Your Guide To The Medicare Maze

DEREK CASSELS March 1 1970

Your Guide To The Medicare Maze

DEREK CASSELS March 1 1970

Your Guide To The Medicare Maze



Medicare is undoubtedly a major social achievement. But it can also be a monster of bureaucratic complexity for the patient. Whom does he pay? How much? For what? And is he taxed three times for one thing? For those who run a fever trying to figure out what to do with their doctor's bills, Maclean’s presents


AFTER A LONG and painful labor, Medicare was born as the 1960s ended. Essentially it is a bid to “socialize” medicine by melding government schemes with private-enterprise insurance and the billing practices of entrepreneurial doctors. A step forward? Yes, but the result is that an employee’s pay slip now reads like a computer printout for nuclear weaponry. It seems you need to become an accountant with a file clerk to assist you before you can risk being sick.

The confusion is compounded by the fact that while all but one of the provinces have agreed to join Medicare in principle, only seven had in fact done so by the beginning of 1970. And each of the seven has a different plan. Some are free; some cost as much as private insurance ever did. In one province, Medicare pays the total doctor’s bill; in another, only part. In some provinces you’re covered the moment you move there; in others you wait for three months, hoping to stay healthy. In one place, Medicare won’t even pay for an optometrist to test your eyes; in another it will even pay to have your corns cut.

It is impossible to detail here all the permutations of Medicare and privateinsurance plans. This is merely a quick and oversimplified guide to the riddle of Medicare across Canada. Since it’s not definitive, get copies of the local regulations and read the fine print. NEWFOUNDLAND is one of two provinces where Medicare is free — which means it’s paid for by federal and provincial taxes. If you live there, you’re covered, and the government will pay all doctor bills, and for some dental surgery performed in hospital.

To join, you fill in a simple form at the local post office, city hall or doctor’s office. Even if a resident — as opposed

to a transient, or visitor — has not formally applied, he’s still covered, but must fill in the form when he visits the doctor.

A word of warning: if you go to a specialist without first being referred to him by your GP, you may find yourself with an extra bill. That’s because the specialist will only be paid a GP rate by the government, and he can bill you for the difference.

Doctors and government have agreed that the Medicare fee (which is only 90 percent of the local medical association fee schedule) will be accepted as payment in full. Even if your doctor is not working within the Medicare plan, he must also send his bill to the government, which then pays you so you can pay him.

If your eyes are tested by an optometrist, you must pay. If you go to an ophthalmic surgeon (who is also a doctor), the government pays. The government is thinking of including optometrists.

The list of things not covered is much the same as in most other provinces. The government doesn’t pay for ambulances, drugs and appliances, medical examinations needed for employment, insurance — or for “nonessential” surgery, such as a nose job.

NOVA SCOTIA’s Medicare plan, like the one in Newfoundland, is free and covers all residents. With this difference: if you move to the province from a nonMedicare province then you must wait 90 days to be eligible. However, if you come from another Medicare province your coverage is valid during this time.

Again, ambulances and drugs are not included — but most provinces already have hospitalization schemes that cover ambulance costs, and cheap private insurance can cover drug costs.

If you are taken ill outside Nova Sco-

tia, the government will pay only what it pays doctors within Nova Scotia. If your out-of-province doctor charges more than that, then you pay the difference. But this is true of all provincial plans.

Only 16 Nova Scotia doctors have not joined Medicare, but if you consult one of them the government will pay its fee schedule and you must pay the difference — if any. If a participating doctor wants to charge more than the government fee, he must tell you beforehand.

It’s hard to say how many doctors are charging more than the fee schedule. About a quarter of the claims processed last year bore some indication that the patient was also being asked to pay an additional amount. But officials say that this proves nothing; it may be that all doctors are asking a few of their betterheeled patients to pay more than the fee schedule, or that just a few are doublebilling everyone they treat.

PRINCE EDWARD ISLAND has not yet said if it will join Medicare.

NEW BRUNSWICK is not yet in the federal scheme, and at the end of 1969 no date had been set for it to join. But enabling laws were passed back in December 1968 and, when it is finally introduced, the province’s plan will parallel those of Newfoundland and Nova Scotia, at least insofar as everyone who lives there will be covered free of charge. QUEBEC should be in the plan by July. What is proposed would be a universal, publicly administered provincial health plan in which the province’s share of the cost will be covered by a special provincial tax of 0.8 percent of a married man’s pay if he earns more than $4,000 a year, or the same percentage of a single man’s pay if he earns more than $2,000. Employers will pay the same amount for each employee. But the premium ceiling ►

No province makes it easier to join Medicare than Saskatchewan. None charges more than Ontario

will be $125 a year, so it can’t cost anybody more than that.

ONTARIO is where the Medicare Maze gets thickest, and where it is most expensive. Premiums are: $5.90 for a single person, $11.80 for a married couple, $14.75 for a family of three or more. However, if you are married, with two or more dependents, and earn less than $1,300 a year in taxable income you can plead poverty, and the government will partly subsidize your premiums. A couple with $1,000 or less in taxable income, and a single person with $500 or less, can also get a government subsidy.

And then, when you get to the doctor, it could — and often does — cost more than in other provinces. If the doctor’s bill is higher than the government is prepared to pay, then the fee gap is your responsibility. As in most other provinces, the government will pay only 90 percent of the fee schedule set by the provincial medical association. Since Medicare was introduced last October, indications are that most doctors are asking patients to cough up the extra 10 percent.

Ontario’s plan doesn’t include the frills found in the more generous schemes of BC and Alberta. But it does cover eye tests by optometrists. As elsewhere, most dental surgery performed in hospital is paid for. But again drugs, ambulances, “nonessential” surgery and some ancillary medical services are not provided for, so private insurance schemes to cover such areas still thrive.

If your company has more than 15 employees, both it and you must join the scheme. Anyone employing more than five people can also apply for membership.

It also takes time to get coverage in Ontario — there is a three-month vacuum between applying for membership and being covered.

However, in Ontario inadequacies of the provincial version of Medicare are a hot political issue, so changes are expected.

MANITOBA also charges for Medicare, but modestly. It costs 55 cents a month for a single person, and twice that for a family. As you move westward in Canada, you find changes, and increases, in the variety of medical services covered. Manitoba, for instance, will pay for optometrists and for chiropractors.

There is a 90-day waiting period between applying for coverage, and getting it. If you have come from another Medicare province, you’re in good shape because that province will accept responsibility for bills incurred during those 90 days. If you come from a non-Medicare

province, tough luck: you still have to wait 90 days, and hope you don’t fall sick in that time.

By law, residents must register with the plan. As everywhere, registration is relatively simple — just fill in the appropriate forms at the local city hall or at your place of work; your employers usually will deduct your premiums from your pay. Otherwise, you must pay at least one month in advance.

Regular checks are made to ensure premiums are being paid. If you’re a defaulter, you are still covered under the plan, but may be prosecuted.

The province’s plan pays 85 percent of the medical association fee schedule, and participating doctors accept this as payment in full. A nonparticipating doctor must tell you before he begins treatment, and it’s up to either him or you to claim as much as the government will pay. You cough up the rest. SASKATCHEWAN is, of course, where socialized medicine began in North America eight years ago. And yet it isn’t as “socialist” as in some other provinces that have since joined the federal Medicare plan.

For instance, it isn’t free: the premiums are one dollar a month for a single person, and two dollars for families. And then there is the “utilization fee.”

When Saskatchewan first introduced socialized medicine there was a massive increase in the number of people consulting doctors. This placed too large a strain on the province’s medical facilities, so to dissuade people from indiscriminate use of the services the government started charging the patient $1.50 every time he visits a doctor and two dollars when the doctor visits him. This “utilization fee” worked: the pressure was almost immediately eased.

But it is easier to join Saskatchewan Medicare than to join any other provincial scheme. You don’t even have to fill in a form, but you do have to go to your local provincial government office and provide details of your family.

Again, optometrists are included in the plan, though chiropractors are not. As elsewhere, big firms usually collect premiums through payroll deductions, but the fine print of the Act says it is each individual’s personal responsibility to ensure the premium is paid.

Bills are paid in one of three ways. The doctor can bill you; bill the government; or bill one of two doctor-sponsored plans, which then pass the bill on to the government. This last option is provided for doctors who find it distasteful to deal directly with the government. Doctors who bill the government directly or use

the doctor-sponsored plans are tacitly agreeing to accept 85 percent of the provincial medical association fee schedule as payment in full for their services. If the doctor bills you directly he can charge more than the 85 percent, and you pay the difference. The onus is on the doctor to tell the patient what his billing practice is.

ALBERTA, like Manitoba, won’t cut you off from medical treatment if you don’t pay the premiums of five dollars a month for a single person and $10 per family. But if you default, you’re breaking the law and may be prosecuted.

All residents must register, and there is no waiting period: you’re covered the moment you fill in the form.

Until the end of last year, the government paid 100 percent of the provincial medical association fee schedule. But then the fee schedule was revised upward, and the government didn’t immediately accept the new charges. Result: patients were sometimes asked to pay the difference between old and new fees. But an adjustment to match Medicare fees and the medical association fee schedule is in the works.

As elsewhere, dental care is covered only if it is surgery performed in hospital. But otherwise, the Alberta scheme is more liberal. It includes optometrists, chiropractors, podiatrists, osteopaths and appliances prescribed by podiatrists. BRITISH COLUMBIA is a great place to be sick. All doctors are participating members of the Medicare plan, which means they all accept 90 percent of the medical association fee schedule as payment in full.

Premiums are five dollars a month for a single person, $10 for a couple and $12.50 for a family. As everywhere else, the “nonessential” surgery — that new nose job again, or any other kind of cosmetic surgery —«, is a luxury you pay for yourself. But the BC plan throws in more extras than any other province.

Apart from doctors and surgeons and optometrists, the plan covers chiropractors, naturopaths, osteopaths, podiatrists and orthoptic treatment (correction of defective visual habits). Physiotherapists, Red Cross nurses, special nursing care and visits by the Victorian Order of Nurses can also be paid for under the plan. And if you earn less than $1,000 taxable income, the government will help pay the premiums.

But if all this makes you want to move to the hypochondriac’s Valhalla, be warned: there’s a waiting period of at least two months between applying for Medicare benefits, and being eligible to receive them. □