Medical Services (POC 6)

Issuing Authority: Director General, Policy and Research
Effective Date: April 1, 2019
Document ID: 1215

Care has been taken to ensure these policies accurately reflect the acts and regulations. Should any inconsistencies be found, the acts and regulations will prevail.

Purpose

This policy provides direction on the approval of medical services to eligible clients.

Policy

  1. Veterans Affairs Canada (VAC) may pay for medical services provided to eligible clients.
  2. Medical Services encompass the full range of medically-necessary procedures, actions, and processes within a provincially/territorially-established scope of practice for physicians, including medical assessments, diagnostic services, examinations, treatments, consultations or reports requested by the Department. The provision of services by other regulated health care professionals is covered within other applicable Programs of Choice (POC) (i.e. POC 8, nursing services, POC 12, occupational therapist, psychologist, chiropractor, etc.).
  3. The full range of medical and surgical services provided by physicians (including specialists) on an in-or out-patient basis is available to eligible clients on referral from their family doctor.

Eligibility

  1. See Eligibility for Heath Care Programs – Eligible Client Groups for information on eligibility for Treatment Benefits.
  2. Clients eligible for rehabilitation services under the Veterans Well-being Act may receive medical services on a case by case basis as required to meet the goals of a client’s rehabilitation plan.
  3. For Rehabilitation Program clients, in order to be considered an eligible rehabilitation service, the object of the medical services for which funding approval is being sought must be to stabilize and restore basic physical and/or psychological functions as related to:
    1. A health problem that results primarily from service and that is creating a barrier to re-establishment in civilian life; or
    2. The physical or mental health problem for which the Veteran was medically released.
  4. The medical service must also be determined appropriate to achieve a rehabilitation goal. The Rehabilitation decision maker will be responsible for determining and authorizing rehabilitation eligibility for POC 6 benefits for Rehabilitation Program clients.
  5. Authorization of all medical services requires a solid rationale to support the decision to approve payment of these services. Rationale is also required to ensure that the intervention will not pose a risk to the client’s health, well-being or progress. The need and legitimacy of the service must be confirmed by the decision maker as being appropriate in each particular case based on the evidence available.

Physicians Outside Provincial Insurance Plans

  1. In some provinces, physicians are not prohibited from providing medical services outside provincial health insurance plans, with the understanding that, in such cases, the province is not responsible for any part of the payment to the physician. These physicians generally charge their patients in excess of the rate that would be paid for the service under the provincial medical insurance plan. This differs from the provincially-prohibited practice of “extra billing” where the province pays the health insurance plan rate, and the physician levies an additional charge to be paid by the patient.
  2. The Department is responsible for treatment for a condition for which entitlement to a disability pension, disability award or pain and suffering compensation has been granted. If this treatment is provided by a physician practicing outside the provincial health insurance plan, payment may be made up to, but not exceeding, the rate outlined in the provincial medical association’s fee schedule for the service(s) rendered. (see Rates Payable for Treatment Benefits policy for additional information.)
  3. A client requiring treatment for a condition not related to a disability benefits entitled condition or the condition for which they were determined eligible for rehabilitation is required to access provincially-insured health services.

Out of Province/Territory Medical Services

  1. A client may receive medical services (including specialist services) outside their province/territory of residence when:
    1. Referred by their family doctor or a medical specialist; and
    2. The required service is not available in the province/territory in which they reside.
  2. In such cases, the Department will pay the reasonable costs of all required out of province/territory medical and hospital services incurred by the client (e.g. the costs not covered by the health insurance plan of the client’s province/territory of residence).
  3. The referring physician is responsible for making arrangements with the out of province/territory physician or hospital for the medical services to be provided to the client.

Qualifications

  1. As with other health professionals for whom VAC authorizes payment, physicians must be registered in the province/territory in which the services are provided.

Medical Services for Pensioners Travelling or Living Outside Canada

  1. Clients in receipt of disability benefits travelling or living outside Canada are eligible to receive pension-related medical services, in addition to all other pension-related treatment benefits, in the country in which they are travelling or living. Treatment benefits for non pension-related conditions are not provided outside Canada.

Medical Services for Rehabilitation Clients Living Outside Canada

  1. Rehabilitation clients who live outside of Canada are eligible for rehabilitation services including medical services that are required to stabilize and restore basic physical and psychological functions in accordance with the goals and objectives of their rehabilitation plan.

Medical Assessments for Rehabilitation Clients

  1. Medical assessments may begin in conjunction with Rehabilitation Program eligibility decisions and may occur throughout the duration of the rehabilitation plan to assess the physical or mental health problem, the impact of the problem on function, medical improvement and readiness to return to work.
  2. The use of medical assessments for rehabilitation clients must be focussed on the health problem for which the client was medically released or the health problem(s) that resulted primarily from service and that are creating a barrier to re-establishment.
  3. Medical assessments can include, but are not limited to, physical examinations, diagnostic screenings/tests and functional assessments.
  4. The rate of payment for assessment services must be in accordance with the provincial medical association’s fee schedule for the service(s) rendered.

References

Veterans Well-being Act, sections 8 - 17 and sections 73 & 75.

Veterans Health Care Regulations, sections 3(3), 4, 5 and 13

Treatment for a Disability Benefits Entitled Condition

Hospital Services (POC 5)

Rates Payable for Treatment Benefits

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