Hospital Services (POC 5)

Purpose

This policy provides direction on the approval of in-patient, out-patient and convalescent care in hospitals, multi-disciplinary clinics and other health care facilities.

Policy

General

1. For purposes of this policy, “hospital” is as defined in section 2 of the Canada Health Act.
2. Eligible Veterans may access multi-disciplinary clinics. Multi-disciplinary clinics are facilities which provide several specialized fields of expertise (integrated care) and they include clinics providing out-patient services and/or in-patient service facilities. Clinics or facilities must be registered as a multi-disciplinary clinic with the Department’s third party health claims administrator.
3. Accommodation and meals fees do not apply for any in-patient services provided under Hospital Services (POC 5).

Eligibility

4. See Eligibility for Heath Care Programs – Eligible Client Groups for information on eligibility for Treatment Benefits.
5. Veterans Affairs Canada is responsible for the payment of a service or benefit required by disability benefits recipients for their disability benefits entitled condition (generally referred to as “A-line”), see the policy entitled Treatment for a Disability Benefits Enititled Condition policy.
6. Other Veterans may be eligible for treatment benefits in Canada for any health condition, to the extent that the requested services or care are not available to the Veteran as a former member of the Canadian Armed Forces or, if applicable, under a provincial / territorial health care system, or if the cost of such services or care is not recoverable from a third party (otherwise known as “B-line”). See the policy entitled Requirement to Access Provincial Programs.
7. Hospitalized pensioners, disability award, or pain and suffering compensation recipients are eligible to receive treatment benefits for their disability benefits entitled condition both in and outside Canada provided that these treatment benefits are not available to them as former members or reserve force members of the Canadian Armed Forces.
8. Coverage is provided when there is uncertainty as to whether the hospitalization is required for a pensioned condition.

Payment of Semi-private and Private Accommodations

9. Payment may be made for semi-private or private accommodations for care for a disability benefit recipient (A-line) or for chronic care for a non-disbaility benefit recipient (B-line) if:
   1. A semi-private or private room is medically warranted because of the seriousness of the Veteran’s condition, as certified in writing by the attending physician;
   2. A semi-private or private room is medically warranted for the safety of other patients, as certified in writing by the attending physician;
   3. There is no other suitable accommodation and the semi-private or private room is not covered by a provincial health or hospital insurance plan. In this case, the semi-private or private room rate may be paid until such time as a ward accommodation becomes available; or,
   4. The facility does not provide ward accommodations, in which case payment may be made for semi-private accommodations.
10. Payment cannot be made for private or semi-private rehabilitative or acute care hospital room charges for non-disbaility benefit recipients (B-line), as provincial/territorial health or hospital insurance plans are responsible for providing these services to those Veterans, if required.

Convalescent Care

11. Convalescent care is care intended to enable an individual to recover their strength, endurance and independence.
12. Convalescent care may be authorized for a person who, in the opinion of the attending physician:
    1. is not ready to return home following hospitalization for surgery or serious illness; or
    2. does not require acute care in hospital due to a medical condition, but requires short-term care for convalescence.
13. Convalescent care may be provided to Veterans who satisfy the eligibility requirements as outlined in paragraphs 4 and 5.
14. Convalescent care is not intended to replace intermediate or chronic care. Veterans in convalescent care should be monitored to determine whether or not they require intermediate or chronic care (refer to the policy entitled Approval Authorities, Assessments, Cost of Care, and Kinds of Accommodation Payable).

References

Eligibility for Heath Care Programs – Eligible Client Groups

Canada Health Act, section 2

Veterans Health Care Regulations, section 4

Approval Authorities, Assessments, Cost of Care, and Kinds or Accomodation Payable policy

Requirement to Access Provincial Programs policy

Treatment for a Disability Benefits Entitled Condition policy

Guide to Treatment Benefits, health-related travel and VIP (Blue Cross)