Qp Date
This Act has "Not in Force" sections. See the Table of Legislative Changes.

Medicare Protection Act

[RSBC 1996] CHAPTER 286

Contents
1Definitions
2Purpose
Part 1 — Medical Services Commission
3Commission and Medical Services Plan
4Special committees respecting health care practitioners
5Responsibilities and powers of the commission
5.01Investigations by commission
5.1Guiding principles
5.2Public administration
5.3Comprehensiveness
5.4Universality
5.5Portability
5.6Accessibility
5.7Sustainability
6Power to delegate
Part 2 — Beneficiaries
7Application for enrollment of beneficiaries
7.1Exemptions by commission
7.2Enrollment of beneficiaries
7.3Change of enrollment information
7.4Cancellation of beneficiary enrollment
8Premiums
8.1Interest on late payments of premiums
8.2Certificate of default
9Payments for benefits
10Beneficiary requesting payment
11Order in respect of beneficiary
12Misuse of identity number
Part 3 — Practitioners
13Enrollment of practitioners
13.1Repealed
14Election
15Order in respect of practitioner
16Referral of complaint
Part 4 — Limits on Billing
17General limits on direct or extra billing
18Limits on direct or extra billing by a medical practitioner
19Notice requirement
20Refunds required
20.1Persons acting for beneficiaries
21Civil action
22Agreements
Part 5 — Payments
23Definitions for Part 5
24Limitations on payments
25Available amount
26Payment schedules and benefit plans
27Submission, assessment and payment of claims
28Non-resident benefits
29Payment for services outside British Columbia
30Recovery of money
31Critical care services
32Obligation to remit
Part 6 — Diagnostic Facilities
33Approval of diagnostic facility
34Obligation of practitioner
35Conflict of interest
Part 7 — Audit and Inspection
36Audit and inspection — practitioners and employers
37Orders of the commission
38Settlement of claims ascertained under section 37
39Filing of order
40Audit and inspection — diagnostic facilities
Part 8 — Appeals
41–42Repealed
43Appeals — practitioners and diagnostic facilities
44Repealed
Part 9 — General Provisions
45Private insurers
45.1Injunctions
46Offences
47 Offence Act
47.1Duty to report
48Protection against action
49Duty to keep information confidential
50Delivery of documents
51Power to make regulations

Preamble

WHEREAS the people and government of British Columbia believe that medicare is one of the defining features of Canadian nationhood and are committed to its preservation for future generations;

WHEREAS the people and government of British Columbia wish to confirm and entrench universality, comprehensiveness, accessibility, portability, public administration and sustainability as the guiding principles of the health care system of British Columbia and are committed to the preservation of these principles in perpetuity;

WHEREAS the people and government of British Columbia are committed to building a public health care system that is founded on the values of individual choice, personal responsibility, innovation, transparency and accountability;

WHEREAS the people and government of British Columbia are committed to developing an efficient, effective and integrated health care system aimed at promoting and improving the health of all citizens and providing high quality patient care that is medically appropriate and that ensures reasonable access to medically necessary services consistent with the Canada Health Act;

WHEREAS the people and government of British Columbia wish to ensure that all publicly funded health care services are responsive to patients' needs and designed to foster improvements in individual and public health outcomes and ongoing value-for-money for all taxpayers;

WHEREAS the people and government of British Columbia recognize a responsibility for the judicious use of medical services in order to maintain a fiscally sustainable health care system for future generations;

AND WHEREAS the people and government of British Columbia believe it to be fundamental that an individual's access to necessary medical care be solely based on need and not on the individual's ability to pay.

Definitions

1  In this Act:

"adult" means a person 19 years of age or older;

"appropriate disciplinary body" means the person or body that may cancel or suspend the right to practise under

(a) an enactment, as a chiropractor, a dentist, a medical practitioner, an optometrist or a podiatrist in British Columbia, or

(b) the governing Act, bylaws or rules for a member of the health care profession or occupation prescribed for the purposes of paragraph (b) of the definition of "health care practitioner";

"appropriate licensing body" means the person or body having the power to grant the right to practise as a practitioner under

(a) an enactment, as a chiropractor, a dentist, a medical practitioner, an optometrist or a podiatrist in British Columbia, or

(b) the governing Act, bylaws or rules for a member of the health care profession or occupation prescribed for the purposes of paragraph (b) of the definition of "health care practitioner";

"approved diagnostic facility" means a diagnostic facility approved under section 33;

"beneficiary" means a resident who is enrolled in accordance with section 7.2, and includes the resident's child if the child is enrolled under section 7.2;

"benefits" means

(a) medically required services rendered by a medical practitioner who is enrolled under section 13, unless the services are determined under section 5 by the commission not to be benefits,

(b) required services prescribed as benefits under section 51 and rendered by a health care practitioner who is enrolled under section 13, or

(c) unless determined by the commission under section 5 not to be benefits, medically required services performed

(i)   in an approved diagnostic facility, and

(ii)   by or under the supervision of an enrolled medical practitioner who is acting

(A)  on order of a person in a prescribed category of persons, or

(B)  in accordance with protocols approved by the commission;

"chair", other than with reference to a special committee, means the individual who is appointed under section 3 to chair the commission;

"child" means a person who

(a) is a child of a beneficiary or a person in respect of whom a beneficiary stands in the place of a parent and who

(i)   is a minor,

(ii)   [Repealed 2011-13-108(c).]

(b) does not have a spouse, and

(c) is supported by the beneficiary;

"commission" means the Medical Services Commission continued under section 3;

"diagnostic facility" means a facility, place or office principally equipped for

(a) prescribed diagnostic services, studies or procedures, or

(b) the taking or collecting of specimens for purposes of diagnosis, treatment or prevention of illness, injury or disease

and includes any branches of a diagnostic facility;

"enroll" means,

(a) in respect of a beneficiary, enrollment under section 7.2, and

(b) in respect of a practitioner, enrollment under section 13;

"former Act" means the Medical Service Act, R.S.B.C. 1979, c. 255;

"health care practitioner" means a person entitled to practise as

(a) a chiropractor, a dentist, an optometrist or a podiatrist in British Columbia under an enactment, or

(b) a member of a health care profession or occupation that may be prescribed;

"payment schedule" means a payment schedule established under section 26;

"plan" means the Medical Services Plan continued under section 3;

"practitioner" means

(a) a medical practitioner, or

(b) a health care practitioner

who is enrolled under section 13;

"premium" means an amount prescribed under section 8;

"render" means perform personally by or under the personal supervision of the person to whom reference is being made and "personal supervision" in this context means

(a) in the case of a practitioner, personal supervision authorized by the commission in the circumstances, and

(b) in the case of a medical practitioner or health care practitioner who is not enrolled, personal supervision acceptable to the appropriate disciplinary body for the medical practitioner or health care practitioner;

"resident" means a person who

(a) is a citizen of Canada or is lawfully admitted to Canada for permanent residence,

(b) makes his or her home in British Columbia, and

(c) is physically present in British Columbia for

(i)   at least 6 months in a calendar year, or

(ii)   a shorter prescribed period,

and includes a person who is deemed under the regulations to be a resident but does not include a tourist or visitor to British Columbia;

"special committee" means a special committee established under section 4;

"spouse" means a resident who

(a) is married to another person, or

(b) is living with another person in a marriage-like relationship.

Purpose

2  The purpose of this Act is to preserve a publicly managed and fiscally sustainable health care system for British Columbia in which access to necessary medical care is based on need and not an individual's ability to pay.

Part 1 — Medical Services Commission

Commission and Medical Services Plan

3  (1) The Medical Services Commission is continued consisting of 9 members appointed by the Lieutenant Governor in Council as follows:

(a) 3 members appointed from among 3 or more persons nominated by the British Columbia Medical Association;

(b) 3 members appointed on the joint recommendation of the minister and the British Columbia Medical Association to represent beneficiaries;

(c) 3 members appointed to represent the government.

(2) The commission reports to the minister.

(3) The Medical Services Plan established under the former Act is continued and the function of the commission is to facilitate, in the manner provided for in this Act, reasonable access, throughout British Columbia, to quality medical care, health care and diagnostic facility services for residents of British Columbia under the Medical Services Plan.

(4) The Lieutenant Governor in Council must designate a member of the commission appointed under subsection (1) (c) as its chair and may designate another member of the commission as its deputy chair.

(5) The chair of the commission must call a meeting at least once every 2 months and, by giving written notice to the chair, 3 or more members of the commission can require the chair to call a meeting.

(6) In the event that a member of the commission is absent for more than 3 consecutive meetings of the commission, the member ceases to be a member of the commission.

(7) Despite subsection (6) the commission may waive this requirement with the agreement of a majority of the commission.

(8) Each member of the commission has one vote.

(9) Decisions of the commission are on the agreement of the majority of members present at a meeting.

(10) If the commission is not meeting, the chair may exercise a power, duty and function that the commission may exercise unless the commission has directed that the chair is not to exercise the power, duty or function.

(11) The commission may sue or be sued in its own name or in the name of the government in any civil action respecting the commission or a special committee, but any proceeding by or against the commission is binding on the government, and the Crown Proceeding Act applies accordingly.

(12) Members of the commission or a special committee who are not public servants are entitled to receive reimbursement for expenses, remuneration and benefits set by the Lieutenant Governor in Council.

(13) The Lieutenant Governor in Council may appoint a public administrator to discharge the powers, duties and functions of the commission under this Act if the Lieutenant Governor in Council considers this necessary in the public interest.

(14) On the appointment of a public administrator under subsection (13), the members of the commission cease to hold office unless otherwise ordered by the Lieutenant Governor in Council.

Special committees respecting health care practitioners

4  (1) After consultation with the appropriate licensing body, the Lieutenant Governor in Council may establish one or more special committees to exercise the powers, duties or functions of the commission under this Act that are specified by the Lieutenant Governor in Council for a body of health care practitioners.

(2) A special committee established under subsection (1) is composed of the persons the Lieutenant Governor in Council specifies and exercises its powers, duties or functions on the terms and conditions the Lieutenant Governor in Council specifies.

(3) A special committee established under subsection (1) may establish a panel and the powers, duties and functions of the special committee may be exercised, subject to the regulations, by the panel.

(4) A power, duty or function given under subsection (1) to a special committee may continue to be exercised by the commission unless the Lieutenant Governor in Council directs that the commission not exercise the power, duty or function.

(5) A power, duty or function given under subsection (1) to one special committee may also be given under subsection (1) to another special committee.

(6) The Lieutenant Governor in Council must designate the chair of each special committee and may designate a deputy chair of each special committee.

Responsibilities and powers of the commission

5  (1) The commission may do one or more of the following:

(a) administer this Act on a non-profit basis;

(b) receive premiums that are payable by beneficiaries;

(c) determine the services rendered by an enrolled medical practitioner, or performed in an approved diagnostic facility, that are not benefits under this Act;

(d) determine the manner by which claims for payment of benefits rendered in or outside British Columbia to beneficiaries are made;

(e) determine the information required to be provided by beneficiaries and practitioners for the purpose of assessing or reassessing claims for payment of benefits rendered to beneficiaries;

(f) investigate and determine whether a person is a resident and, for this purpose, require the person to provide the commission with evidence, satisfactory to the commission, that residency has been established;

(g) determine whether a person is a spouse or a child;

(g.1) determine whether a person is a member of a prescribed class;

(h) determine whether a person is a medical practitioner or a health care practitioner;

(i) determine for the purposes of this Act whether a person meets the requirements established in the regulations for premium assistance;

(j) determine whether a service is a benefit or whether any matter is related to the rendering of a benefit;

(k) determine before or after a service is rendered outside British Columbia whether the service would be a benefit if it were rendered in British Columbia;

(l) determine whether a diagnostic facility, or a benefit performed in an approved diagnostic facility, meets the requirements of the regulations;

(m) monitor and assess the effectiveness and efficiency of benefits;

(n) enter, with the prior approval of the Lieutenant Governor in Council, into agreements on behalf of the government with Canada, a province, another jurisdiction in or outside Canada or a person in or outside British Columbia for the purposes of this Act;

(o) establish advisory committees, including pattern of practice committees, to advise and assist the commission in exercising its powers, functions and duties under this Act, and may remunerate members of a committee at a rate fixed by the commission and pay reasonable and necessary travelling and living expenses incurred by members of a committee in the performance of their duties;

(p) authorize surveys and research programs to obtain information for purposes related to the provision of benefits;

(q) enter into arrangements and make payment for the costs of rendering benefits that will be provided on a fee for service or other basis;

(q.1) establish, subject to this Act and the regulations, rules to govern its own practices and procedures for the conduct of hearings under section 15 or 37, including the following:

(i)   the conduct of negotiations or a pre-hearing conference for possible settlement of the issues before a hearing is commenced;

(ii)   the means by which particular facts may be proved or the mode in which evidence may be given at a pre-hearing conference or a hearing;

(iii)   the time limits for the exchange of documents, reports and affidavits in preparation for a pre-hearing conference or a hearing;

(iv)   the requirements for the attendance of witnesses, the conduct of witnesses or the compelling of witnesses to give evidence under oath or in some other manner;

(q.2) require that a party to a hearing under section 15 or 37 submit a matter at issue in the hearing to non-binding mediation;

(r) provide to a person or body prescribed by the Lieutenant Governor in Council, for the purpose of an audit or investigation of a practitioner's pattern of practice or billing, information concerning claims submitted by that practitioner to the commission;

(s) apply section 26 for supply management and optimum distribution of medical care, health care and diagnostic services throughout British Columbia;

(t) establish guidelines setting the number of practitioners that a beneficiary may consult respecting the same medical condition within the period specified in the guidelines;

(u) exercise other powers or functions that are authorized by the regulations or the minister.

(2) The commission must not act under subsection (1) in a manner that does not satisfy the criteria described in section 7 of the Canada Health Act.

(3) For the purposes of a hearing under this Act, sections 34 (3) and (4), 48 and 49 of the Administrative Tribunals Act apply to the commission.

(4) The Financial Administration Act applies to the commission as though the commission were a division of the ministry that is administered by the minister.

(5) Without limiting subsection (1) (n), the commission may, with the prior approval of the Lieutenant Governor in Council, enter into an information-sharing agreement with

(a) Canada, a province or another jurisdiction in or outside Canada, or

(b) a public body as defined in the Freedom of Information and Protection of Privacy Act.

(6) For the purpose of subsection (5), "information-sharing agreement" means a data-matching or other agreement to exchange personal or other information for the purpose of administering medical or health care benefits provided under

(a) this Act,

(b) a prescribed enactment of British Columbia, or

(c) a prescribed enactment of Canada, a province or another jurisdiction in Canada.

(6.1) If the commission enters into an information-sharing agreement under subsection (5), the commission may, in accordance with the agreement, collect and use personal information from, and disclose personal information to, the party with whom the agreement was made.

(7) The commission must prepare and file with the minister as soon as practicable each year a report for the fiscal year ending March 31 in that year respecting the work of the commission and its special committees, and the minister must lay the report before the Legislative Assembly as soon as is practicable.

Investigations by commission

5.01  The commission may investigate for the purposes of this Act, including for the purpose of determining whether there is cause within the meaning of section 11 (1) (a), (b), (c) or (c.1).

Guiding principles

5.1  In performing its responsibilities and exercising its powers under section 5 (1) and in performing its responsibilities under section 5 (2), in addition to taking into account any broad policy issues and other matters the commission considers relevant, the commission must have regard to the following principles, as set out in sections 5.2 to 5.7:

(a) the principles established under the Canada Health Act as the criteria for a province to qualify for a full cash contribution for a fiscal year, those principles being public administration, comprehensiveness, universality, portability and accessibility;

(b) the principle of sustainability.

Public administration

5.2  The plan is publicly funded and operated on an accountable basis.

Comprehensiveness

5.3  The plan includes as benefits

(a) all medically required services provided by enrolled medical practitioners,

(b) all required services provided by enrolled health care practitioners and prescribed as benefits under section 51,

(c) benefits that are performed in approved diagnostic facilities, and

(d) any benefits that are performed by practitioners in a health facility that has entered into an agreement with one or more regional health boards designated under the Health Authorities Act or with the Provincial Health Services Authority, in accordance with the agreement.

Universality

5.4  The plan applies to 100% of beneficiaries on uniform terms and conditions.

Portability

5.5  The plan applies to the following individuals:

(a) beneficiaries who are temporarily absent from British Columbia or moving to another province;

(b) eligible individuals who are moving to British Columbia;

(c) eligible individuals visiting British Columbia from another province that has entered into a reciprocal agreement with British Columbia for medical and health care services, in accordance with that agreement.

Accessibility

5.6  The plan provides benefits on uniform terms and conditions on a basis that does not impede or preclude reasonable access to benefits by beneficiaries.

Sustainability

5.7  The plan is administered in a manner that is sustainable over the long term, providing for the health needs of the residents of British Columbia and assuring that annual health expenditures are within taxpayers' ability to pay without compromising the ability of the government to meet the health needs and other needs of current and future generations.

Power to delegate

6  (1) In this section, "panel" means a panel of 3 or more persons who are appointed by the commission and who represent each of the following:

(a) the British Columbia Medical Association;

(b) beneficiaries;

(c) government.

(2) The commission may delegate any of the commission's or the chair's powers or duties, except those under section 11 (2), 15 (2), 24, 25, 26, 33 (4) or 37 (1), to a person or panel.

(3) The commission may delegate powers or duties under section 11 (2), 15 (2), 33 (4) or 37 (1) but only to a panel selected by the commission.

Part 2 — Beneficiaries

Application for enrollment of beneficiaries

7  (1) A resident must apply to the commission

(a) for enrollment as a beneficiary, if not already enrolled, and

(b) for enrollment of each of the resident's children as a beneficiary if the child

(i)   is a resident, and

(ii)   is not already enrolled, or does not already have someone applying for enrollment on the child's behalf.

(2) Unless exempted under this Act, an adult resident must apply to the commission, within the prescribed period or at the prescribed time, to renew the resident's enrollment as a beneficiary.

(3) Subsections (1) (a) and (2) do not apply to an adult resident who submits, or has submitted, a statement to the commission in the manner required by the commission stating that the resident does not want to be enrolled as a beneficiary.

(4) A statement under subsection (3) may not be submitted for the purpose of requesting that a child described by subsection (1) (b) not be enrolled.

(5) Applications under this section must

(a) be made in the prescribed manner, and

(b) be accompanied by proof of identity and residency in accordance with the regulations.

Exemptions by commission

7.1  (1) Subject to subsection (2), the commission may exempt a person from one or more of the following requirements:

(a) to renew enrollment under section 7 (2);

(b) to renew enrollment within the prescribed period or at the prescribed time;

(c) to provide proof of identity or residency for the purposes of enrollment or renewal of enrollment.

(2) Before making an exemption, the commission must be satisfied that

(a) the person is, or is likely, a resident, and

(b) the exemption is necessary because compliance with a requirement referred to in subsection (1) is impractical or would cause undue hardship in the circumstances.

(3) The commission may, in making an exemption,

(a) make an alternative requirement, or

(b) attach limits or conditions to the exemption.

Enrollment of beneficiaries

7.2  (1) After confirming the identity and determining the residency of

(a) an applicant under section 7 (1) or (2), and

(b) each of the applicant's children named in the application,

the commission must enroll as beneficiaries those covered by the application who are residents.

(2) After confirming the identity and determining the residency of a child, the commission may, at any time, enroll as a beneficiary a child who is a resident.

(3) Enrollment is effective on the date stated by the commission, that date being

(a) on or before the date on which the application under section 7 (1) or (2) was made, or

(b) not more than 3 months after receipt of the application.

(4) The commission must not enroll a person as a beneficiary for a prescribed period from the date that the commission

(a) receives a statement under section 7 (3) from the person, or

(b) cancels the enrollment of the person under section 7.4 (1) (a).

(5) The following persons must pay to the commission the applicable premiums:

(a) a beneficiary;

(b) a person who is required to renew the person's enrollment as a beneficiary under section 7 (2).

Change of enrollment information

7.3  A beneficiary must, within 10 days of the change, provide the commission with the beneficiary's former and new

(a) addresses, if the beneficiary's address changes, or

(b) names, if the beneficiary's name changes.

Cancellation of beneficiary enrollment

7.4  (1) The commission may cancel the enrollment of a beneficiary as follows:

(a) on application by an adult beneficiary, effective on a date subsequent to the date of the application as determined by the commission;

(b) if the commission believes the beneficiary has ceased to be a resident, effective on the date the commission determines to have been the date that the beneficiary ceased to be a resident;

(c) if the commission determines that the beneficiary was not eligible for enrollment, effective on the date of enrollment as a beneficiary.

(2) Subsection (1) (a) does not apply for the purpose of requesting that the enrollment of a child described by section 7 (1) (b) be cancelled.

(3) If a beneficiary does not apply to renew enrollment in accordance with section 7 (2), the beneficiary's enrollment is cancelled effective on the date by which the beneficiary was required by the regulations to renew.

Premiums

8  (1) The Lieutenant Governor in Council may prescribe premium rates.

(2) The rates may be different for different categories of persons, as defined in the regulations.

(3) The regulations may provide that, in respect of a category of persons as defined in the regulations, no premiums are payable.

(4) A premium that has not been paid during any period in which

(a) a beneficiary has been enrolled, or

(b) a person who was required to renew the person's enrollment as a beneficiary under section 7 (2) was not enrolled

may be recovered by the commission as a debt owing to the commission.

(5) If a person paid premiums for a period after which cancellation under section 7.4 (1) or (3) of that person's enrollment as a beneficiary took effect, the commission may, if the commission believes it to be in the public interest, refund all or part of the amount of those premiums to the person who paid them.

Interest on late payments of premiums

8.1  If payments under section 7.2 (5) are not made in the prescribed manner and within the prescribed time, the person liable to make these payments is also liable to pay the commission interest at the prescribed rate on these payments.

Certificate of default

8.2  (1) If a person defaults in the payment of part or all of the premiums, including any interest on premiums, payable under this Act, the commission may issue a certificate in the prescribed form stating

(a) that payment is in default,

(b) the amount remaining unpaid, including interest, and

(c) the name of the person by whom it is payable.

(2) The commission may file the certificate with a court of competent jurisdiction 30 days after the commission has served the person in default with

(a) a copy of the certificate, and

(b) a notice stating the location of the court where the certificate will be filed.

(3) The documents referred to in subsection (2) (a) and (b) sent by registered mail to the last known address of the person in default are conclusively deemed to be served on the person to whom they are addressed on the earlier of

(a) the 14th day after these documents were deposited with Canada Post, or

(b) the date on which these documents were actually received by the person, whether by mail or otherwise.

(4) An appeal from a certificate filed under subsection (2) lies to the court at the location where the certificate is filed and, if an appeal is commenced, the application of subsection (7) is not stayed unless the court orders otherwise pending the outcome of the appeal.

(5) No appeal referred to in subsection (4) shall be instituted later than 45 days after the filing of the certificate under subsection (2).

(6) An appeal referred to in subsection (4) shall be a trial de novo and the court may make any order it considers just, including an order that the commission amend its certificate.

(7) On being filed, the certificate, including any amendment made under subsection (6) and interest at the prescribed rate referred to in section 8.1 that later accrues on the amount of the payment remaining unpaid, has the same force and effect, and all proceedings may be taken on it, as if it were a judgment of the court in favour of the government for the recovering of a debt against the person named in the certificate.

(8) Section 32 (2) to (4) applies to the amount referred to in subsection (1) (b) stated in a certificate as though

(a) that amount was the premiums referred to in section 32 (2) collected under an agreement referred to in section 32 (1), and

(b) the person named in the certificate was the person referred to in section 32 (2) who collected the premiums.

Payments for benefits

9  Subject to sections 10 (1), 11, 14 and 15, a beneficiary is entitled to have payment made in accordance with amounts in a payment schedule for a benefit that the beneficiary has received and this payment will be

(a) at a reduced rate, if applicable, as provided for under this Act, and

(b) less any applicable patient visit charge.

Beneficiary requesting payment

10  (1) If a beneficiary receives benefits from a practitioner who has

(a) made an election under section 14 (1), or

(b) been the subject of an order made under section 15 (2) (b),

or if a beneficiary is enrolled or reinstated retroactively after receipt of benefits, the beneficiary may submit the claim form, completed as required by section 14 (9), and any other prescribed or required information to the commission for payment of the amount that would otherwise be payable to the practitioner.

(2) After assessing the claim under section 27 (2), the commission may pay the beneficiary.

Order in respect of beneficiary

11  (1) In this section, "cause", in respect of a beneficiary, includes, but is not limited to the following:

(a) knowingly requesting services that are not medically required from a practitioner to be claimed as a benefit;

(b) submitting a claim under section 10 (1) to the commission for payment knowing that

(i)   a benefit had not been rendered, or

(ii)   the nature or extent of the benefit that was rendered had been misrepresented;

(c) contravening section 12;

(c.1) providing to another person the beneficiary's identity number, issued by the commission to the beneficiary, knowing that the other person would, or would likely, use the identity number to contravene section 12;

(d) refusing to reply in good faith to a communication from the commission.

(2) The commission may, for cause, after giving the beneficiary an opportunity to be heard, make an order to restrict

(a) the number of practitioners who will be paid for benefits rendered to that beneficiary, or

(b) the liability of the commission for payment for specified benefits rendered to that beneficiary.

(3) Despite subsection (4), if the commission has reason to believe that the beneficiary is not a resident, it may make an order described in subsection (2) for a period of not longer than 30 days without hearing the beneficiary.

(4) Before making an order under subsection (2), or a cancellation under section 7.4 (1) (b) or (c), the commission must notify the beneficiary in a manner the beneficiary can understand

(a) of the commission's intention to proceed,

(b) of the circumstances giving rise to the commission's intended action,

(c) that the beneficiary has the right to a hearing, to be requested by the beneficiary within 21 days from the date that the notice was delivered, and to appear in person or with legal counsel at the hearing, and

(d) that if the beneficiary does not request a hearing or appear at the hearing, an order may be made in his or her absence.

(5) If the commission makes an order under subsection (2), a practitioner who renders a benefit to the beneficiary in a manner that conflicts with the order is not entitled to payment by the commission for the benefit, unless the commission otherwise orders.

(6) If the commission makes an order under subsection (2), the commission must not pay for any benefit rendered in an approved diagnostic facility if the benefit is rendered in a manner that conflicts with the order, unless the commission otherwise orders.

(7) If the commission makes an order under subsection (2), the commission must

(a) give written notice to the affected beneficiary stating the nature of the order and the reasons why it was made, and

(b) give a written or electronically recorded message to all appropriate practitioners advising that the order has been made.

(8) If a beneficiary, in respect of whom an order has been made under subsection (2), receives a benefit contrary to the terms of the order,

(a) the beneficiary is liable to pay the practitioner or approved diagnostic facility for the benefit, or

(b) if the practitioner or approved diagnostic facility has been paid by the commission for that benefit, the beneficiary must reimburse the commission and until reimbursement has been made, the amount that was paid for the benefit is a debt owing to the commission.

Misuse of identity number

12  A person must not knowingly, in order to obtain benefits,

(a) use an identity number other than the one issued to that person by the commission, or

(b) use the identity number issued to that person if

(i)   the commission has cancelled his or her enrollment, or

(ii)   he or she contravenes a restriction imposed under section 11 (2).

Part 3 — Practitioners

Enrollment of practitioners

13  (1) A medical practitioner or health care practitioner who wishes to be enrolled as a practitioner must apply to the commission in the manner required by the commission.

(2) On receiving an application under subsection (1), the commission must enroll the applicant if the commission is satisfied that the applicant is in good standing with the appropriate licensing body and is not a person in respect of whom enrollment has been cancelled under section 15 (2).

(3) A practitioner who renders benefits to a beneficiary is, if this Act and the regulations made under it are complied with, eligible to be paid for his or her services in accordance with the appropriate payment schedule, less any applicable patient visit charge or reduction made under section 24 (2).

(4) Payments for benefits performed in an approved diagnostic facility must be paid to the practitioner who was responsible for rendering the benefit.

(5) If a practitioner renders a benefit, payment may be made to a corporation so long as the practitioner may lawfully conduct business respecting that benefit through that corporation.

(6) A practitioner is not entitled to be paid if that practitioner provides a service contrary to any directions or prohibitions that have been imposed on that practitioner

(a) by the appropriate disciplinary body,

(b) under this Act, or

(c) by rules that regulate services provided by the practitioner.

(7) A medical practitioner or health care practitioner who, on the date this Act comes into force, holds a practitioner number granted under the former Act is enrolled under subsection (1).

(8) A practitioner who is enrolled under this section may cancel this enrollment by giving 30 days' written notice of the cancellation to the commission.

(9) A medical practitioner whose enrollment is cancelled under subsection (8) may not apply for enrollment under subsection (1) within 12 months of the date of the cancellation unless the commission, because it considers this to be in the public interest, allows the application.

Repealed

13.1  [Repealed 2002-16-9.]

Election

14  (1) A practitioner may elect to be paid for benefits directly from a beneficiary.

(2) An election under subsection (1) may be made by giving written notice to the commission in the manner required by the commission.

(3) The election under subsection (1) takes effect

(a) immediately on enrollment if the practitioner is not enrolled under section 13 on receipt by the commission of the notice under subsection (2), or

(b) on a date specified by the commission between 30 and 45 days after notice of the election is received by the commission, if the practitioner is enrolled under section 13 on that date.

(4) An election under subsection (1) may be revoked

(a) before the date the election under subsection (1) takes effect, if the commission and the practitioner agree to this, or

(b) if the election under subsection (1) has taken effect, by the giving notice of revocation in the same manner as giving notice under subsection (2).

(5) The revocation takes effect on a date to be specified by the commission between 60 and 75 days after receipt by the commission of the request for revocation.

(6) If a practitioner revokes an election, the practitioner is not entitled to be paid by the commission for benefits rendered during the period referred to in subsection (5).

(7) If an election is in effect and the practitioner has complied with subsection (9),

(a) the beneficiary must make a request for reimbursement directly to the commission, and

(b) the beneficiary is only entitled to be reimbursed for the lesser of

(i)   the amount that is provided in the appropriate payment schedule for the benefit, less any applicable patient visit charge, and

(ii)   the amount that was charged by the practitioner.

(8) If a practitioner makes an election under subsection (1), he or she must not submit a claim on his or her own behalf under section 27 (1) for services rendered to a beneficiary after the date the election becomes effective.

(9) As soon as practicable after rendering a benefit, a practitioner who has made an election under subsection (1) must give the beneficiary a claim form that is completed by the practitioner in the manner required by the commission.

Order in respect of practitioner

15  (1) In this section, "cause", in respect of a practitioner, includes, but is not limited to,

(a) a determination by the commission that, as a result of a finding by the appropriate disciplinary body that a practitioner has inadequate skills or knowledge or has been guilty of infamous conduct or repeated instances of serious misconduct, the practitioner is no longer able to provide proper care or treatment to beneficiaries,

(b) a determination by the commission that, as a result of conduct giving rise to a conviction of a criminal offence, the practitioner is no longer able to provide proper care or treatment to beneficiaries,

(c) the submission of a claim by the practitioner to the commission for payment knowing that

(i)   the benefit had not been rendered, or

(ii)   the nature or extent of the benefit that was rendered had been misrepresented,

(d) contravention of section 17, 18 or 19,

(e) failure to meet accreditation standards established by the licensing body appropriate to the practitioner,

(f) failure to comply with a written order made under section 37 (1) (e) to adopt an appropriate pattern of practice or billing, or

(g) refusal to reply in good faith to a communication from the commission.

(2) The commission may, for cause, after giving the practitioner an opportunity to be heard,

(a) cancel a practitioner's enrollment and order that the practitioner not apply under section 13 (1) for a period specified by the commission,

(a.1) order that the practitioner, for a period fixed by the commission, be paid for rendering benefits at a rate specified by the commission that is less than the rate under the applicable payment schedule, or

(b) order the practitioner, for a period fixed by the commission, to make claims, including claims for services provided by a diagnostic facility, as though an election had been made under section 14, and section 14 (7) to (9) applies.

(3) Before taking action under subsection (2), the commission must notify the practitioner in writing

(a) of the commission's intention to proceed under this section,

(b) of the circumstances giving rise to the commission's intended action,

(c) that the practitioner has the right to a hearing, to be requested by the practitioner within 21 days from the date that the notice is delivered, and to appear in person or with legal counsel at the hearing, and

(d) that if the practitioner does not request a hearing or attend at the hearing, an order may be made in his or her absence.

(4) If the commission makes an order under subsection (2), the commission must notify the practitioner by written notice giving reasons for the order.

(5) If the commission has cancelled the enrollment of a practitioner under subsection (2), a beneficiary is not entitled to have payment made by the commission for any service rendered by that practitioner.

Referral of complaint

16  If he or she has reasonable grounds to believe that there has been misconduct or incompetence on the part of a practitioner, the chair must report the grounds on which that belief is based to the appropriate disciplinary body.

Part 4 — Limits on Billing

General limits on direct or extra billing

17  (1) Except as specified in this Act or the regulations or by the commission under this Act, a person must not charge a beneficiary

(a) for a benefit, or

(b) for materials, consultations, procedures, use of an office, clinic or other place or for any other matters that relate to the rendering of a benefit.

(2) Subsection (1) does not apply:

(a) if, at the time a service was rendered, the person receiving the service was not enrolled as a beneficiary;

(b) if, at the time the service was rendered, the service was not considered by the commission to be a benefit;

(c) if the service was rendered by a practitioner who

(i)   has made an election under section 14 (1), or

(ii)   is subject to an order under section 15 (2) (b);

(d) if the service was rendered by a medical practitioner who is not enrolled.

Limits on direct or extra billing by a medical practitioner

18  (1) If a medical practitioner who is not enrolled renders a service to a beneficiary and the service would be a benefit if rendered by an enrolled medical practitioner, a person must not charge the beneficiary for, or in relation to, the service an amount that, in total, is greater than

(a) the amount that would be payable under this Act, by the commission, for the service if rendered by an enrolled medical practitioner, or

(b) if a payment schedule or regulation permits or requires an additional charge by an enrolled medical practitioner, the total of the amount referred to in paragraph (a) and the additional charge.

(2) Subsection (1) applies only to a service rendered in

(a) a hospital as defined in section 1 of the Hospital Act, or

(b) a community care facility as defined in section 1 of the Community Care and Assisted Living Act.

(3) If a medical practitioner described in section 17 (2) (c) renders a benefit to a beneficiary, a person must not charge the beneficiary for, or in relation to, the service an amount that, in total, is greater than

(a) the amount that would be payable under this Act, by the commission, for the service, or

(b) if a payment schedule or regulation permits or requires an additional charge, the total of the amount referred to in paragraph (a) and the additional charge.

Notice requirement

19  (1) Before a beneficiary is rendered a service that would be a benefit if rendered by a practitioner, the person who intends to require the beneficiary to pay all or a portion of the costs of the service must advise the beneficiary, in a manner the beneficiary can understand, of the following:

(a) that the person proposes to collect the amount directly from the beneficiary;

(b) how much the person will charge for the service;

(c) how much, if anything, the person reasonably expects that the commission will reimburse the beneficiary for the rendering of the service.

(2) Subsection (1) does not apply if the medical condition or incapacity of the beneficiary makes compliance with that subsection impractical but, if the service would be a benefit if rendered by a practitioner, the beneficiary must not be charged for the service an amount that, in total, is greater than

(a) the amount that would be payable under this Act, by the commission, for the service, or

(b) if a payment schedule or regulation permits or requires an additional charge, the total of the amount referred to in paragraph (a) and the additional charge.

(3) If a beneficiary is not advised, as required by subsection (1), the beneficiary is not liable to pay for the service unless the service was rendered in an emergency situation that made it impractical to comply with that subsection.

Refunds required

20  (1) If a beneficiary pays for a service described in section 18, the person who charged for, or in relation to, the service must refund to the beneficiary any amount paid for the service that is in excess of the amount allowed for that service by section 18.

(2) If a beneficiary pays for a service but was not liable to pay for it because of section 19 (3), the person who charged for, or in relation to, the service must refund to the beneficiary the amount paid for the service.

Persons acting for beneficiaries

20.1  (1) A person requesting a benefit for a beneficiary must not be charged for the benefit in place of the beneficiary if this Part requires that the beneficiary not be charged for the benefit.

(2) A person requesting a benefit for a beneficiary must receive advice concerning a requirement to pay for the benefit if this Part requires that the beneficiary receive advice concerning the requirement to pay for the benefit.

Civil action

21  An amount that is to be refunded under this Part is a debt due to the person who paid the amount, recoverable by action in any court of competent jurisdiction.

Agreements

22  The minister, or a person designated by the minister for the purpose, may enter into an agreement to pay an amount to offset all or part of the cost for materials, consultations, use of an office, clinic or other place or for any other matter that relates to the rendering of a benefit.

Part 5 — Payments

Definitions for Part 5

23  In this Part:

"appropriation" means an appropriation as defined in the Financial Administration Act for the operation of

(a) the commission, or

(b) the plan;

"available amount" means, for a category, the available amount set under section 25 (1) for that category for a fiscal year;

"category" means a category established under section 26;

"fiscal year" means, for an adjustment under this Part, the 12 month period ending March 31 in any given year during which the benefits were rendered for which the adjustment in payments is being calculated.

Limitations on payments

24  (1) All reasonable and practical measures must be taken by the commission to ensure that the total of payments made under sections 26 and 27 for a fiscal year is not greater than the appropriations for the fiscal year for those payments and these measures may include the establishment of public or professional educational programs, the establishment or limitation of benefits, the establishment of guidelines for the rendering of benefits or the making of adjustments under subsection (2).

(2) If the commission considers that payment for a fiscal year under all payment schedules to practitioners in a category will be greater than or less than the available amount for that category, the commission may adjust its payments to the practitioners in the category under the payment schedules to a level that the commission considers appropriate to remain within the available amount for the fiscal year.

(3) If the commission considers that the special circumstances of a practitioner's patients warrant, the commission may order that a reduction calculated under subsection (2) does not apply, or applies to a limited extent, to payments to the practitioner.

Available amount

25  (1) The commission may set the available amount for a category that may be paid under all payment schedules to practitioners in the category for rendering benefits under this Act in the fiscal year specified by the commission.

(2) The total amount that may be paid by the commission to all practitioners in a category for rendering benefits under this Act in a fiscal year must not be greater than the available amount for the fiscal year.

Payment schedules and benefit plans

26  (1) The commission

(a) must establish payment schedules that specify the amounts that may be paid to or on behalf of practitioners for rendering benefits under this Act, less applicable patient visit charges, and

(b) may establish different categories of practitioners for the purposes of those payment schedules.

(2) The payment schedules may

(a) be different for different categories of practitioners,

(b) treat professional and other aspects of services differently for the purposes of payments under this Part,

(c) include, for specified benefits, extra payments that may be made in special circumstances that the commission establishes, or

(d) in respect of a particular benefit or class of benefits, be different for different geographical areas of British Columbia, as specified by the commission.

(3) The commission may, at any time, amend the payment schedules

(a) in any manner that the commission considers necessary or advisable, and

(b) without limiting paragraph (a), by increasing or decreasing any amount in a payment schedule.

(4) An amendment referred to in subsection (3) (b) may apply

(a) to a specified geographical area,

(b) to a category of practitioners,

(c) to a category of practitioners within a specified geographical area, or

(d) to a specified benefit or class of benefits within a specified geographical area.

(5) The commission may act retroactively under this section to

(a) include or increase payment for a benefit in a payment schedule, or

(b) determine that a service is a benefit and establish a payment schedule item for this benefit.

(6) The commission may continue or establish a practitioner educational program, a disability insurance program or other practitioner benefit plan for practitioners and the plans may be different for different categories of practitioners.

(7) The commission may, out of an appropriation for that purpose, pay money to fund practitioner benefit plans.

(8) No category may be established under this section on the basis of age or gender of practitioners.

Submission, assessment and payment of claims

27  (1) A practitioner who renders a benefit to a beneficiary must, for the purpose of assessing or reassessing the claim for payment, provide particulars of services and accounts to the commission that are required under this Act in the manner the commission specifies.

(2) The commission must assess and, if appropriate, reassess the particulars of claims for payment and determine the amounts payable for them in accordance with this Act, the regulations and the appropriate payment schedule.

(3) The Lieutenant Governor in Council may prescribe the period of time within which

(a) a claim for payment must be submitted to the commission,

(b) a practitioner or beneficiary may request reassessment of a previously submitted claim, or

(c) the commission can assess or reassess a claim.

(4) The commission must, to the extent authorized by the appropriation, pay for claims for benefits that the commission has assessed or reassessed and that comply with this Act, the regulations and the appropriate payment schedule.

(5) The commission is not liable for payment if a claim is submitted outside the period prescribed under subsection (3) but, in its discretion, may pay the claim.

(6) For the purposes of this section

(a) a practitioner must provide the commission with any record that the commission considers relevant to substantiate a claim, including any medical or clinical record, in the care or control of the practitioner, and

(b) a practitioner must retain records, including medical or clinical records, for a period specified by the appropriate licensing body or, if the appropriate licensing body has not specified a period, for a period the commission specifies.

Non-resident benefits

28  A person who is not a resident of British Columbia and who provides evidence to a practitioner that he or she is enrolled under an Act, plan or scheme in another province of Canada in respect of which British Columbia has made reciprocal agreements related to the provision of medical or health care services is, subject to the agreements, entitled to receive benefits under this Act, and this Act applies in respect of those benefits as though the person were a beneficiary under this Act.

Payment for services outside British Columbia

29  (1) In this section, "medical practitioner" includes a medical practitioner or dentist who is authorized to practise medicine or dentistry in the jurisdiction where the services were rendered.

(2) If a beneficiary receives a service from a medical practitioner outside British Columbia that would be a benefit if rendered in British Columbia, the beneficiary may apply to the commission, in the manner required by the commission, to have payment made for the service in the amount the commission determines.

(3) If a beneficiary receives a service outside British Columbia from a medical practitioner that would not be a benefit if rendered in British Columbia, the beneficiary may apply to the commission to determine if the cost of this service should be paid and, if so, the amount to be paid for the service.

(4) A beneficiary is entitled to have payments made under subsection (2) or (3) if the commission considers the service was medically required and

(a) the need for the service arose unexpectedly while the beneficiary was outside British Columbia, or

(b) the regulations respecting out of British Columbia services have been complied with.

(5) If the government has made an agreement with the government of another province that provides for arrangements to pay for medically required services rendered in that other province, the agreement applies.

Recovery of money

30  (1) If the commission has paid an amount

(a) for a service rendered to a person who is not a beneficiary,

(b) for a service that was not a benefit, or

(c) by mistake,

the person who was paid must repay the amount to the commission.

(2) If the commission has paid an amount after relying on a representation of fact that was untrue, the person who made the misrepresentation must repay the amount to the commission.

(3) An amount that must be paid to the commission under this section or section 37 may be recovered as a debt owing to the commission, or the commission may deduct it from other money owed by the commission to the person.

Critical care services

31  (1) Despite any other section of this Act or the regulations, the commission may pay a practitioner for benefits rendered to a resident for a condition that the commission considers to be immediately life threatening.

(2) Subsection (1) does not apply if the practitioner charges the resident any fee for the service other than an authorized patient visit charge.

Obligation to remit

32  (1) If a person makes an agreement

(a) to pay all or part of another person's premiums, or

(b) to collect premiums from another person for remission to the commission,

that person must pay the premiums to the commission in the manner and at the times specified by the commission.

(1.1) If the payment of another person's premiums referred to in subsection (1) (a) is in arrears, including arrears arising before the making of an agreement referred to in subsection (1) respecting the other person, the person making the agreement, if requested by the commission, must collect and remit the arrears, including applicable interest on these arrears, by payment to the commission as specified by the commission under subsection (1).

(2) Subject to subsection (3), premiums collected under an agreement referred to in subsection (1) and arrears collected under subsection (1.1) constitute a lien in favour of the commission or its assignee payable in priority over all liens, charges or mortgages of any person, whenever created or to be created, with respect to property or proceeds of property, real, personal or mixed of the person who collected the premiums.

(3) Subsection (2) applies despite any other enactment but a lien under section 52 of the Workers Compensation Act, or a lien for wages due to workers by their employer other than a lien postponed to a mortgage or debenture by section 87 (5) of the Employment Standards Act, is payable in priority over a lien constituted under subsection (2) of this section.

(4) Without limiting subsection (2), the commission may enforce its lien under subsection (2) by proceedings under the Court Order Enforcement Act.

(5) If a person is convicted under section 46 (3), the court

(a) must determine the amount of the premiums the person failed to pay or to collect and remit,

(b) may assess a penalty, of not greater than 10 times the amount that was not paid or collected and remitted, and

(c) must make an order requiring that person to pay to the commission the total amount determined under paragraphs (a) and (b), plus interest at a prescribed rate.

(6) Every director or officer of a corporation who concurs in a failure to remit the premiums required to be paid or collected and remitted by the corporation is liable, jointly and separately, with every other director and officer of the corporation, to make a payment ordered to be made under subsection (5).

Part 6 — Diagnostic Facilities

Approval of diagnostic facility

33  (1) On application, in the manner required by the commission, the commission may, in accordance with the regulations,

(a) approve a diagnostic facility for purposes of permitting benefits to be performed in it,

(b) grant a temporary approval for a diagnostic facility for those purposes and for the period the commission specifies, and

(c) impose conditions on an approval or a temporary approval for a particular diagnostic facility or class of diagnostic facilities, including conditions restricting the types of benefits for which payment will be made.

(2) On application under subsection (1) or on its own initiative, the commission may, in accordance with the regulations, attach new conditions or amend existing conditions to an approval or temporary approval previously given under subsection (1).

(3) If an approval is given under this section, the commission must give the approval in the name of the owner of the diagnostic facility.

(4) If, in respect of an approved diagnostic facility, there is a contravention of this Act, the regulations made under it or a condition imposed on an approval under this section, the commission may, after giving the owner of the diagnostic facility an opportunity to be heard, amend, suspend or cancel an approval granted under this section and section 30 applies to the amount, if any, that was paid by the commission for services on the basis of the approval applying.

(5) Before taking action under subsection (2) or (4), the commission must notify in writing the person in whose name the approval was granted,

(a) of the commission's intention to proceed under this section,

(b) of the circumstances giving rise to the commission's intended action,

(c) that the owner of the diagnostic facility has the right to a hearing, to be requested by the owner of the diagnostic facility within 21 days from the date that the notice is received, and to appear in person or with legal counsel at the hearing, and

(d) that if the owner of the diagnostic facility does not request a hearing or attend at the hearing, an order may be made in his or her absence.

(6) If the commission takes action under subsection (2) or (4), the commission must give the owner of the diagnostic facility written notice stating the action taken and the reasons why this action was taken.

(7) Except if the commission gives leave, a person who applied under subsection (1) in respect of a location may not apply again under subsection (1) in respect of that location until 18 months from the date of that application.

(8) An owner of a diagnostic facility who on July 24, 1992 has an approval under the former Act to operate the diagnostic facility also has an approval under this section to operate the diagnostic facility.

Obligation of practitioner

34  (1) A practitioner must not knowingly refer a beneficiary to a diagnostic facility that is not approved under this Part unless he or she first notifies the beneficiary that services performed in the diagnostic facility are not benefits in respect of which payment will be made under this Act.

(2) If a beneficiary is referred by a practitioner to a diagnostic facility that is not approved under this Part, the beneficiary is not liable for payment of services performed in the diagnostic facility unless, before the services are provided, he or she agrees to pay for them.

(3) Subsections (1) and (2) only apply if the service to be provided to the beneficiary would be a benefit if it were rendered by an approved diagnostic facility.

Conflict of interest

35  (1) A practitioner must not refer beneficiaries to an approved diagnostic facility in which he or she has a financial or other interest, without the prior written approval of the commission.

(2) An approval under subsection (1) permits referrals for the period specified in the approval.

Part 7 — Audit and Inspection

Audit and inspection — practitioners and employers

36  (1) In this Part:

"former practitioner" means an individual who was formerly enrolled under section 13 or under the former Act;

"practitioner" includes

(a) a former practitioner, and

(b) a medical practitioner who is not enrolled and to whom section 18 (1) applies;

"prescribed agency" means a corporation or other body that is prescribed for the purposes of this Part.

(2) The commission may appoint inspectors to audit

(a) claims for payment by practitioners and the patterns of practice or billing followed by practitioners under this Act,

(b) the billing or business practices of persons who own, manage, control or carry on a business for profit or gain and, in the course of the business, direct, authorize, cause, allow, assent to, assist in, acquiesce in or participate in the rendering of a benefit to beneficiaries by practitioners, and

(c) the billing or business practices of persons who own, manage, control or carry on a business for profit or gain and who the commission on reasonable grounds believes

(i)   in the course of the business, direct, authorize, cause, allow, assent to, assist in, acquiesce in or participate in the rendering of a benefit to beneficiaries by practitioners, or

(ii)   have contravened section 17, 18, 18.1 or 19.

(2.1) If the commission, on behalf of a prescribed agency, pays a practitioner, an owner of a diagnostic facility or a representative of a professional corporation for services rendered, or claimed to have been rendered, this Part applies to the services as though these services were benefits.

(2.2) The claims and patterns of practice or billing concerning a prescribed agency

(a) need not be under this Act, and

(b) can have arisen at any time since July 24, 1992.

(3) Medical records may only be requested or inspected under this section or section 40 by an inspector who is a medical practitioner.

(4) An audit under subsection (2) (a) may be made in respect of claims and patterns of practice or billing followed by practitioners before this Act came into force.

(4.1) An audit under subsection (2) (b) or (c) may be made in respect of billing or business practices followed by persons before the coming into force of this subsection.

(5) An inspector may, at any reasonable time and for reasonable purposes of the audit, enter any premises and inspect

(a) records of a person described in subsection (2) (b) or (c) or of a practitioner, and

(b) records maintained in hospitals, health facilities and diagnostic facilities.

(6) The power to enter a place under subsection (5) or (12) must not be used to enter a private dwelling without the consent of the occupier except under the authority of a warrant under subsection (7).

(7) On being satisfied on evidence on oath or affirmation that there are in a place records or other things for which there are reasonable grounds to believe that they are relevant to the matters referred to in subsection (5) or (12), a justice may issue a warrant authorizing an inspector named in the warrant to enter the place in accordance with the warrant in order to exercise the powers referred to in subsection (5) or (12).

(8) A person must, on the request of an inspector,

(a) produce and permit inspection of the records referred to in subsection (5) or (12),

(b) supply copies of or extracts from the records at the expense of the commission, and

(c) answer all questions of the inspector respecting the records referred to in subsection (5) or (12).

(9) If required by the inspector, a person must provide to the inspector all books of account and other records that the inspector considers necessary for the purposes of the audit.

(10) A person must not hinder, molest or interfere with an inspector doing anything that the inspector is authorized to do under this section or prevent or attempt to prevent the inspector doing any such thing.

(11) An inspector must make a report to the chair of the results of an audit made under subsection (2).

(12) An inspector may, at any reasonable time and for the purposes of the audit, enter any premises and inspect the payroll, financial and membership records of an employer or an association responsible for collecting and remitting premiums under this Act.

Orders of the commission

37  (1) If the commission, after giving a practitioner, an owner of a diagnostic facility or a representative of a professional corporation an opportunity to be heard, determines that, because of

(a) an unjustifiable departure from the patterns of practice or billing of practitioners in the practitioner's category,

(b) a claim for payment in respect of a benefit that was not rendered, or

(c) a misrepresentation about the nature or extent of benefits rendered,

the commission has paid an amount to the practitioner or any other person, or both, the commission may, by written order,

(d) require the practitioner, owner of the diagnostic facility or representative of the professional corporation to pay to the commission money that the commission considers appropriate as arising out of the departure, claim or misrepresentation referred to in paragraphs (a) to (c), and

(e) require the practitioner, owner of the diagnostic facility or representative of the professional corporation to adopt an appropriate pattern of practice or billing, as specified by the commission in the order.

(1.1) If a practitioner, an owner of a diagnostic facility or a representative of a professional corporation is ordered under subsection (1) (d) to pay money to the commission, they must also pay a prescribed surcharge.

(1.2) In subsection (1.3), "audit period" means, for a person, the period during which an audit takes place, giving rise to an order under subsection (1) (d) respecting the person.

(1.3) A person who must pay a prescribed surcharge under subsection (1.1) must also pay interest from the last day of the audit period, compounded semi-annually, on the sum of

(a) the amount ordered under subsection (1) (d),

(b) the surcharge under subsection (1.1) on the amount ordered under subsection (1) (d), and

(c) the compound interest accrued to date under this subsection.

(1.4) Interest under subsection (1.3) is payable at an annual rate equal to the prime lending rate of the banker to the government.

(1.5) Interest payable under subsection (1.3) for any of the first 6 months of a calendar year must be calculated at the annual rate applicable on January 1 in the calendar year.

(1.6) Interest payable under subsection (1.3) for any of the last 6 months of a calendar year must be calculated at the annual rate applicable on July 1 in the calendar year.

(2) Before taking action under subsection (1), the commission must notify in writing the practitioner, owner of a diagnostic facility or representative of a professional corporation

(a) of the commission's intention to proceed under this section,

(b) of the circumstances giving rise to the commission's intended action,

(c) that the practitioner, owner of a diagnostic facility or representative of a professional corporation has the right to a hearing, to be requested by the practitioner, owner of a diagnostic facility or representative of a professional corporation within 21 days from the date that the notice is delivered, and to appear in person or with legal counsel at the hearing, and

(d) that, if the practitioner does not request a hearing or attend at the hearing, an order may be made in his or her absence.

(3) Despite subsections (1) and (2), the commission may proceed to make an order under subsection (1) without holding a hearing if the practitioner, owner of the diagnostic facility or representative of the professional corporation, having been given notice of the proceeding for the order, agrees to waive the right to a hearing.

(4) The commission must advise the appropriate licensing or disciplinary body that an order under subsection (1) has been made respecting the practitioner or the owner of the diagnostic facility, if the owner is a practitioner.

(5) The commission may, for the purposes of this section and for the guidance of practitioners, prepare guidelines and criteria that may be applied to the patterns of practice of practitioners.

(6) In making an order under subsection (1), the commission may consider, and base the order on, any relevant source of information, including a source created on a statistical basis or by a comparison between benefits provided by the practitioner or diagnostic facility and corresponding benefits provided by other practitioners or diagnostic facilities, but it is not necessary for the commission to consider any particular benefit that the practitioner or owner of the diagnostic facility provided.

(7) The chair must give a copy of any order made under subsection (1) to the practitioner or owner of the diagnostic facility affected by it.

(8) An order under subsection (1) may include a requirement to pay the costs, or part of the costs, of the audit and hearing.

Settlement of claims ascertained under section 37

38  If the commission believes it to be in the public interest to accept less than 100% payment in settlement of money required to be paid by a practitioner, owner of the diagnostic facility or representative of the professional corporation under section 37, the commission may accept the greater of

(a) the percentage of the money required to be paid under section 37 that the commission considers appropriate in settlement, and

(b) the percentage of the money required to be paid under section 37 that Treasury Board sets for the purposes of settlement under this section, if Treasury Board sets this percentage.

Filing of order

39  (1) The chair may file an order made under section 37 in the Supreme Court.

(2) On the order being filed in the court, it is enforceable in the same manner as an order of the Supreme Court.

Audit and inspection — diagnostic facilities

40  (1) An inspector appointed under section 36 (2) may inspect records, equipment and premises in a diagnostic facility for the purpose of ensuring that this Act, the regulations and any conditions of approval under section 33 are being complied with.

(2) An inspector may enter the premises of the approved diagnostic facility during the normal business hours of that diagnostic facility, and may inspect and examine

(a) those premises,

(b) records located on those premises that are relevant to the rendering of approved diagnostic facility services or to the submission of claims and the payment of appropriate amounts for benefits rendered by the diagnostic facility, including specimen collection stations,

(c) records that would aid the commission in determining whether a hearing under section 33 is warranted, which

(i)   relate to the conditions of the approval of the diagnostic facility or the quality of services provided by the diagnostic facility, or

(ii)   indicate whether the diagnostic facility or any person is not in compliance with protocols established by the commission for the purposes of this Act, and

(d) records and equipment located on those premises that will aid the commission in determining whether, in respect of the diagnostic facility,

(i)   the standards of testing and analysis,

(ii)   the qualifications, number and skills of personnel who work there, and

(iii)   the range and availability of services and equipment

are appropriate to the operation and functions performed by the diagnostic facility under the approval or whether there has been a significant change in the circumstances from those that applied when the diagnostic facility was approved under section 33.

(3) A person who operates a diagnostic facility approved under this Act must, on the request of an inspector, permit the inspector to enter the diagnostic facility's premises to inspect, in accordance with subsection (1), the diagnostic facility's premises and the records and equipment located on those premises.

(4) If records referred to in subsection (1) are not located on the premises of an approved diagnostic facility, a person who has possession of those records must, on the request of the inspector, produce and permit inspection of those records by the inspector.

Part 8 — Appeals

Repealed

41–42  [Repealed 2003-96-47.]

Appeals — practitioners and diagnostic facilities

43  (1) A practitioner, an owner of a diagnostic facility or a representative of a professional corporation in respect of whom an order was made under section 15 (2) or 37 (1) may appeal the order to the Supreme Court not more than 30 days after the date of the order or cancellation.

(2) An appeal from a decision of the Supreme Court on appeal under subsection (1) lies to the Court of Appeal with leave of a justice of the Court of Appeal.

(3) An appeal under this section does not operate to stay the order appealed from unless the court to which the appeal is made otherwise orders.

Repealed

44  [Repealed 2003-96-47.]

Part 9 — General Provisions

Private insurers

45  (1) A person must not provide, offer or enter into a contract of insurance with a resident for the payment, reimbursement or indemnification of all or part of the cost of services that would be benefits if performed by a practitioner.

(2) Subsection (1) does not apply to

(a) all or part of the cost of a service

(i)   for which a beneficiary cannot be reimbursed under the plan, and

(ii)   that is rendered by a health care practitioner who has made an election under section 14 (1),

(b) insurance obtained to cover health care costs outside of Canada, or

(c) insurance obtained by a person who is not eligible to be a beneficiary.

(3) A contract that is prohibited under subsection (1) is void.

Injunctions

45.1  (1) The commission may apply to the Supreme Court for an injunction restraining a person from contravening section 17 (1), 18 (1) or (3), 18.1 (1) or (2) or 19 (1) or (2).

(2) The court may grant an injunction sought under subsection (1) if the court is satisfied that there is reason to believe that there has been or will be a contravention of this Act or the regulations.

(3) The court may grant an interim injunction until the outcome of an action commenced under subsection (1).

Offences

46  (1) A beneficiary or practitioner who misrepresents the nature or extent of the benefit in a claim for payment commits an offence.

(2) A person who knowingly obtains or attempts to obtain payment for a benefit to which he or she is not entitled commits an offence.

(3) A person who fails to pay or to collect and remit premiums in accordance with an agreement referred to in section 32 (1) commits an offence.

(4) A person who obstructs an inspector in the lawful performance of his or her duties under this Act commits an offence.

(5) A person who contravenes section 12 or 49 commits an offence.

(6) A person who knowingly assists another person to commit an offence under this section commits an offence.

Offence Act

47  Section 5 of the Offence Act does not apply to this Act or the regulations.

Duty to report

47.1  A person prescribed for the purposes of this section must promptly report to the commission, in the manner required by the commission, if the prescribed person has reason to believe that another person

(a) has provided to the commission false or misleading information about the other person's identity, residency or children,

(b) has obtained, or has attempted to obtain, benefits or a payment under section 9, 10 or 29 to which the other person is not entitled, or

(c) has contravened section 12.

Protection against action

48  (1) No action for damages because of anything done or omitted to be done in good faith under this Act,

(a) in the performance or intended performance of any duty, or

(b) in the exercise or intended exercise of any power,

may be brought against a member of the commission, a member of a special committee, an inspector appointed under Part 7, a member of an advisory committee or any employee or other person who is subject to the commission's direction or to whom a power has been delegated under this Act.

(2) Subsection (1) does not absolve the government from vicarious liability for an act or omission of an inspector or an employee referred to in subsection (1) for which act or omission the government would be vicariously liable if this section were not in force.

(3) If a practitioner provides information in good faith in the manner and as required under this Act, no action for damages may be brought against the practitioner based solely on the fact that the information was provided.

(4) If a person makes a report in good faith, in the manner and as required under this Act, no action for damages may be brought against the person based solely on the fact that the report was made.

Duty to keep information confidential

49  (1) In this section, "person engaged in the administration of this Act" includes the following persons:

(a) each member or former member of the commission;

(b) each former member of the Medical and Health Care Services Appeal Board;

(c) each employee or former employee of the ministry employed in the administration of this Act;

(d) each inspector or former inspector appointed under this Act;

(e) each member or former member of an advisory committee;

(f) any person engaged or previously engaged in the administration of this Act.

(2) A person engaged in the administration of this Act must keep confidential matters respecting an individual beneficiary or practitioner that come to his or her knowledge in the course of his or her employment or duties, and must not communicate any of those matters except as follows:

(a) in the course of the administration of this Act or another Act or program administered by the minister;

(b) to communicate prescribed information to a person who

(i)   is a beneficiary and is, or whose personal information is, identified in a hearing under section 15 or 37,

(ii)   provides information to the commission that leads to an audit or inspection under section 36, or to a determination that no audit or inspection is required under that section, or

(iii)   provides information to the commission that leads to an application for an injunction under section 45.1, or to a determination that no injunction is required under that section;

(c) to communicate prescribed information to one or more persons if a person is the subject of

(i)   a notice of hearing under section 15 or 37,

(ii)   an audit or inspection under section 36, or

(iii)   an application for an injunction under section 45.1, and

if, in the opinion of the minister or the chair, there is a compelling public interest in the disclosure of that information;

(d) for a purpose listed in section 5 or 18 of the E-Health (Personal Health Information Access and Protection of Privacy) Act.

Delivery of documents

50  (1) Unless otherwise provided under this Act, a document or notice required to be given to a person under this Act must be given by delivering it to that person or to the last known address of that person.

(2) If a document is deposited at the office of the commission during normal business hours, the document is deemed to have been personally delivered to the commission.

Power to make regulations

51  (1) The Lieutenant Governor in Council may make regulations referred to in section 41 of the Interpretation Act.

(2) Without limiting subsection (1), the Lieutenant Governor in Council may make regulations for the following purposes:

(a) specifying the services rendered by an enrolled health care practitioner that are benefits under this Act;

(b) prescribing additional benefits and services for different categories of beneficiaries;

(b.1) prescribing for hearings under section 15 or under section 37

(i)   the practices and procedures for the conduct of negotiations or a pre-hearing conference for possible settlement before a hearing is commenced,

(ii)   the practices and procedures to be used for a pre-hearing conference or a hearing,

(iii)   the means by which particular facts may be proved or the mode in which evidence may be given at a pre-hearing conference or a hearing,

(iv)   the time limits for the exchange of documents, reports and affidavits in preparation for a pre-hearing conference or a hearing, or

(v)   the requirements for the attendance of witnesses, the conduct of witnesses or the compelling of witnesses to give evidence under oath or in some other manner;

(c) imposing monetary limits on benefits rendered by an enrolled health care practitioner available to different categories of beneficiaries;

(c.01) for the purposes of section 7,

(i)   respecting applications for, or renewal of, enrollment as a beneficiary,

(ii)   respecting records and other information that must be provided to prove identity and residency,

(iii)   making different requirements in relation to applications for, or renewal of, enrollment as a beneficiary,

(iv)   making different requirements for the purposes of investigations,

(v)   respecting alternative means of establishing identity and residency,

(vi)   establishing classes of beneficiaries and making different provisions for different classes,

(vii)   exempting classes of beneficiaries from one or more requirements under section 7 (2) or (5) (b), and

(viii)   prescribing periods and times for the purposes of section 7 (2);

(c.02) respecting the issuing of cards or other records for the purposes of identifying beneficiaries, and the use, return, replacement or destruction of such cards or records;

(c.1) prescribing the period for the purposes of section 7.2 (4);

(c.2) for the purposes of section 8,

(i)   establishing different categories of persons who, under section 7.2 (5), must pay premiums,

(ii)   respecting premiums for family units and dependents, and defining family units and dependents, and

(iii)   establishing the manner and time for the making of payments of premiums;

(c.3) prescribing the rate for the purposes of section 8.1;

(c.4) prescribing the form of certificate under section 8.2;

(d) establishing a program of premium assistance to beneficiaries or any designated categories of beneficiaries, including prescribing conditions of eligibility, suspension and termination of eligibility;

(e) establishing systems for submitting claims for payment of benefits;

(e.1) respecting verification of the identity and enrollment of a person requesting benefits;

(f) respecting the approval of diagnostic facilities under Part 6, including the establishment of criteria and conditions for approval of diagnostic facilities and including, but not limited to, the establishment of different criteria and conditions

(i)   for different categories of diagnostic facilities,

(ii)   for different geographic locations of diagnostic facilities,

(iii)   for ownership of diagnostic facilities,

(iv)   according to proximity to other approved diagnostic facilities, and

(v)   according to need for diagnostic facility services;

(g) establishing terms and conditions relating to the functions and operations of specific approved diagnostic facilities and categories of approved diagnostic facilities and authorizing the commission to establish those terms and conditions;

(h) respecting applications for approval of diagnostic facilities and the information required to be disclosed;

(h.1) prescribing bodies for the purposes of the definition of prescribed agencies in Part 7;

(h.2) prescribing a surcharge or a method of calculating a surcharge for the purposes of section 37 (1.1);

(i) respecting the provision of dental care services and benefits to beneficiaries or any designated categories of beneficiaries, including specifying those provisions of this Act and the regulations respecting the plan which apply or do not apply to the provision of dental care services and benefits;

(j) respecting rights of subrogation in favour of the commission;

(k) providing for transition arising from repeal of the former Act and the Medical Service Plan Act, 1981;

(l) providing for sampling and confirmation of claims submitted for payment under this Act;

(m) setting standards and conditions for the purposes of services provided outside British Columbia;

(n) establishing fees for applications or renewals under this Act and establishing different fees for different applications;

(o) respecting terms and conditions that are to be included in information-sharing agreements under section 5 (5) and prescribing enactments for the purposes of section 5 (6);

(p) respecting any other matter for which regulations are required under this Act;

(q) permitting a health care practitioner to request that a beneficiary pay a patient visit charge to cover all or part of the cost of a visit.

(r) prescribing persons who must make a report under section 47.1.

(s) for the purposes of paragraph (c) (ii) of the definition of "resident" in section 1,

(i)   prescribing periods,

(ii)   establishing limits and conditions that must be met for a shorter period to apply, and

(iii)   conferring on the commission a discretion to grant approvals and to waive or modify limits and conditions established under subparagraph (ii) of this paragraph.

(3) A regulation made under subsection (2) (c.01) in respect of proof of identity may do one or more of the following:

(a) establish requirements;

(b) incorporate by reference, and as amended from time to time, requirements established under another enactment;

(c) modify requirements incorporated by reference under paragraph (b);

(d) provide that proof of identity under another enactment or for the purposes of a specified program or activity of a public body, within the meaning of the Freedom of Information and Protection of Privacy Act, is sufficient proof of identity for the purposes of this Act.