of an emergency resulting from an acute and unexpected illness, disease, condition or injury that requires medically required treatment without delay outside Canada; (e) repealed AR 291/2025 s14; (f) “OOCHSC” means the Out-of-Country Health Services Committee continued under section 3. (2) For the purposes of this Regulation, a service is available in Canada if a resident could have obtained the service in Canada within the time period generally accepted as reasonable by the medical or dental profession for any resident with a similar condition. AR 78/2006 s1;24/2021;291/2025 Application 2 (1) Subject to subsections (2) and (3), an application may be submitted to the OOCHSC for approval of the payment for expenses with respect to insured health services or insured hospital services received outside Canada where (a) the resident or the resident’s dependant who has or will receive the services is registered and eligible for coverage under the Alberta Health Care Insurance Plan, (b) the resident or the resident’s dependant has endeavoured to receive the services in Canada, the services are not available in Canada and all other appropriate options in Canada have been exhausted, (c) the services are medically necessary, (d) the services are insured under the Alberta Health Care Insurance Plan, (e) the services will be provided in a manner that accords with accepted standards of practice in Alberta, and (f) the services are not part of a research study or clinical trial, and are not an experimental service. (2) An application may only be submitted under subsection (1) with respect to insured health services or insured hospital services for (a) elective services, if the application is submitted prior to receiving the services, or (b) emergency services, if the application is submitted (i) prior to receiving the services, or (ii) not later than 365 days after the services were received. (3) An application under subsection (1) must (a) be in writing in a form established by the OOCHSC, (b) contain any information required under section 7(1)(b), and (c) be submitted on the resident’s behalf or the resident’s dependant’s behalf by (i) a physician registered under the Health Professions Act , if the services are insured medical services referred to in the Medical Benefits Regulation (AR 84/2006) or insured hospital services, or (ii) a dentist registered under the Health Professions Act , if the insured health services are oral and maxillofacial surgery services referred to in the Oral and Maxillofacial Surgery Benefits Regulation (AR 86/2006). (4) If an application has not been declared complete by the Chair under section 7(3)(a) within 365 days of when the services were received, the OOCHSC shall not consider the application. AR 78/2006 s2;80/2011;24/2021;291/2025 OOCHSC continued 3 The Out‑of‑Country Health Services Committee established under the Alberta Health Care Insurance Regulation (AR 216/81) is continued. Members 4 (1) The OOCHSC consists of the following members appointed by the Minister: (a) 4 physicians; (b) an employee of the Department of Primary and Preventative Health Services. (2) The term of a member appointed under subsection (1)(a) shall not exceed 3 years, and the member is eligible for reappointment. (3) The person referred to in subsection (1)(b) is the Chair. (4) The Minister may designate an employee of the Department of Primary and Preventative Health Services as an alternate for the member referred to in subsection (1)(b) to act as Chair in the place of that member when that member is temporarily absent or unable to act. (5) Members of the OOCHSC who are not employees of the Department of Primary and Preventative Health Services are entitled to (a) $525 for up to and including four hours in any day and $131 for each additional hour or part of an hour in the day spent on the business of the OOCHSC, and (b) travelling and living expenses in accordance with Schedule 1, Part A of the Committee Remuneration Order . AR 78/2006 s4;240/2008;170/2012;158/2025 Quorum and voting 5 (1) The quorum for the purpose of meetings of the OOCHSC is 3 members, one of whom must be the Chair. (2) The Chair is a non‑voting member of the OOCHSC. (3) A tie vote on a matter is deemed to be a vote against the matter. (4) A decision made by the majority of the members of the OOCHSC who are present at a meeting is, if the members present constitute a quorum, deemed to be a decision of the OOCHSC. Functions of OOCHSC 6 (1) The OOCHSC shall review, evaluate and decide on all applications submitted under section 2 that are declared to be complete by the Chair under section 7. (2) The OOCHSC shall, on the request of the Minister, (a) submit reports to the Minister on its activities, and (b) carry out any other activities related to insured health services and insured hospital services that the Minister considers appropriate. AR 78/2006 s6;24/2021;291/2025 Screening of application 7 (1) When an application under section 2 is received by the OOCHSC, the Chair shall conduct an initial screening of the application to ensure that the application (a) was not submitted more than 365 days after the service was received, (a.1) was submitted on behalf of a person who is registered and eligible for coverage under the Alberta Health Care Insurance Plan, (a.2) was submitted by (i) a physician registered under the Health Professions Act , if the services are insured medical services referred to in the Medical Benefits Regulation (AR 84/2006) or insured hospital services, or (ii) a dentist registered under the Health Professions Act , if the insured health services are oral and maxillofacial surgery services referred to in the Oral and Maxillofacial Surgery Benefits Regulation (AR 86/2006), and (b) contains any other information, including health information, that the Chair considers to be required for the proper review by the OOCHSC. (2) In carrying out the initial screening of an application under subsection (1), the Chair, or the person designated by the Chair for that purpose, may conduct any independent investigation that may be considered necessary in order to complete the initial screening of an application. (3) After the Chair has concluded the initial screening of an application, (a) if the Chair is satisfied that the application meets the requirements set out in subsection (1), the Chair may declare the application complete and forward that application to the OOCHSC for review, or (b) if the Chair is not satisfied that the application meets the requirements set out in subsection (1), the Chair may (i) deny the application, or (ii) hold the application, return a copy of the application to the applicant and provide the applicant with the opportunity to remedy a deficiency in the application. (4) The Chair shall, within 20 business days of making a decision under subsection (3), send (a) a written copy of its decision with reasons to the Minister, the resident and the physician or dentist who submitted the application on the resident’s or the resident’s dependant’s behalf, and (b) notice of the right to appeal the decision to the resident and the physician or dentist who submitted the application on the resident’s or the resident’s dependant’s behalf. AR 78/2006 s7;80/2011;24/2021;291/2025 Review and decision of OOCHSC 8 (1) Within 60 business days from the date that the Chair has declared under section 7 that an application is complete, the OOCHSC shall decide (a) whether the services referred to in the application are insured health services or insured hospital services, (b) whether to approve payment with respect to insured health services and insured hospital services received or to be received outside of Canada, and (c) whether, in respect of insured health services and insured hospital services received or to be received outside of Canada, to impose conditions on payment. (2) In making a decision under subsection (1), the OOCHSC may not approve payment for (a) subsistence and accommodation costs of the person receiving insured health services or insured hospital services outside of Canada or of anyone who accompanies that person, (b) insured health services or insured hospital services provided outside Canada if the services are available in Canada, and (c) services that the OOCHSC decides are experimental or applied research. (3) The OOCHSC may, if it considers it to be advisable or necessary, consult with health specialists in respect of the matter under its consideration before it renders its decision under subsection (1). (4) Where the OOCHSC consults with a health specialist under subsection (3), the Minister may pay that health specialist an appropriate fee in respect of that consultation. (5) The OOCHSC shall, within 20 business days of making a decision under subsection (1), send (a) a written copy of its decision with reasons to the Minister, the resident and the physician or dentist who submitted the application on the resident’s or the resident’s dependant’s behalf, and (b) notice of the right to appeal the decision to the resident and the physician or dentist who submitted the application on the resident’s or resident’s dependant’s behalf. AR 78/2006 s8;80/2011;24/2021;291/2025 Payment by Minister 9 If the OOCHSC approves an application for payment under section 8, the Minister shall pay for those services approved by the OOCHSC. Appeal of Chair or OOCHSC decision 10 The resident or a physician or dentist acting on the resident’s or resident’s dependant’s behalf may appeal a decision of the Chair under section 7 or a decision of the OOCHSC under section 8 to the Appeal Panel by submitting a notice of appeal to the Appeal Panel within 60 business days of receipt of the decision. AR 78/2006 s10;80/2011;24/2021 Appeal Panel 11 (1) The Out‑of‑Country Health Services Appeal Panel established under the Alberta Health Care Insurance Regulation (AR 216/81) is continued. (2) The Appeal Panel consists of 6 members appointed by the Minister, of which 4 must be physicians, one must be an ethicist and one must be a member of the general public. (3) The term of the members referred to in subsection (2) shall not be more than 3 years, and those members are eligible for reappointment. (4) The Minister may designate a member of the Appeal Panel as the chair and a member of the Appeal Panel as the vice‑chair. (5) A quorum of the Appeal Panel consists of 3 members, 2 of whom must be physicians, and one of whom must be either the ethicist or the member of the general public. (6) Members of the Appeal Panel who are not employees of the Government are entitled to, (a) in the case of the chair who is a physician, (i) $790 for up to and including four hours in any day and $197 for each additional hour or part of an hour in the day spent on the business of the Appeal Panel, and (ii) travelling and living expenses in accordance with Schedule 1, Part A of the Committee Remuneration Order , (a.1) in the case of a member who is a physician, (i) $525 for up to and including four hours in any day and $131 for each additional hour or part of an hour in the day spent on the business of the Appeal Panel, and (ii) travelling and living expenses in accordance with Schedule 1, Part A of the Committee Remuneration Order , and (b) in the case of a member who is not a physician, (i) remuneration in accordance with the Committee Remuneration Order at 1.5 times the rate set out in Schedule 1, Part A of that Order, and (ii) travelling and living expenses in accordance with Schedule 1, Part A of the Committee Remuneration Order . AR 78/2006 s11;240/2008;69/2009 Majority decision 12 (1) The chair and the vice‑chair of the Appeal Panel are voting members of the Appeal Panel. (2) A decision of the majority of the members of the Appeal Panel who review the appeal is deemed to be a decision of the Appeal Panel. (3) A tie vote on a matter is deemed to be a vote against the matter. Appeal Panel reviews of Chair decisions 13 (1) The Appeal Panel shall review the application and the decision of the Chair made under section 7 if a notice of appeal is received within 60 business days of the appellant receiving the decision under section 7. (2) In reviewing a decision of the Chair, the Appeal Panel shall review only the application, the written decision and reasons and the matters before the Chair, and shall not review any new evidence. (3) An appeal must be reviewed and a decision made within 60 business days of receipt of a notice of appeal. (4) The Appeal Panel may confirm the decision of the Chair or, if the Appeal Panel determines that the Chair erred in its decision, return the application to the Chair for reconsideration in accordance with the directions of the Appeal Panel. (5) The Appeal Panel shall, within 20 business days of making a decision under this section, send a copy of its decision with reasons to (a) the Minister, (b) each member of the OOCHSC, (c) the resident, and (d) if the notice of appeal was submitted by a physician or dentist on the resident’s or resident’s dependant’s behalf, that physician or dentist. AR 78/2006 s13;80/2011;24/2021 Appeal Panel reviews of OOCHSC decisions 13.01 (1) The Appeal Panel shall review the application and a decision of the OOCHSC if a notice of appeal is received within 60 business days of the appellant receiving the decision under section 8(5). (2) In reviewing the OOCHSC’s decision, the Appeal Panel shall review only the application, the written decision and reasons and the matters before the OOCHSC, and shall not review any new evidence. (3) An appeal must be reviewed and a decision made within 60 business days of receipt of a notice of appeal. (4) The Appeal Panel may confirm or vary the decision of the OOCHSC or substitute its decision for the OOCHSC’s decision. (5) If the Appeal Panel confirms, varies or substitutes its decision for the OOCHSC’s decision regarding approving the payment of services, the Minister shall pay for those services approved by the Appeal Panel. (6) The Appeal Panel shall, within 20 business days of making a decision under this section, send a copy of its decision with reasons to (a) the Minister, (b) each member of the OOCHSC, (c) the resident, and (d) if the notice of appeal was submitted by a physician or dentist on the resident’s or resident’s dependant’s behalf, that physician or dentist. AR 24/2021 s8 Transitional 13.1 (1) Where (a) a person has (i) made an application to the OOCHSC, or (ii) submitted a notice of appeal to the Appeal Panel, and a decision has not been rendered respecting the application or notice of appeal on the coming into force of this section, or (b) the time for submitting a notice of appeal has not expired on the coming into force of this section, the application or appeal, if any, must be dealt with or continue to be dealt with in accordance with this Regulation as it read immediately before August 1, 2011. (2) Where, prior to the coming into force of this subsection, (a) a person (i) who is a physician registered under the Health Professions Act or a dentist registered under the Health Professions Act has made an application to the OOCHSC, or (ii) has submitted a notice of appeal to the Appeal Panel, and a decision, other than a decision by the Chair to forward the application to the OOCHSC, has not been rendered respecting the application, or a decision has not been made by the Appeal Panel respecting the notice of appeal, or (b) the time for submitting a notice of appeal has not expired, the application or appeal, if any, must be dealt with or continue to be dealt with in accordance with this Regulation as it read immediately before the coming into force of this subsection. (3) For greater certainty, (a) section 10 does not apply with respect to a decision of the Chair under section 7 if the application was received prior to the coming into force of this subsection, and (b) Section 13 does not apply with respect to a decision of the Chair if the application was received prior to the coming into force of this subsection. AR 80/2011 s7;24/2021 Expiry 14 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 November 30, 2028. AR 78/2006 s14;5/2016;135/2017;24/2021;262/2022