With this Bulletin, the Financial Services Commission of Ontario (FSCO) is highlighting, for your reference, a revised
, and clarification regarding administration fees.
Revised Transportation Expense Guideline
The amendments to the Statutory Accident Benefits Schedule - Accidents On or After November 1, 1996 (SABS) set out in O. Reg. 458/03 require certain changes to the Transportation Expense Guideline.
Under the amended provisions of the SABS, as reflected in the revised Transportation Expense Guideline, an insurer is no longer liable to pay, in the case of accidents occurring on or after April 15, 2004, for the first 50 kilometres of any transportation to and from treatment sessions, counselling sessions, training sessions, assessments or examinations unless the person has sustained a catastrophic impairment. These provisions also extend to the transportation expenses of the insured person’s aide or attendant.
The revised Transportation Expense Guideline is effective as of April 15, 2004 and replaces Superintendent’s Guideline No. 03/01 released on March 31, 2001.
Revised Guideline on Insurers’ Delivery of Documents to Insured Persons
Additional amendments to the SABS made by O. Reg. 458/03, effective as of January 10, 2004, the date of publication of O. Reg. 458/03 in The Ontario Gazette, revoke the prohibition against the use of certified or registered mail when delivering documents, including a notice, that must be given within five or fewer days. In light of these amendments, the revised Guideline clarifies the circumstances in which a health care provider may act as an insured person’s authorized representative for the limited purpose of receiving certain documents from an insurer if specific conditions have been met.
The revised Guideline on Insurers’ Delivery of Documents to Insured Persons replaces Superintendent’s Guideline No. 09/03 released in October 2003.
Revised OCF-1 Accident Benefits Application Package
The OCF-23/198 Pre-approved Framework Treatment Confirmation Form will now replace the OCF-18 Treatment Plan in the OCF-1 Accident Benefits Application Package to encourage use of the Pre-approved Framework (PAF) Guidelines. The OCF-23/198 is a claim form used by a provider to notify the insurance company that they have initiated treatment under a PAF Guideline.
The new forms are effective March 1, 2004.
Revised Professional Services Guideline
The Professional Services Guideline released on January 9, 2004 with Bulletin No. A- 02/04 outlines new hourly rates for certain professional services applicable to catastrophic impairments. The revised Professional Services Guideline released with this Bulletin clarifies the application of the maximum hourly rates for catastrophic impairments.
When the insured person has been determined to have sustained a catastrophic impairment, the higher hourly rates for catastrophic impairments will be applied back to the later of February 1, 2004 (the effective date of the revised Professional Services Guideline) or the date of the accident. For example, if the insured person has an automobile accident on December 2, 2003 and is determined on March 1, 2004 to have a catastrophic impairment, the higher hourly rates are effective for all applicable services rendered on or after on February 1, 2004. Insurers will be expected to readjust accounts already paid where required as the result of a catastrophic impairment determination.
"Expenses related to professional services" under the SABS, the Professional Services Guideline and the Designated Assessment Centre Fee Guideline include all administration costs, overhead, and related fees. Health care providers and Designated Assessment Centres (DACs) are not permitted to bill for administration or any other charges or add surcharges that have the result of increasing the effective hourly rate beyond what is permitted under the Professional Services Guideline or Designated Assessment Centre Fee Guideline.
Copies of Guidelines and Forms
Copies of the revised Transportation Expense Guideline, Guideline on Insurers’ Delivery of Documents to Insured Persons and revised Professional Services Guideline, referred to in this Bulletin are attached for your information and will be published in the March 13, 2004 edition of The Ontario Gazette. Also attached is the revised OCF-1. The Guidelines and forms can also be downloaded from the FSCO Web site at: www.fsco.gov.on.ca
Bryan P. Davies
Chief Executive Officer and Superintendent of Financial Services
March 3, 2004