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  • 1.

    In relation to an application for elective out of country medical care, MSB may consider:

    • a)

      whether the treatment is recommended by the medical profession in BC and/or elsewhere in Canada;

  • b)

    if the treatment is experimental or developmental, Health Canada's position with respect to the efficacy of the treatment including if a drug or device has been approved by Health Canada for the proposed use;

  • c)

    if a procedure offered in the United States is beyond Phase III clinical trials and approved by the Centers for Medicare & Medicaid Services; and

    • d)

      whether all avenues for treatment within the Canadian healthcare system have been exhausted.

  • 2.

    Funding approval will not be granted in the following circumstances:

  • a)

    the application is incomplete;

  • b)

    the application is for services that are not medically necessary;

  • c)

    appropriate and acceptable medical care is available in BC or elsewhere in Canada;

  • (i)

    If an appropriate and medically acceptable treatment (standard of care) for a beneficiary's condition is available in BC or elsewhere in Canada, funding for out of country medical services will not be approved;

  • (ii)

    If appropriate and medically acceptable treatment for a beneficiary's condition is not available in BC or elsewhere in Canada because of significant medical controversy, and the appropriate specialist recommends out of country medical care that is of proven value,* and when prior approval is given, funding may be approved at a negotiated usual and customary rate (U&C)*.

  • (iii)

    The appropriate specialist making application on behalf of a beneficiary must provide documented evidence showing the requested out of country medical care will result in a significant difference in success or mortality rates for the patient's condition.

  • (iv)

    The existence of a wait-list in BC or elsewhere in Canada for the requested care will not be accepted as evidence that the care is not available in BC or elsewhere in Canada. The existence of a wait-list will only be taken into account in considering whether delay in the provision of medical care available in BC or elsewhere in Canada can be shown to be immediately life-threatening or result in medically significant irreversible tissue damage.

  • d)

    the delay in the provision of medical care available in BC or elsewhere in Canada cannot be shown to be immediately life threatening or result in medically significant irreversible tissue damage;

    • (i)

      The existence of a wait-list in BC or elsewhere in Canada for the requested care will only be taken into account in the context of determining whether there is evidence that the delay caused by the wait-list can be shown to be immediately life threatening or to result in medically significant irreversible tissue damage.

  • e)

    the application has been made without a referral from the appropriate specialist* involved in the beneficiary's care in BC;

  • *

    Terms with an asterisk are defined in Appendix 1

_________________________________________________________________________________________________________

Medical Services Commission Out of Country Funding Guidelines January 19, 2011

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