RECIPROCAL BILLING & MEDICARE
Repealing New Brunswick’s regulation is critical not only to improve hospital access for New Brunswick, but to ensure that anyone who moves to or travels to another province will be automatically covered for abortion care if they need one.
What is Reciprocal Billing?
As per Health Canada: “Residents moving from one province/territory to another continue to be covered by their ‘home’ province/territory during any minimum waiting period, not to exceed three months, imposed by the new province/territory of residence. After the waiting period, the new province/territory of residence assumes your health care coverage.”
For example, if you are visiting another province and get injured in a car accident, you don’t have to worry about your healthcare insurance – you are automatically covered under Canada’s Reciprocal Billing Agreement between provinces (except for Quebec, which is not part of the Agreement).
One of the five guarantees of the Canada Health Act is portability. The intent of this provision is to allow Canadians to obtain hospital and medical health care services outside their home province without having to pay point of service fees.
The federal Interprovincial Health Insurance Agreements Coordinating Committee administers the interprovincial/territorial agreements for health services. All provinces participate in these agreements, with the exception of Quebec, which participates in the hospital agreements, but not the medical agreements.
In practice, with some exceptions, if a patient presents a health care card in another province or territory, it will be accepted in lieu of payment. The province or territory providing the service will then directly bill the patient’s home province.
The “Excluded Services” List
Despite the fact that abortion is a legal medical service, and is treated as an insured service in every province in Canada, it is one of the exceptions included on a list of excluded services list (see Sidebar below for full list) in the Reciprocal Billing Agreement. Canadians must pay out of pocket for services on that list during the minimum waiting period, usually three months. Only 14 services are included on the list, and all of them except abortion are:
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Not a time-sensitive procedure, or
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Insured by a federal institution such as the military, the RCMP or Corrections Canada, or
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Still in an experimental stage, or
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A service where a more conventional (cheaper) treatment exists
Abortion Does Not Belong on the List
Because abortion is on the excluded services list, it creates a tremendous burden to women (and *trans persons) in need of abortions, particularly students who are temporarily living away from home, or those who have recently relocated to another province and have not yet qualified for health care insurance in their new home province.
Excluded Services List
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Cosmetic surgery to alter appearance.
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Sex-reassignment.
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Surgery for reversal of sterilization.
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Routine periodic health examinations, including routine eye examinations.
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Therapeutic abortion.
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In-vitro fertilization; artificial insemination.
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Lithotripsy for gall bladder stones.
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Treatment of port-wine stains other than on the face or neck
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Acupuncture, acupressure; transcutaneous electro-nerve stimulation (TENS), moxibustion, biofeedback, hypnotherapy.
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Services to persons covered by the RCMP, Canadian Armed Forces, Workers’ Compensation Board, Veterans Affairs, Correctional Services (federal penitentiaries)
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Services requested by a third party (i.e., your employer, insurance company)
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Team conferences.
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Genetic screening and other genetic investigations, including DNA probes.
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Anaesthetic services and surgical assistant services associated with any of the above.
Abortion is a very time-sensitive procedure. Women cannot always wait until their insurance is activated in their new province of residence (usually three months) as it could mean waiting to a point beyond the gestational limits of many abortion services. Travelling home usually doesn’t work either, for the cost of travel is often more than the abortion procedure itself. If you are a student, or have recently moved to obtain work, the cost of an abortion is an often an enormous and sometimes insurmountable burden.
Abortions are insured by the provinces, yet outside the home province are only insured if a woman is a member of the RCMP or military or is incarcerated. A pregnant woman who chooses to continue her pregnancy however, will continue to receive health services wherever she may be in Canada.
Finally, abortion methods used in Canada today are safe, reliable, and conventional—certainly not experimental. There is no other safe treatment available to terminate a pregnancy, and in fact, abortion is cheaper than pregnancy and delivery care.
Exclusion of abortion from a health policy that benefits Canadians for most other health services, discriminates against women on the basis of sex. It remains on the list of excluded services because some politicians and their provincial health bureaucracies wish to restrict access. Without unanimous consent of the interprovincial committee, this inequity will continue to exist, and pregnant women who are living away from home and are unable to continue their pregnancies will find themselves disenfranchised from their health care insurance.* It is time the workings of this committee were exposed, and the committee made accountable to Canadian women.
What Can Be Done?
No-one knows how or why abortion got on the excluded services list in the first place – not even the Interprovincial Health Insurance Agreements Coordinating Committee.** Furthermore, the Committee claims they do not have the authority to make any changes to the list.
There appears to be only three possible ways to remove abortion from the excluded services list:
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Consensus by all provinces and territories
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Direct intervention by the federal Health Minister
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A lawsuit
The Committee has been unable to achieve consensus because New Brunswick is the sole province withholding its agreement. It probably refuses to join the consensus because it knows that would render its Regulation null and void. The province would be forced to concede that all abortions are medically necessary, as it would be paying for abortions on request for NB women living in other provinces. Of course, no other jurisdiction in Canada has a two-doctor approval process to “certify” that the abortion is medically necessary.
Lawsuits are very expensive and time-consuming, but another problem is figuring out who to sue, since no one appears to be responsible for the excluded services list.
Unfortunately, women in Canada are probably stuck with abortion being on the excluded services list until New Brunswick repeals its regulation, or until we have a different federal government willing to step in and remove it from the list.
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* Some provinces recognize the hardship created by this inequity, so some unofficial arrangements have been struck between a few service providers and provincial or territorial healthcare plans. These local arrangements allow women to use a designated abortion service outside the province without having to pay point-of-service fees. Such arrangements greatly benefit women in areas of Canada where local abortion services are abysmal, but they are not the solution. There is no universality because availability of coverage depends solely on the policies of the woman’s province of residence. For example, provider-insurer arrangements only permit women to use designated services, usually in the nearest province. In practice, a Saskatchewan patient can go to Alberta and Manitoba clinics free of charge, but if she's living in BC, she must travel to Alberta for an insured abortion. Also, arrangements are unofficial; sometimes even verbal, and are therefore subject to cancellation without notice or cause.
** The information in this section was derived from a research presentation on reciprocal billing given by lawyer Nitya Iyer at the National Abortion Federation conference in Vancouver in in April 2012.
How New Brunswick’s Regulation Hurts All Canadian Women
(Editor's Note: The article below was written in August 2014. On Jan 1, 2015, the NB government repealed Reg 84-20, which should open the way to finally fix the reciprocal billing problem in 2015. Stay tuned!)
Few people realize that New Brunswick’s unconstitutional payment regulation also deprives other Canadians of abortion funding. If a woman or trans* person from any province – not just New Brunswick – moves to another province, they must pay out of pocket for an abortion until they meet the residency requirement for that province. That’s because abortion is wrongly excluded from the Reciprocal Billing Agreement between provinces.
All provinces and territories are willing to fix this situation by taking abortion off the “excluded services” list – except for New Brunswick. It refuses to agree because it means the province would have to pay for out-of-province abortions for NB women without the two-doctor approval process.