The federal government says provincial health plans should start covering the services of nurse practitioners who provide primary care as of April 1, but will delay enforcement for non-compliance for a year.
Some of the estimated six million Canadians not connected to family doctors have turned to alternative health-care providers, often staffed with nurse practitioners, that may charge fees for services that would otherwise be covered by public insurance if provided by a physician.
This kind of out-of-pocket billing is prohibited for physicians but was until now a legal grey area for other professionals.
Closing this loophole amounts to one of the most significant updates to the Canada Health Act in years. The decision will add to costs for provincial health plans.
Federal Health Minister Marjorie Michel issued the directions to her provincial counterparts in a recent letter that has not been publicly released.
The federal government first sent a letter to provinces in January of 2025 that sought to discourage non-physician health professionals from charging patients out of pocket for the kinds of services a physician might provide.
Provinces receive billions of dollars from Ottawa to pay for health services, and some of that money is clawed back if a province is found to be allowing health care providers to inappropriately bill patients. In the 2024-25 fiscal year, Ottawa transferred $52.1-billion to provinces and territories for health care and levied $62.2-million in penalties for inappropriate patient charges.
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Ms. Michel wrote in her latest letter, sent Dec. 19, that the new Canada Health Act policy still takes effect on April 1, 2026, but will essentially not be enforced until April 1, 2027, as long as the province or territory starts covering these services by the end of 2028. Penalties for not extending coverage would be retroactive.
The letter also clarifies that the policy only affects services from nurse practitioners, midwives and pharmacists.
“Some provinces and territories have raised concerns that the CHA Services Policy could negatively impact decisions to expand the scope of practice of health care professionals in the future,” Ms. Michel wrote in the letter. “Specifically, there are concerns that these changes might automatically fall under the Policy. I assure you that this is not the case.”
The federal government had also signalled in the past that it might issue a directive on billing for virtual care, which currently varies by province. But the Health Minister now says she will not do so.
“I reiterate my commitment that there will not be a virtual care policy interpretation letter,” Ms. Michel wrote, who earlier in the message referenced discussions at an in-person meeting with her provincial and territorial counterparts last October. She said all the ministers would continue to discuss virtual care at their next in-person meeting in the fall.
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Alberta said Ottawa’s policies were “violating” the province’s jurisdiction over health care and urged the federal government to repeal the interpretation letter and pause implementation of the new policy.
“While the federal government has offered a one-year waiver of financial penalties, that is not sufficient,” Maddison McKee, spokesperson for Adriana LaGrange, Alberta Minister of Primary and Preventative Health Services, wrote in an e-mail.
“Using ‘interpretation letters’ to change how the Canada Health Act is applied bypasses proper federal–provincial collaboration and creates confusion, risk, and costs for Alberta’s health system.”
The provincial government did not provide an estimated cost of covering the additional services. But it added that the new policy was “unclear and hard to apply, and likely to lead to billing mistakes, unexpected patient charges, or gaps in coverage – exactly what the rules are supposed to prevent.”
Guillaume Bertrand, spokesperson for the federal minister, said the office was “working collaboratively with provinces and territories to ensure a smooth transition.”
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The Canadian Nurses Association said it was supportive of Ottawa’s plans. Chief executive officer Valerie Grdisa said that nurse practitioners provide a strong value for money in the health care system, as they can provide many primary-care services at a lower cost than physicians.
“The provincial and territorial governments are not realizing a proven, cost-effective, high-quality solution in a timely way,” Ms. Grdisa said.
Danyaal Raza, a family physician and board member of the Canadian Doctors for Medicare, said it was “good news” that the federal government was continuing with this policy, even through a change in prime minister and health minister since the January, 2025 letter was issued. He said it was reasonable to give provinces and territories a grace period to adjust their funding structures.
But he said virtual care was a vital tool and he hoped that the lack of direction on funding virtual-care services wasn’t a sign of foot dragging.
Brett Belchetz, an emergency physician and chief executive officer of Maple Corp., one of the largest telehealth providers in Canada, said he has had “constructive conversations” with federal and provincial governments about virtual care’s role as critical infrastructure in the health care system.
However, Dr. Belchetz said expanding the Canada Health Act beyond physicians carried significant financial and operational implications. He said major changes should be done through legislation and public debate.
“Simply layering new financial obligations onto a decades-old framework without addressing underlying capacity and funding constraints risks compounding pressures rather than resolving them,” he said in an e-mail.