It's time to talk consultations on public and private care in Canada
A glossary of terms on public and private health care
Meaningful discussions about different models of health care depend on a shared language. These definitions, used by the Canadian Medical Association (CMA), are intended to provide context for important terms and concepts.
First dollar coverage
Health services covered 100% by public insurance, with no charges to patients seeking care.
Insured health services
The Canada Health Act requires all provinces and territories to provide public insurance for medically necessary hospital services, physician services and surgical-dental services in a hospital setting.
Provinces and territories also provide a wide range of other programs and services, such as prescription drug coverage, non-surgical dental care, ambulance and optometric services, at their discretion. These services often target specific population groups — such as seniors, children and those receiving social assistance — with levels of funding and scope of coverage varying between provinces and territories.
Insured hospital services
Medically necessary in-patient and out-patient services such as nursing service, diagnostic procedures, medical and surgical equipment and supplies, accommodation and meals.
Residents of a province or territory eligible for public health insurance. Sometimes referred to as a beneficiary.
An insured person does not include serving members of the Canadian forces, inmates of federal penitentiaries and refugees covered by the federal government, and people covered by provincial workers’ compensation.
Insured physician services
Medically required services provided by emergency, specialty or family doctors. Which services are included is generally determined by the provincial or territorial health care insurance plan, in consultation with the medical profession.
Opting out or in (to public health insurance plans)
With the exception of Ontario, physicians can choose to give up their right to bill the public health insurance plan and take up private practice. There are differences in terminology among provinces and territories for this, such as "non-participation," "non-enrolment," "practicing outside the Act," and "not subject to the agreement.”
There are many forms of point-of-service charges:
Extra-Billing: A charge to an insured person for an insured service, in addition to the amount paid by the provincial or territorial health care insurance plan. For example, if a physician were to charge a patient any amount for an office visit that is insured by the provincial or territorial health care insurance plan, the charge would constitute extra-billing. A barrier to accessing health care, extra-billing is not allowed under the Canada Health Act.
Facility Fees: Fees charged directly to patients receiving medically necessary services at private clinics. When a provincial or territorial health care insurance plan pays the physician fee for a medically necessary service delivered at a private clinic, it must also pay the facility fee or face a deduction from federal transfer payments.
User Charges: A user charge, or user fee, is defined as any charge for an insured health care service, other than extra-billing. If patients are charged a fee as a condition of receiving insured health care services, that fee is considered a user charge. A barrier to accessing health care, user charges are not allowed under the Canada Health Act.
Co-payments and deductibles: A co-payment is a fixed amount that is paid at the time you receive uninsured medical services or get a prescription filled. In contrast, the deductible is the amount you're required to pay before health insurance begins to cover defined benefits.
Out-of-pocket expenses: A medical expense not covered by insurance; therefore, the patient pays directly for it.
Private delivery of health care is carried out by health care provider organizations that aren’t government agencies, or otherwise directly accountable to government. This can range from self-employed health care professionals (e.g., physicians) to not-for-profit or for-profit organizations. Those providing private delivery can still receive public funding for their services, so long as residents aren’t charged for insured services.
Private health insurance (PHI)
Various forms of private health insurance coverage are found in different countries:
- Primary private health insurance: Basic health coverage because individuals don’t have, or aren't eligible for, public health insurance (e.g., in the United States), or because they choose to opt out of public coverage.
- Duplicate (parallel) private health insurance: Offers coverage for health services already included under public health insurance (e.g., in Australia), sometimes with access to different providers or levels of service.
- Complementary primary health insurance: Coverage complements that of publicly insured services (e.g., in France), reimbursing plan holders for co-payments and out-of-pocket expenses. not covered by the public plan.
- Supplementary private health insurance: Covers additional health services not covered by public care (e.g., in Canada). Depending on the country, it may include mental health services, pharmaceuticals, rehabilitation, long-term care, dental care, alternative or complementary medicine, etc.
Delivery of a service either directly by government, by regional health authorities or through a not-for-profit charitable organization that is directly accountable to government through statute or regulation (e.g., public hospitals act).
Any instance where there is a mix between public and private sectors regarding the funding or delivery of health services.
Uninsured hospital services
Services for which patients can be charged, including preferred hospital accommodation, private duty nursing services, parking and the provision of telephones and televisions.
Uninsured physician services
Services for which patients can be charged, including the provision of medical certificates, the transfer of medical records, court testimony and cosmetic services. The costs of these services are governed by provincial and territorial Colleges of Physicians.
Any interaction between patients and members of their circle of care — physicians and other health care practitioners — over the phone, through email, text or video.
Since the COVID-19 pandemic, publicly funded virtual care has been available in provinces and territories at varying rates — however, in most jurisdictions it has yet to become a permanent service.
Health system performance goals that reflect a broad medical consensus on reasonable wait times for services delivered to patients.
What we mean when we talk about private health care
The term “private health care” can refer to a range of services, from out-of-pocket virtual consultations at $70 a visit to publicly funded hip replacements at privately operated medical centres. Solutions-focused conversations must start with a common understanding of what we actually mean when we talk about public and private care. Read the CMA’s primer.