Designated Medical Practitioner Handbook

Chapter 10: DMP Activities in Canada

While the majority of Canadian immigration medical examinations are performed outside of the country, a significant number of individuals have their immigration processing undertaken in Canada. Many of those who are examined for immigration purposes in Canada do so as part of the refugee determination process. Performing IMEs within the country, combined with the practices related to the domestic refugee determination system, creates issues and situations specific to DMPs in Canada.

This chapter of the DMP Handbook provides information, reference and instruction for DMPs operating in Canada. It does not apply to DMPs who perform Canadian immigration medical examinations in other countries, including those in the United States.

10.1 Providing Primary Care to IME Applicants

Some newly arrived individuals in Canada may not have primary-care providers and may seek to use the IME encounter as an opportunity to begin a provider-patient relationship with the DMP. If DMPs agree to provide care to those who have visited them for IME services, it is recommended that they ensure that the individual understands the differences between the provider’s role as a DMP and as a personal health-care provider. It must also be clearly understood that any medical activities or services other than those related to or required for the IME have no relationship or involvement with CIC or the Health Management Branch.


10.2 Providing Services for Culturally Diverse Clients

The evolving diversity of Canada’s immigration program creates situations where people who require immigration medical services in Canada may have cultural characteristics that differ from those of the DMP. Cultural backgrounds and characteristics influence behavior, values and institutions.

One of the goals of Canadian immigration medical activities is the effective performance and provision of services in culturally diverse environments. This is often referred to as “cultural competency.” It is based on the understanding and acceptance of and respect for cultural differences that may include religious beliefs, family responsibilities, sexuality and dress codes.

Through their interest in becoming DMPs, health-care professionals involved with IMEs in Canada have already indicated their readiness to function in situations of cultural diversity. The following comments provide general guidance for those who may be new to such situations. In terms of the immigration medical examination, the most commonly encountered challenges include those related to the sex of the examiner and aspects of the physical exam that may be new or novel to applicant.

  • DMPs should ensure that applicants are aware of the sex of the examiner who will be undertaking their IME before the examination begins. Some female applicants may wish to be accompanied by relatives or husbands during the examination process.
  • Applicants who refuse to be examined by a practitioner of a particular sex should be offered referral to a DMP of the other sex, or approval should be obtained from CIC to have the IME completed by a nearby practitioner of the other sex who is not a DMP.
  • In some locations, undressing for medical examinations is unusual. Applicants may request to be palpated or oscultated through the examination gown or sheet. In these situations, DMPs are to record those events on the immigration medical examination form.
  • Similarly, breast, genital or rectal examinations may be refused. When they are, DMPs should indicate that the applicant refused the examination in the appropriate sections of the immigration medical examination form. Applicants should then be referred to an appropriate physician, acceptable to the applicant, for a report on the examination findings, as described in Chapter 9.

The Use of Translators in Canada

During the performance of IMEs in Canada, DMPs may frequently encounter applicants who speak neither of the two official languages. In some cases, the DMP may have linguistic capacities that meet the applicants’ needs. Occasionally, however, translation services will be required. In many circumstances, non-professional translators are utilized.

The use of non-professional translators, particularly family members, can be a sensitive issue for questions or topics involving personal health. Applicants may be uncomfortable providing this information in the presence of family member or friends. For this reason, the use of professional translation services is recommended. The fee policy for translation services is described in Chapter 7.


10.3 The Refugee Determination System in Canada

Description of the Process in Canada

One of the pillars of Canadian immigration policy is the humanitarian and refugee protection component of the immigration program. This program fulfils Canada’s international legal obligations with respect to refugees and affirms Canada’s commitment to international efforts to provide assistance to those in need of resettlement.

The selection of refugees for permanent residence in Canada takes place in one of two ways. Individuals already determined to be refugees under existing international standards and who are residing abroad can be selected and admitted to Canada. They undergo their immigration processing, including medical examination, abroad.

Refugee claimants constitute another group of people who access the humanitarian pathway to enter Canada (frequently known as asylum seekers in other areas of the world). Refugee claimants are individuals who, following their arrival in Canada, make a formal claim to an immigration or Canada Border Services Agency officer requesting protection on the basis of fear of persecution if they return to their country of origin. Those eligible for determination under this process are referred to the Immigration and Refugee Board (IRB) for a decision on their claim for refugee status. The IRB is an independent administrative tribunal responsible for making decisions on who needs refugee protection among the thousands of claimants who come to Canada annually. Further information about the IRB can be obtained at www.irb-cisr.gc.ca/Eng/Pages/index.aspx.

Immigration Medical Requirements for Refugee Claimants in Canada

Canada’s immigration legislation requires all persons claiming protection as refugees to undergo an immigration medical examination. The examination uses many of the same medical forms and requires the same investigations as IMEs for other immigrants, although its intent and nature are slightly different.

As noted earlier in this handbook, immigrants are examined with the intent to identify medical conditions that could affect their admissibility to Canada under IRPA (see Section 2.1). However, those applying for refugee status are examined only with the intent of identifying conditions related to risks to public health and public safety. Aspects of the IME related to identifying conditions that might be associated with excessive demand, do not apply to refugee claimants. As a result, refugee claimants will present for their examination with the immigration medical examination form IMM 1017 EDE-EFE (see Appendix II) DMPs are to complete this form when examining refugee claimants.

Individuals claiming refugee status in Canada are referred for their IME when they file their claim. They are given medical instructions and a list of DMPs. The medical examination is to be undertaken within 30 days following the claim for refugee status.


10.4 The Interim Federal Health Program (IFHP)

10.4.1. How the IFHP Operates

Most refugee claimants in Canada do not have access to provincial/territorial health insurance and may not have personal funds to meet needed expenses. Citizenship and Immigration Canada (CIC) coordinates and manages the Interim Federal Health Program (IFHP) which pays for health care for those refugee claimants who are unable to pay for their health-care expenses. Coverage is provided pending their qualification for other means of payment.
IMPORTANT NOTES:

  • CIC determines IFHP coverage and eligibility for services.
  • The adjudication and payment of claims for the program is provided by the IFHP Claims Administrator, Medavie Blue Cross. Individuals covered by the IFHP must not be charged directly.
  • For those eligible, IFHP also covers the fees for specific services such as the Immigration Medical Examination (IME) and IME-related approved costs.
  • Designated Medical Practitioners (DMPs/Examiners) performing IMEs must forward invoices for their services to Medavie Blue Cross for reimbursement.
  • DMPs/Examiners cannot refuse to provide IMEs to persons covered by IFHP.

Generally, only DMPs/Examiners are mandated to perform the IME for refugee claimants eligible under the IFHP. In certain cases, CIC may approve a non-DMP/Examiner to perform the examination but, unless authorized by CIC, Medavie Blue Cross will not reimburse a non-Examiner for this service.

The IFHP provides coverage for more than the IME, and details can be found in the IFHP Information Handbook for Health Care Professionals (Provider Handbook) which describes how the program functions. Chapter 9 in the Provider Handbook contains important information for DMPs/Examiners who routinely perform IMEs for refugee claimants and will find it a useful reference.

The IFHP Provider Handbook, IFHP Benefit Grid, as well as advisory bulletins and other documents for providers are available electronically on the Medavie Blue Cross provider website.

10.4.2. Verifying IFHP Eligibility

DMPs/Examiners must verify with Medavie Blue Cross if their patients’ IFHP coverage is still current BEFORE the examination is done, as their eligibility can be canceled without notice should their immigration or financial status change.

At the first point of contact with CIC or the Canada Border Services Agency (CBSA), or as soon as possible thereafter, clients who fall within certain eligible client groups are assessed to determine their need for health care coverage. If eligible, they are issued one of the computer-generated forms (IMM 1442) with security features and a stamped photograph. Effective March 26, 2011, a revised IFHP eligibility paragraph on recipients’ responsibilities and the sharing of their personal and medical information appears on IFHP eligibility documents and is followed by the recipient’s signature. IFHP recipients are advised of their responsibility to renew their coverage before the expiry date and annually thereafter, as required.

Patients can have one of the following documents that identify them as individuals who may be eligible for IFHP coverage:

  • Refugee Protection Claimant Document (RPCD) printed on an IMM 1442 form.

The RPCD identifies refugee claimants, i.e. individuals whose claim to refugee status has been referred to the Immigration and Refugee Board (IRB). In addition, the RPCD contains language confirming the claimant's initial eligibility for IFHP coverage. The default validity period of the RPCD is five (5) years. However, the initial IFHP coverage validity period on the RPCD is two (2) years.

  • IFHP Certificate of Eligibility (IFHC) printed on an IMM 1442 form.

The IFHC can be issued as the first IFHP eligibility document to resettled refugees and victims of trafficking in persons. It may also be issued to any other IFHP recipients when their coverage is extended. The initial validity period of the IFHP coverage on the IFHC, as well as the default extension period, is one (1) year.

  • IMM 1017 Medical Report Section A form – this form can be issued to (1) clients referred for their first IME as refugee claimants or (2) clients referred for their repeat IME as protected persons.

Special designation of either “Ref claimant” or an “OPM” (Other Paid Medical) stamped or written in the “Category of Applicant” box on the IMM 1017 Medical Report Section A form indicates that the IME and IME-related tests are payable by the IFHP.

An “OPM” designation is for those refugee claimants who have been granted Protected Person status by the Canadian authorities and now qualify for provincial/territorial health insurance. Since these persons must undergo another IME as part of their application for permanent residence, the cost of IME and IME-related tests will be reimbursed by the IFHP (see current IFHP fees for the IME and IME-related tests in Appendix XVII). The IFHP coverage validity period for a repeat IME for protected persons is four (4) months.

IMPORTANT NOTE: Clients presenting an IMM-1017 Medical Report Section A form may have an IFHP eligibility document with an expired valid date, or may not have such document at all; however, their coverage may have been extended electronically and it must be verified through Medavie Blue Cross.

Samples of these documents are included in Appendix XV.

Note that it takes a minimum of two (2) working days after IFHP coverage is issued by CIC before it becomes active in Medavie Blue Cross’ system.

If a client presents an IFHP eligibility document that was issued less than 2 working days before the medical visit, their eligibility information may not have been transferred to Medavie Blue Cross yet. In such cases, DMPs/Examiners can either submit a paper claim, or wait 2–3 days before submitting the claim electronically. However, they should keep in mind that, until the eligibility is transferred, Medavie Blue Cross has no way of determining if a client is eligible for an IFHP benefit.

IMPORTANT REMINDERS:

  • DMPs/Examiners must ask IFHP recipients to sign a provider claim form or a printout of the electronic claim screen before the provider claim is submitted for reimbursement to Medavie Blue Cross. Providers who submit claims electronically must keep a copy of the “Claims Payment Result Screen” signed by the client. This document must be kept on file for a period of two years as proof of service for audit purposes.
  • DMPs/Examiners should not accept an IFHP eligibility document if it is not signed by the document owner in the area entitled “Signature of Holder”. Since the IFHP eligibility documents are issued individually for persons older than 14 years, the recipient’s signature on a claim form must match the signature on her/his IFHP eligibility document. For children younger than 14 years, their parent or legal guardian, where present, must sign the IFHP eligibility document and the provider claim form upon receiving a health-care service.
  • DMPs/Examiners should not refer to the date in the “Valid Until” section in the upper right corner of the IFHP document to determine the IFHP coverage validity.
  • The IFHP eligibility document, either RPCD or IFHC, will be issued once for the duration of coverage. Their coverage extension will only be registered electronically in CIC’s system and transferred to Medavie Blue Cross.

More information on IFHP eligibility documents can be found in the IFHP Information Handbook for Health Care Professionals on the Medavie Blue Cross provider website.

10.4.3. Billing for Services

Once the examination is completed, the IME results must be sent to the CIC Regional Medical Office in Ottawa as instructed in the Designated Medical Practitioner/Examiner’s Information Handbook. However, the invoice for this service must be sent to Medavie Blue Cross.

a. Charging patients:

  • DMPs/Examiners must NOT ask patients who are eligible for IFHP coverage to pay surcharges, supplemental costs, or ask for a deposit or any other fee in connection with the IME. Instead, they should bill the IFHP through Medavie Blue Cross.
  • DMPs/Examiners may charge for missed appointments in accordance with local standards of practice.

b. Coding benefits:

  • DMPs/Examiners submitting claims for IMEs and IME-related tests must use the appropriate benefit codes listed under the section “IME AND IME RELATED TESTS” in the IFHP Benefit Grid which can be found on Medavie Blue Cross’ website and in Appendix XVII.
  • For all other services not listed in the IFHP IME fee schedule, DMPs/Examiners must use provincial/territorial benefit codes and will be reimbursed according to the rate of the code submitted, which may be less than the IME-related code for the same service.
  • ICD-10 codes are not required when submitting claims for IMEs and IME-related tests.

c. Furtherance for “OPM” clients:

  • OPM” clients may already be covered by provincial/territorial health (P/T) insurance plans which do not cover the cost of IMEs and IME-related tests. DMPs/Examiners are advised to ask such clients to present P/T health insurance card.
  • Refugees will not be “furthered” for complementary tests and investigations unless there is a public health concern (i.e. tuberculosis) or a public safety concern.
  • If additional services outside of the IME fee schedule are requested by those “OPM” clients who are already covered by P/T health insurance, the cost of such services will be paid by P/T plans (see list of IME-related tests in Appendix XVII). DMPs/Examiners should submit their claims for these services not to IFHP but to the provincial/territorial health insurance plans.

d. Reimbursement:

  • CIC determines fees for the IME under the IFHP (see current fees in the IFHP Benefit Grid on Medavie website).
  • For reimbursement for services, DMPs/Examiners may use the Electronic Claims Submission Service available through the Medavie Blue Cross secure provider web portal at https://provider.medavie.bluecross.ca, or submit claims by mail to the following address:

Interim Federal Health Program
Medavie Blue Cross
644 Main Street PO Box 6000
Moncton, NB E1C 0P9


10.5 Conditions of Public Health Importance

The medical assessment of applicants for immigration to Canada includes provisions to notify provincial/territorial public health authorities of the arrival of persons who may require public health follow-up. This program, termed “Public Health Surveillance,” was designed to ensure that individuals processed abroad and noted to have conditions or diseases requiring public health attention systematically received appropriate management following arrival in Canada. Public health surveillance is also utilized for individuals who have IMEs in Canada, and provincial authorities are notified by CIC of individuals with inactive pulmonary tuberculosis and treated syphilis infection.

However, CIC’s Public Health Surveillance Program does not eliminate the requirement for DMPs to report and notify provincial authorities of conditions and diseases requiring notification or reporting under provincial or territorial public health legislation. DMPs should report to and notify provincial, territorial or regional public authorities according to the standards and guidelines of the jurisdiction in which they practice.

For conditions that require expedient management, such as active pulmonary tuberculosis, DMPs should not wait for the completion of the entire IME process, but should report the conditions and arrange for immediate care as they would for other patients.


10.6 Conditions and Situations for which Mandatory or Statutory Reporting is Required

Provincial/territorial legislation and/or professional college requirements define conditions and situations for which mandatory reporting and notification of appropriate authorities is required. These standards apply to the immigration medical examination.


10.7 Providing Government Services in Canada

The Canadian immigration process, including the IME, is defined and mandated by federal legislation and managed by a federal department, CIC. As such, the IME and DMPs’ services in this regard must meet some of the basic requirements for government services delivered in Canada. Specifically, individuals seeking these services should have the opportunity to receive them in their preferred official language where there is a significant demand.

Official Languages Policy and Dispensation

In Canada, CIC is committed to providing applicants with the opportunity to receive their immigration medical examination in their preferred official language. If these services are not available in a DMP’s office or clinic, information must be available about the location of the nearest DMP who can provide service in the official language requested by the applicant. If there are no DMPs with appropriate linguistic capacity available nearby, the DMP must advise applicants or their agents as follows:

If the nearest designated medical practitioner (DMP) offering services in your preferred official language is located more than 242 km (150 miles) from where you reside, please contact us to find out how to access IME services in your preferred official language.

Clinic staff should be aware of and instructed on how to deal with such requests.
DMPs seeking additional information or clarification about this issue should contact:

Director of Operations
Health Management Branch
Citizenship and Immigration Canada
219 Laurier Ave. West, 3rd floor
Ottawa ON K1A 1L1

Official Language Self-Evaluation and Competencies

DMPs have to identify their level of competency concerning official languages on the application form. This requirement helps CIC fulfil its official language obligations and identify areas where additional services may be required. DMPs should identify the level at which they feel comfortable providing medical services. If their level of competency changes due to language training or any other factors, DMPs are required to inform CIC as soon as possible and send in a new application.

Process for Delivering Forms

CIC is making every effort to offer its services in the candidate’s preferred official language. Consequently, CIC offices have been told to give applicants the IMM 1017 in their preferred language. DMPs print or generate the IMM 5419 and should have the ability to generate both these forms in either official language. DMPs can assist the Department in maintaining this standard of service by informing the regional medical office whenever a situation arises in which it has been unable to fulfil this requirement.


10.8 Records Management

Medical Examinations Issued Abroad

Immigration medical examinations performed in Canada (and the United States) should normally be forwarded to the Health Management Branch in Ottawa when completed, no matter where the documents were issued.

Document Control

The forms, documents and results of investigations required for the completion of the IME are the property of CIC. DMPs in Canada should forward all documents related to the IME to the Health Management Branch. DMPs may be required to maintain their own copies and records in accordance with local regulatory and licensing requirements.

Applicants may request copies of this information under the Privacy Act, and their representatives who are Canadian residents may request copies under the Access to Information Act. See Section 2.2 for more information. Alternatively, they can contact the CIC office responsible for their application.

Information collected during the IME is for immigration medical purposes only. It may not be used for other purposes, including research, clinical studies or investigations, without the appropriate consent and approval. Requests to use information obtained during the IME process for any other purpose should be directed to:

Director of Operations
Health Management Branch
Citizenship and Immigration Canada
219 Laurier Ave. West
Ottawa, ON K1A 1L1

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