Hospital Chronic Care Co-Payment/Questions and Answers

September 2016



General co-payment information

What is chronic care/complex continuing care (CCC)?

In Ontario, the term "complex continuing care" 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.

What is the hospital chronic care co-payment?

Patients receiving publicly funded chronic care as insured persons under the Ontario Health Insurance Plan 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 copayment would apply. For example, if a patient in an acute care bed is ALC and waiting for a rehabilitation bed (e.g. to acquire adaptive skills) 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.

Where does the co-payment revenue go?

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

What date should be used as a 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.

What is the maximum co-payment rate effective July 1, 2016?

Effective July 1, 2016, the maximum co-payment rate is $58.99 per day, or $1,794.28 per month.

How have the co-payment increases been determined?

The ministry is increasing the basic daily maximum co-payment rate by the Consumer Price Index (rate of inflation) for 2015. The total increase effective July 1, 2016 is 1.1%.

$58.35 (old rate) + (1.1%) = $58.99 (new rate)

When will the chronic care co-payment be changed again?

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.

Which hospitals are authorized to charge co-payments?

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.

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Co-payment rate reduction calculations

Do all patients who are subject to the chronic care co-payment pay the full co-payment rate?

No. 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 age; and
    • Any patient who, on the day before the patient was admitted to the hospital where they are receiving insured in-patient services, was receiving:
  • Low-income patients
    Low-income patients are eligible to apply for a reduced co-payment rate based on their estimated income, as set out below in the answer to Patients with dependents.
  • 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 his or her dependents, and the number of dependents that a patient has.

    Table 1 below sets outs estimated monthly income levels that guide a patients’ eligibility for a reduced rate where the patient has dependents. If the monthly aggregate income of the patient and his or her dependents falls in the range for partial rate reduction, patients will pay a portion of the co-payment.

  • Table 1: Monthly aggregate income (patient and dependents) determining care co-payment rates, effective July 1, 2016.
    Number of Dependents No
    Co-Payment
    Reduced
    Co-Payment
    Maximum
    Co-Payment
    One $3,967 or less $3,968 – $9,350 $9,351 or more
    Two $4,533 or less $4,534 – $9,916 $9,917 or more
    Three $5,051 or less $5,052 – $10,434 $10,435 or more
    Four or more $5,512 or less $5,513 – $10,895 $10,896 or more

    For 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 he or she is 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; and
    • the spouse lives outside an LTC Home, hospital, or other government-funded facility.
      See Where can the forms for calculating chronic care co-payments be found 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 he or she is experiencing financial hardship and does 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 copayment provisions and collect chronic care co-payments as set out in the relevant regulations, there are no mandatory minimum co-payment amount set out in the regulations and hospitals may, at their discretion, determine an appropriate co-payment amount .

How is ‘estimated income’ calculated?

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; and
  • 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 Where can the forms for calculating chronic care co-payments be found?).

Excluded income:

  1. Non-taxable income sources: The following income sources are not taxable and are therefore excluded from estimated income calculations:

    [1]Where the income is $72,809 or greater, hospital administrators are advised to contact the Canada Revenue Agency to determine which portion of the GIS, if any, is non-taxable.

  2. Other income sources: The following income sources are also excluded from estimated income calculations:

Is it permissible to use the patient’s recent Notice of Assessment (‘NOA’) from the Canada Revenue Agency to determine the estimated income or is it necessary to use the worksheet provided on the Hospital Chronic Care Co-payment Form?

It is permissible to use the patient’s recent 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 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 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 if it has already been calculated for an NOA (i.e. Line 260) 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 show 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.

Are the patient's family members responsible for co-payments?

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

Do any other sources pay amounts for accommodation and meals on behalf of a patient?

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 him or her.

When calculating the co-payment, can the hospital consider the value of assets the patient (or their dependents) own, such as a home or RRSP?

No, assets are not included in co-payment calculations.

Where can the forms for calculating chronic care co-payments be found?

The following hospital chronic care co-payment calculation forms are available on-line.

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Comfort Allowance

What is the 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.

How much will the comfort allowance increase in 2016?

The comfort allowance will increase by 1.5%, effective September 1, 2016. Since the comfort allowance amount is rounded, the proposed increase will result in the comfort allowance increasing from $140.00/month to $143.00/month. This increase is aligned with the increase to the Ministry of 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.

How is the comfort allowance increase determined?

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.

Formula for increasing comfort allowance:
$140 x 1.5% = $2.10 which rounds up to $3.00. $140 + $3.00 = $143.00

How will the comfort allowance increase affect patients with rate reductions?

Effective September 1, 2016, 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.

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Application of the chronic care co-payment provisions

Can patients in rehabilitation beds in an acute care hospital be charged a chronic care co-payment?

The type or designation of the bed 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.

Are all patients in complex continuing care beds automatically subject to the chronic care co-payment?

No. The type or designation of the bed a patient occupies does not determine whether the patient can be charged a chronic care co-payment. 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 Long-Term Care 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.

Can a hospital patient who is awaiting placement in a retirement home, group home, or assisted living facility be charged the co-payment?

No. This patient is not "more or less permanently resident in a hospital or other institution" and therefore is not subject to the chronic care co-payment.

Can a hospital patient who is on a very long waitlist for a group home or assisted living facility, and is not likely to leave the hospital for a long period of time, be charged the co-payment?

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 he or she is 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 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.

Is the chronic care co-payment applicable to those patients who have been designated as requiring chronic care and more or less permanently resident in the hospital or other institution, but at some time following that designation require acute care services?

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.

Can a patient receiving palliative care be charged the co-payment?

No. 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, he or she 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.

Can a psychiatric patient be charged the chronic care co-payment?

No. 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 long-term care placement.

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