Except as noted in these Guidelines, the referral or opinion of a specialist from outside of BC will not be accepted in support of an application for out of country funding.
the medical care or service applied for is unproven, experimental, or in the early stages of development;
Funding is not provided for unconventional, experimental or developmental* treatment, emerging treatments or diagnostic processes or clinical trials where the efficacy of the service is not known.
The appropriate medical specialist making application on behalf of a beneficiary for pre-approval of out of country new or emerging medical services and treatment under this provision must provide documentation of reputable clinical trials beyond Phase III, published in peer reviewed medical literature.
an application for services that are not considered benefits under the Medicare Protection Act, the Medical and Health Care Services Regulations or the Hospital Insurance Act and Regulations. Such services include travel and related accommodation costs, ambulance fees, out of hospital drug costs and services provided by non-physician professionals; or
an application for supplementary benefits* to be provided by a health care practitioner.*
GUIDELINES SPECIFIC TO ELECTIVE (NON-EMERGENCY) OUT OF COUNTRY CARE
Additional Consultations and Investigations
In the event that the appropriate specialist(s) in BC and Canada has not been able to provide
a diagnosis or medical management plan, coverage may be approved for out of country consultations and medically necessary related investigations. If funding is approved, payment will be made up to negotiated U&C* rates.
If there is a working diagnosis and/or medical management plan, and the appropriate BC specialist requests another opinion from an out of country centre of excellence, coverage will be reviewed and if funding is approved, payment will be made up to the BC fee rates.
If the out of country medical treatment is recommended to the beneficiary as a result of out of country consultations and related investigations, coverage will be reviewed under the Guidelines.
Coverage for Continuing Out Of Country Medical Care
If coverage is approved for out of country medical care and the attending specialist wishes to extend the treatment period, the specialist must submit the application to extend funding for out of country treatment and must include the current medical evaluation, the treatment plan and the transfer protocol.
If a beneficiary does not have a family/support network in BC, and the appropriate specialist supplies evidence to detail how family support is essential to a patient's recovery, coverage may be considered for out of country medical care in the location in which that family support is available. The coverage decision will take into consideration the broad range of provincially funded community and social services that are available in BC.
If coverage is approved under this provision, payment will be made at the BC rates for physician and hospital services, in Canadian funds.
Terms with an asterisk are defined in Appendix 1
Medical Services Commission Out of Country Funding Guidelines January 19, 2011