Chronic care/complex continuing care

In Ontario, the term complex continuing care (CCC) is used interchangeably with chronic care. Chronic care provides continuing, medically complex and specialized services to both young and old, sometimes over extended periods of time. Chronic care is provided in hospitals for people who have long-term illnesses or disabilities typically requiring skilled, technology-based care not available at home or in long-term care facilities. Chronic care provides patients with room, board and other necessities in addition to medical care.

Hospital chronic care co-payment

Patients receiving publicly funded chronic care as insured persons under the Ontario Health Insurance Plan (OHIP) in a designated hospital can be required by the hospital to contribute to the cost of their meals and accommodation through a co-payment if, in the opinion of the attending physician, the patient both requires chronic care and is more or less permanently resident in hospital or another institution, including a Long-Term Care (LTC) Home.

Subject to the attending physician having both those opinions, this includes patients in designated hospitals who are Alternate Level of Care (ALC) for a long-stay bed in an LTC Home.

Not all ALC patients can be charged a chronic care co-payment. The immediate and longer-term discharge destinations of ALC patients are important to making a determination on whether the hospital chronic care co-payment applies. A patient who has an immediate or longer-term discharge destination in the community cannot be charged the co-payment. For example, ALC patients requiring chronic care who have been designated as requiring (and are waiting for) a short-stay Convalescent Care Program bed in an LTC Home or for home care, supportive housing, or other care in the community cannot be charged the co-payment.

For ALC patients with an immediate next destination of a rehabilitation bed or complex continuing care bed in hospital, the attending physician must consider whether the patient may ultimately be discharged to the community. If the patient is expected to ultimately be discharged to the community following their expected stay in the rehabilitation or complex continuing care bed for which they are currently waiting as an ALC patient, the chronic care co-payment does not apply.

Conversely, if the patient is expected to remain more or less permanently resident in hospital or another institution, even subsequent to their anticipated stay in the rehabilitation or complex continuing care bed they are currently waiting for as an ALC patient, then the chronic care co-payment would apply. For example, if a patient in an acute care bed is ALC and waiting for a rehabilitation bed (to acquire adaptive skills, for example) and is expected, following their future stay in that rehabilitation bed, to require long-stay care in an LTC Home, then the attending physician could form the opinion that the patient was more or less permanently resident in hospital or another institution, and the chronic care co-payment would apply.

Patients who are subject to the chronic care co-payment may not be charged more for their meals and accommodation than the maximum chronic care co-payment rate set out in the regulations and this document.

Hospital chronic care co-payment revenue

The money collected from the hospital chronic care co-payment is not government revenue. Each hospital collects the co-payment and uses the money to support its operations.

Co-payment charge schedule, calculation and rates

Start date for co-payment charges

The attending physician’s determination that the patient requires chronic care and is more or less permanently resident in the hospital or other institution is the start date for co-payment charges, as such charges are applicable.

Hospital administrators should note that co-payments only begin to apply from the date of the attending physician’s determination that a patient requires chronic care and is more or less permanently resident in hospital or another institution, and not because the patient has exceeded any expected length of stay.

Maximum co-payment rate effective July 1, 2023

Effective July 1, 2023, the maximum co-payment rate is $65.32 per day, or $1,986.82 per month.

Calculating the co-payment rate increase

The ministry is increasing the basic daily maximum co-payment rate by the Consumer Price Index (rate of inflation). Although the CPI rate as of December 31, 2022 was 6.8%, the total increase effective July 1, 2023 is capped at 2.5%.

Next co-payment rate increase

The chronic care co-payment has historically been adjusted annually. This change generally occurs on July 1 of each year.

Note: Hospitals are required to give patients at least 30 days written notice of any increase.

Hospitals charging the co-payment

Only certain hospitals are entitled to charge a co-payment.

Section 10(2) of Reg. 552 under the Health Insurance Act (HIA) specifies which hospitals may charge a co-payment. Where amalgamations have occurred between hospitals, hospital administrators are advised to verify whether their particular site or campus is entitled to charge co-payments.

Co-payment rate reduction calculations

Patients exempt from paying the full co-payment rate

In the following circumstances, either no co-payment or only a partial co-payment applies:

Exempt patients
The following patients are exempt under the regulations from any co-payment:any patient under 18 years of ageany patient who, on the day before the patient was admitted to the hospital where they are receiving insured in-patient services, was receiving:income support under the Ontario Disability Support Program Act, 1997 orincome assistance under the Ontario Works Act, 1997
If either condition above applies, the co-payment cannot be charged.
Low-income patients
Low-income patients are eligible to apply for a reduced co-payment rate based on their estimated income. Please refer to the section Calculating estimated income.
Patients with dependents
Patients with dependents, as defined below, may apply for a reduced co-payment rate.
The reduced co-payment rate depends on the monthly aggregate income of the patient and their dependents, and the number of dependents that a patient has.
The table below sets out estimated monthly income levels that guide a patient’s eligibility for a reduced rate where the patient has dependents. If the monthly aggregate income of the patient and their dependents falls in the range for partial rate reduction, patients will pay a portion of the co-payment.
Monthly aggregate income (patient and dependents) determining care co-payment rates, effective July 1, 2023.
Number of dependentsNo co-paymentReduced co-paymentMaximum co-payment
One$4,393 or less$4,394 – $10,353$10,354 or more
Two$5,018 or less$5,019 – $10,978$10,979 or more
Three$5,593 or less$5,594 – $11,553$11,554 or more
Four or more$6,103 or less$6,104 – $12,063$12,064 or more

For the purposes of chronic care co-payment rates, a "dependent" means:

  • a spouse who is not receiving benefits under the Old Age Security Act (Canada) or the Ontario Guaranteed Annual Income Act and was co-habiting with the patient immediately prior to the patient being admitted to the hospital, or if continuously hospitalized, immediately before first admitted or
  • a child under 18 years of age
  • patients with spouses who are not dependents

A co-payment reduction may still be available if the patient has a spouse in the community who is not a dependent. Specifically, a patient or their spouse may apply for a rate reduction if:

  • the spouse was cohabiting with the patient immediately before the patient was admitted to the hospital where they are receiving insured in-patient services or, if the patient has been in more than one hospital or institution continuously, immediately before the patient was first admitted to the hospital they are currently in
  • the spouse is receiving benefits under the Old Age Security Act (Canada) or the Ontario Guaranteed Annual Income Act
  • the spouse lives outside an LTC Home, hospital, or other government-funded facility

See Hospital chronic care co-payment forms for information about the application form for this reduction.

Financial hardship
A patient may also be able to apply to the hospital to pay a reduced chronic care co-payment if they are experiencing financial hardship and do not qualify for a rate reduction under the criteria outlined above. In such cases, it is within the discretion of the hospital to waive a portion of the chronic care co-payment. Although hospitals may apply the chronic care co-payment provisions and collect chronic care co-payments as set out in the relevant regulations, there are no mandatory minimum co-payment amounts set out in the regulations and hospitals may, at their discretion, determine an appropriate co-payment amount.

Calculating estimated income

For purposes of calculating co-payment rates, estimated income means the average monthly income of the patient and the patient’s dependents, as applicable, as estimated by patient or the patient’s representative, of any nature or kind whatsoever, so long as it is taxable under the Income Tax Act of Canada.

This amount includes taxable income from:

  • the Old Age Security (OAS) pension and Canada Pension Plan (CPP) pension, or any other taxable pensions
  • any other payments received under any Act of Parliament of Canada or Ontario law, unless listed below under the section excluded income
  • salaries and wages
  • an interest in, or the operation of, a business
  • investments

The income of any family members who are not dependents of the patient is not relevant to income calculations, except that the income of a non-dependent spouse may be considered in the case where a patient (or their spouse) chooses to apply for a co-payment reduction (see Hospital chronic care co-payment forms).

Excluded income

Non-taxable income sources

The following income sources are not taxable and are therefore excluded from estimated income calculations:

Note: Hospital administrators are advised to contact the Canada Revenue Agency to determine which portion of the GIS, if any, is non-taxable.

Other income sources

The following income sources are also excluded from estimated income calculations:

Notice of Assessment (NOA) or the hospital chronic care co-payment form worksheet to calculate estimated income

It is permissible to use the patient’s recent Notice of Assessment (NOA) so long as the hospital has confirmed with the patient that the NOA accurately reflects their current situation. Please note that Reg. 552 under the Health Insurance Act (HIA) does not require an NOA as an income statement, as some patients do not receive NOAs, while for other patients, an NOA may not be a current, accurate, or complete reflection of their income. However, where a patient indicates that their recent NOA does reflect their current income, then Line 260 (taxable income) on the NOA is the most accurate reflection of taxable income for the purposes of calculating the hospital chronic care co-payment.

There is no need for patients to provide a break-down of the taxable income figure on Line 260 if it has already been calculated for an NOA and the patient confirms that it accurately and completely represents their current estimated taxable income. The worksheet included in the Hospital Chronic Care Co-payment Form is provided in case a patient doesn’t have an NOA, or indicates that the taxable income shown on their NOA is not current, accurate or complete, in which case they would need to provide their taxable income by source as indicated on the worksheet. The documentation they should show in that case should be determined by the hospital, having consideration for what is reasonable in the circumstances.

Responsibility for co-payment

Only the insured patient is responsible under the regulation for any co-payments.

Third parties
Depending on the patient’s circumstances, a third party such as the WSIB, a private insurance company, the Department of Veterans’ Affairs, or other federal government agency may pay amounts for accommodation and meals on behalf of the patient. The patient is responsible for determining whether these resources are available to them.

Inclusion of assets in calculating co-payment amount

Assets like a home or RRSP (Registered Retirement Savings Plan) are not included in co-payment calculations.

Hospital chronic care co-payment forms

Annual co-payment rate change

Beginning on July 1, 2018, and every July 1 thereafter, daily co-payment rates will be automatically adjusted by the percentage increase in the Consumer Price Index (CPI), if any, for the 12 month period ending on December 31 of the previous year, up to a maximum of 2.5%, and rounded to the nearest $0.01.

To protect patients from potential spikes in inflation rates, annual increases in the co-payment rate will not be more than 2.5%, even if the rate of inflation is higher than 2.5%. If the percentage change in CPI is greater than 2.5%, the amounts will instead be adjusted by 2.5%. If the percentage change in CPI is negative, the amounts will not be adjusted.

Annual percentage increase in the CPI

The percentage increase in the CPI for a calendar year is the increase to the Consumer Price Index for Canada (All-items) for the calendar year, as reported by Statistics Canada under the authority of the Statistics Act (Canada).

Notifying the public about changes to chronic care co-payment rates

The ministry will continue to provide notifications of changes to hospital chronic care co-payment rates. The numerical values of the daily and monthly chronic care co-payment rates will continue to be published each year in a revised version of this information page. In addition, updated versions of Monthly aggregate income (patient and dependents) determining care co-payment rates, will also continue to be provided.

Please note that the rates can also be determined with use of the table entitled “Table maximum co-payment amounts on or after July 1, 2018” found under s. 10 of the Regulation.

Comfort allowance

The comfort allowance is the portion of income retained by low-income hospital patients receiving chronic care for their personal needs above and beyond the meal and accommodation services funded through the co-payment such as clothing, telephone and cable services, and the Ontario Drug Benefit Program’s mandatory prescription co-payment.

Comfort allowance rate increase in 2018

The comfort allowance increased by 2.0% on September 1, 2018. Since the comfort allowance amount is rounded, the proposed increase resulted in the comfort allowance increasing from $146.00/month to $149.00/month. This increase is aligned with the increase to the Ministry of Children, Community and Social Services’ Personal Needs Allowance (PNA). Maintaining alignment between the comfort allowance and the PNA is desirable to promote equity and consistency among low-income Ontarians receiving personal needs benefits under publicly funded programs.

Calculating the comfort allowance increase

The comfort allowance is always stated as an even dollar amount. Thus, any increase is rounded up to the nearest dollar, so the person benefits fully from the increase.

Comfort allowance and co-payment rate reduction for eligible patients

Effective September 1, 2018, hospital chronic care patients approved for reduced co-payment rates will be able to retain an additional $3 per month for their comfort allowance.

Since hospitals have their own system through which rate reductions are administered, hospital administrators are required to make the adjustment for patients with reduced co-payment rates to ensure they retain the additional $3 per month.

Chronic care co-payment provisions

Patients in rehabilitation

The type or designation of the bed (for example, rehabilitation beds or complex continuing care beds) a patient occupies does not determine whether the patient can be charged a chronic care co-payment.

The co-payment provisions apply to any patient who, in the opinion of the attending physician, requires chronic care and is more or less a permanent resident in a hospital or other institution. For example, if a patient is in an acute or rehabilitation bed and, in the opinion of the attending physician, requires chronic care and is more or less a permanent resident in a hospital or other institution, then the patient is subject to the co-payment provisions.

Patients in complex continuing care beds

A patient who occupies a complex continuing care bed with a discharge destination that is not another hospital or a long-stay bed in a LTC Home is not more or less permanently resident in a hospital or other institution and therefore is not subject to the chronic care co-payment.

Patients awaiting placement

A patient who is awaiting placement for a short stay in a LTC home, retirement home, group home, or assisted living facility is not more or less permanently resident in a hospital or other institution and therefore is not subject to the chronic care co-payment.

Patients on waiting lists

For a patient with a discharge destination that is not a hospital or other institution, the patient’s expected length of stay in hospital while on a waitlist for discharge to a destination in the community is not determinative of whether they are subject to the chronic care co-payment. There is no absolute number of days for an expected length of stay or time on a waitlist that triggers the application of the chronic care co-payment. In all cases, the attending physician must be of the opinion that the patient is more or less permanently resident in a hospital or other institution in order for the co-payment to apply.

Chronic care patients requiring acute care

It is anticipated that chronic care patients may be hospitalized for many years. During this period of hospitalization, unanticipated acute episodes may occur, such as pneumonia, heart attack, etc.

If the patient requires acute care or some other type of care but still requires chronic care and will be more or less permanently resident in the hospital, the co-payment remains applicable.

However, if the attending physician is of the opinion that the patient no longer requires chronic care for a period of time, the co-payment cannot be charged during that period of time.

Patients receiving palliative care

Patients receiving palliative care cannot be charged the chronic care co-payment. A patient does not have to have been admitted as a palliative care patient to be exempted from the chronic care co-payment provisions.

Where a patient who was receiving chronic care and was subject to the chronic care co-payment provisions becomes a patient requiring palliative care, as determined by an attending physician, any requirement to pay a chronic care co-payment ceases on the day that the physician determines that the patient requires palliative care.

A patient receiving palliative care cannot be charged the chronic care co-payment simply because they have been receiving palliative care for an extended period of time. So long as the patient is receiving palliative care, no matter how long, they cannot be charged the chronic care co-payment.

The following example explains when co-payments are chargeable

  • May 1 — Patient admitted as acute care and remains acute for 10 days — no co-payment
  • May 11 — Attending physician determines that the patient both requires chronic care and is more or less permanently resident in hospital or another institution, including a Long-Term Care (LTC) Home — co-payment payable as of May 11th
  • October 1 — Attending physician determines that the patient is now palliative — no co-payment from October 1st onward so long as patient continues to receive palliative care

In this scenario, the co-payment provisions could apply from May 11th until September 30th only.

Patients receiving psychiatric care

A patient admitted to hospital under the Mental Health Act cannot be charged the co-payment, even if they have been designated as requiring chronic care or if they are waiting for LTC placement.