Health Care Outside Ontario

Policy

The WSIB expects Ontario workers to receive health care in Ontario. However, there may be situations when workers are entitled to emergency or elective health care outside Ontario as a result of a work-related injury or an occupational disease. If the WSIB approves such care, it is provided and paid for at a rate that the WSIB determines is proper and reasonable.

Guidelines

Emergency health care

For purposes of this policy, emergency health care is the initial treatment a worker requires immediately following an accident or the recurrence of an injury or occupational disease. For other health care definitions, see 17-01-02, Entitlement to Health Care.

Emergency health care generally addresses a critical period of the condition, and ends when:

• the worker is able to safely return to an Ontario health care practitioner or an Ontario facility for further treatment, or
• the worker is able to return to work, or
• the worker is fully recovered,

whichever is sooner. (For non-resident requirements, see below.)

Workers who receive emergency health care outside Ontario and continue to need care, are expected to return to Ontario for treatment at a health care facility, as soon as possible.

Pre-authorization

Emergency health care cannot be scheduled in advance, therefore, no pre-authorization is expected. The WSIB normally pays the full cost of such care, but may review the account with the service provider if it exceeds the payment guidelines.

Elective health care

Elective health care is treatment that can be scheduled in advance.

Pre-authorization

Workers must get the WSIB's approval before going for treatment. The WSIB pays the full cost of treatment only if it considers the treatment and charges appropriate.

The WSIB may approve the type of treatment requested, but may not approve providing it outside the province of Ontario (for Ontario residents), or outside the place of residence (for workers residing outside Ontario).

Workers are individually liable for any costs incurred in excess of the WSIB's treatment fees.

Ontario residents

Workers may be entitled to necessary elective health care outside Ontario (in other provinces or in the United States) if:

• the required health care is not available/offered in Ontario. When making this decision, the WSIB considers whether a particular treatment provided in Ontario is equivalent to the clinical expertise or degree of specialization offered outside the province. (The advice of WSIB medical consultants is significant in these cases); or
• the out-of-province treatment is clinically appropriate. This applies when the worker's health could be put at risk by travelling a longer distance or waiting a longer period of time for treatment in Ontario. Risk can be measured by factors such as:
  • the possibility of significant deterioration
  • increased chance of permanent injury, or greater potential for the deterioration of a currently stabilized condition.
• the WSIB has adopted or negotiated a service agreement with an out-of-province agency (e.g., the Ministry of Health Preferred Provider Network for MRI services in the United States), and there is evidence that there will be reduced claim costs due to lower travel expenses and/or an earlier return to work.

Non-resident workers

For the purposes of this policy, non-resident workers are individuals:

• covered by the Ontario Workplace Safety and Insurance Act but who reside outside Ontario at the time of the accident (see 12-04-12, Non-Resident Workers), or
• who move out of Ontario after the accident.

As long as non-residents maintain an employment connection to Ontario, (e.g., they are employed by an Ontario company) they can choose to seek elective treatment in Ontario or in the community in which they reside.

If there is no longer an employment connection with Ontario, (e.g., a worker retires or takes a new job outside the province), the WSIB does not continue to pay for treatment in Ontario, unless otherwise authorized. In such cases, workers must seek elective treatment in their own community, as determined by availability and medical appropriateness.

The WSIB determines entitlement to elective treatment in locations outside Ontario and beyond the worker's own community, based on the clinical status of the worker and the availability and clinical appropriateness of the treatment required.

Payment guidelines

See summary below.

Interprovincial agreements

The WSIB has negotiated interjurisdictional agreements with each of the other Canadian workers' compensation boards that include provisions relating to health care (see 15-01-11, Interjurisdictional Agreement). If another workers' compensation board provides or arranges for health care for a worker at the request of the Ontario WSIB, the WSIB refunds the full amount paid.

The WSIB pays the Ministry of Health and Long-term Care's inter-provincial rates for any authorized emergency or elective health care outside Ontario, but still within Canada. These rates are established by the provinces for services provided to people who have coverage in one province but are receiving services in another.

No inter-provincial agreement has been signed by Quebec. The WSIB pays for health care provided, in Quebec, to Ontario residents at the WSIB's treatment rates. Services provided in Quebec to residents of Quebec or other provinces are paid at the Quebec provincial health care rates or at rates paid by Quebec's workers' compensation board.

Outside Canada

The WSIB has negotiated reciprocal agreements with Italy, Greece, and Portugal regarding permanent impairment/disability benefits, the provision of health care services, and other compensation benefits (see 17-03-05, Other Countries). If a worker falls under the provisions of such agreements, the WSIB pays the rate set by the compensation authority providing the treatment.

No agreement in place

If there is no applicable interprovincial or reciprocal agreement, the WSIB pays no more than would be properly and reasonably charged to workers, if the workers were billed directly and were paying the fees themselves in the community where the care is provided. In such cases the WSIB may pay as billed, or may review the billed rates to determine if the charge is reasonable based on the fee schedules established in the respective jurisdictions by their workers' compensation board or ministry of health.

Ontario treatment

If the WSIB determines that workers are only entitled to health care treatment in Ontario, services are paid according to the WSIB's schedule of fees.

If the WSIB approves treatment in Ontario, but the worker chooses to obtain the treatment outside the province, the worker is responsible for any costs above the WSIB's fee schedule.

The following charts summarize the payment rates for approved health care outside of Ontario.

Exception

The above guidelines do not apply if doing so would cause significant disruption to health care programs that were established before March 1, 1997.

Application date

This policy applies to all decisions made on or after June 1, 2023, regarding health care treatment provided on or after March 1, 1997, for all accidents.

Document history

This document replaces 17-01-04 dated October 12, 2004.

This document was previously published as:
17-01-04 dated July 7, 2000
17-01-04 dated June 15, 1999
8.12* dated January 1, 1998
06-02-08* dated February 4, 1997.

*documents were replaced by 17-01-04 dated June 15, 1999.

References

Legislative authority

Workplace Safety and Insurance Act, 1997, as amended
Sections 32, 33, 159(7), (8)

Workers' Compensation Act, R.S.O. 1990, as amended
Sections 50, 65(h), (i)

Minute

Administrative
#5, May 25, 2023, page 616