In a letter issued on January 10, addressed to provincial and territorial Ministers of Health, the federal Minister, Mark Holland, announced that a new “CHA [Canada Health Act] Services Policy” (the “Policy”) will come into effect in April 2026. When the Policy is implemented, “patient charges for medically necessary services, whether provided by a physician or other health care professional providing physician-equivalent services, will be considered extra-billing and user charges under the CHA.”
The impetus for the Policy is that with the expansion in their scopes of practice, many regulated health professionals, such as nurse practitioners, are charging for medically necessary services that, if provided by a physician, would normally be insured under provincial and territorial plans. According to the letter, the Minister wants “to ensure access to these services remains based on medical need, and not a patient’s ability or willingness to pay.” He notes that the purpose of the Policy is “not to expand the core basket of services insured under the CHA. It is, instead, to maintain the basket by ensuring patients are not charged for services that would otherwise be provided without charges if delivered by a physician.”
The letter refers to the Extra-billing and User Charges Information Regulations (the “Regulations”) under the CHA. Under the Regulations, the federal Minister can require a provincial government to provide information about extra-billing and user charges in the province. (Under the CHA, the federal government is required to withhold funding to provinces on a dollar-for-dollar basis if they allow extra-billing or user charges.) The letter says that provinces and territories will not have to report patient charges under the Policy until December 2028. But, the Minister adds, since the goal of the CHA is not to levy penalties but rather to ensure access to medically necessary care, “any deductions made under the policy will be eligible for reimbursement under the CHA Reimbursement Policy, once patient charges and the circumstances that led to them are eliminated.”
The letter also makes reference to a practice that has developed of patients in one province travelling to another province to obtain surgery for a fee. Although the Minister expresses concern that this could “undermine the fundamental principle of Medicare, where access to care should be based on health need rather than the ability or willingness to pay”, he does not announce any policy or changes to address it, adding only that he has “directed departmental officials to continue working with [provincial and territorial Ministers of Health] to closely monitor this issue.”
Under the CHA as presently worded, the only extra-billing that is prohibited, and that can lead to a reduction in federal funding to a province, is for “insured health services”, meaning “hospital services, physician services and surgical-dental services” that are billed to insured persons by “medical practitioners or dentists”, with “medical practitioner” being defined as “a person lawfully entitled to practise medicine in the place in which the practice is carried on by that person.” Nurse practitioners are not physicians and are not generally referred to as practising medicine.
It remains to be seen whether the federal government intends to amend the CHA to add to the definition of “insured health services” and to include nurse practitioners along with physicians and dentists. The letter is silent on the point and since Parliament has been prorogued, it will likely fall to the next government to enact any legislative changes required by the Policy.
Of course, a province can choose to include the services of nurse practitioners under its health insurance plan, and to bar them from charging patients for their services, if the province chooses to do so. But if a province chooses not to incur the added cost of doing so, and the CHA is not amended, will the federal government be able to enforce the Policy against that province? It will be interesting to see how this develops.
The Fasken Health Law team remains available to discuss the impact of the letter on your business.
