Rates Payable for Treatment Benefits

/sites/default/files/pdf-e2049-200622091958.pdf

Issuing Authority

Director General, Policy and Research

Effective Date

April 01, 2019

Document ID

2049

Purpose Policy General Veterans Receiving Treatment Benefits for their Disability Benefits Entitled Condition All Other Eligible Veterans Premiums and Fees Veterans Accessing Services in Private Clinics Payment of Home Visits by Health Professionals References

Purpose

This policy outlines the rates payable for treatment benefits under section 5 of the Veterans Health Care Regulations.

Policy

General

For the purpose of this policy, a reference to the term “Veteran” is interpreted to include all individuals eligible for payment of treatment benefits. For detailed information on eligibility, refer to Eligibility for Health Care Programs – Eligible Client Groups.
Veterans Affairs Canada (VAC) covers for the cost of health care benefits and other services provided to eligible individuals by health professionals who are approved by the Minister (see Health Professionals policy for additional information).

Veterans Receiving Treatment Benefits for their Disability Benefits Entitled Condition

Veterans who have a disability benefits entitled condition may receive treatment for the eligible entitled condition. These Veterans are commonly referred to as having A-line coverage (see the Treatment for a Disability Benefits Entitled Condition policy).
VAC may cover the cost of treatment benefits required by Veterans for their disability benefit entitled condition. These payments/reimbursements are made at the following rates:
1. Where the treatment benefits are fully insured health services of the province in which they are provided, the rate established by the province for those services;
2. For services approved by VAC and provided by health professionals who have established a fee schedule, the rates in accordance with the fee schedule, as approved by VAC. The fee schedule approved by VAC will not in all cases equal the rates contained in the association's fee schedule. The schedule should reflect the normal fees paid for these services in the community in which they are provided;
3. For other treatment benefits, the rate approved by VAC for specific treatment benefits. The rates for these benefits should reflect the costs normally paid for these services in the community in which they are provided.

All Other Eligible Veterans

All other eligible Veterans, commonly referred to as having B-line coverage, must access available provincial/territorial and community programs first, before receiving treatment benefits at VAC’s expense. Therefore, Veterans may only be authorized to receive reimbursement for such benefits to the extent that the benefits are not available under a provincial health care system, or if applicable, from the Canadian Armed Forces, or if the cost of the benefits is not recoverable from a third party (refer to the policies entitled Requirement to Access Provincial Programs and Costs Recoverable from Third Parties for additional information). However, Veterans are not required to apply for social assistance in order to access the required provincial/territorial or community program.
Payments/reimbursements for eligible Veterans are made at the following rates:
1. VAC will not cover the cost for treatment benefits which were provided without charge to the Veteran under a provincial/territorial or community program;
2. VAC may cover the costs (e.g. deductible and/or co-payment) of treatment benefits the Veteran is eligible to receive and required to pay under a provincial/territorial or community program; and
3. Payment/reimbursement may be made for treatment benefits that are approved by VAC and unavailable to the Veteran, as resident of a province/territory or community, at the following rates:
  1. For health professionals' services, up to the rate outlined in the health professional association's approved fee schedule (see paragraph 4 b); and
  2. For other treatment benefits, at the rate approved by VAC as being usual and customary for the specific treatment benefit (see paragraph 4 c).

Premiums and Fees

Eligible Veterans as identified in the Premiums and Fees policy may receive the cost of premiums and fees (e.g. Medical Services Plan for B.C. residents and Régie de l’assurance maladie du Québec) payable to access provincial or municipal services.

Veterans Accessing Services in Private Clinics

VAC may pay up to the provincial rate for an eligible Veteran with A-line coverage who accesses a service at a private clinic if the service:
1. could have been obtained through the provincial system; and
2. being obtained is in relation to the disability benefits entitled condition.
If a Veteran with B-line coverage chooses to access a private clinic for a service which is covered by the provincial insurance system, VAC will not pay for this service.