Please note that the following document, although correct at the time of issue, may not represent the current position of the Canada Revenue Agency. / Veuillez prendre note que ce document, bien qu'exact au moment émis, peut ne pas représenter la position actuelle de l'Agence du revenu du Canada.
Excise and GST/HST Rulings Directorate
Place de Ville, Tower A, 15th floor
320 Queen Street
Ottawa ON K1A 0L5
[Addressee]
Case Number: 124636
August 8, 2012
Dear [Client]:
Subject: GST/HST INTERPRETATION
The status of supplies of nursing services
Thank you for your letter received on [mm/dd/yyyy], concerning the application of the Goods and Services Tax (GST)/Harmonized Sales Tax (HST) to the supply of nursing services.
HST applies at the rate of 15% in Nova Scotia, 13% in Ontario, New Brunswick, and Newfoundland and Labrador, and 12% in British Columbia. GST applies at the rate of 5% in the remaining provinces and territories.
All legislative references are to the Excise Tax Act (ETA) unless otherwise specified.
INTERPRETATION REQUESTED
In your letter and during subsequent telephone conversations […], you requested that we re-assess our GST/HST Interpretation […] regarding the Canada Revenue Agency’s (the “CRA”) interpretation of section 6 of Part II of Schedule V to the ETA.
In your letter, you also provided information regarding the scope of your practice and how your work qualifies as a “nursing practice”.
Based on the information provided, we understand the following:
1) You are a […] registered nurse. […].
2) In [yyyy], you began your own business, […], as a health promotion consultant.
3) As a consultant, your work focused mainly on […].
4) As a health promotion consultant, your client groups were populations in settings such as schools, other community organizations and agencies addressing primary prevention with vulnerable groups such as […].
5) In your work as a consultant, you provided interventions such as health teaching and health promotion, communicating with individuals, families, groups, communities and populations, collaborating with care providers, directly or indirectly influencing the practice of care providers and/or policy, developing learning resources for nurses and other care providers and collecting health data, specifically as they supported health promotion work with vulnerable or at-risk populations for […].
6) Also, you […], developed, […] to support information and awareness related to […] lifestyle risks, and so that several health promotion strategies could be employed by public health nurses […]
7) As a health promotion consultant, you also developed training resources for nurses to use with community health center staff regarding health issues, […].
INTERPRETATION GIVEN
Generally, most supplies of property and services made in Canada are taxable for GST/HST purposes, unless they are exempt supplies. Exempt supplies are listed in Schedule V to the ETA. Part II of Schedule V provides that certain health care services are exempt from GST/HST. In order for a supply of property or a service to be exempt from GST/HST under Part II of Schedule V, a specific exempting provision included in Part II must apply to that particular supply.
In addition, it should be noted that the GST/HST is a transactional tax and as such, the exempting provisions in Part II of Schedule V apply on a supply-by-supply basis. These provisions set out specific criteria that must be met in order for a particular supply of a service to fall within those provisions. For every supply or transaction, the supplier must determine whether these criteria are met or whether the tax is applicable. Because of these criteria it is possible for a supplier to make a mix of taxable and exempt supplies and for the tax status of a supply to differ depending on the supplier. Thus, regardless of the manner in which nursing services may be defined, the tax status of a particular supply of nursing services will be conditional on whether the supply meets all of the criteria set out in the exempting provision, as explained below.
Section 6 of Part II of Schedule V
Section 6 of Part II of Schedule V exempts a supply made after February 26, 2008 (Footnote 1) , of a nursing service rendered to an individual by a registered nurse, a registered nursing assistant, a licensed or registered practical nurse or a registered psychiatric nurse, if the service is rendered within a nurse-patient relationship. Given the preceding, there are three criteria that the supply must meet to be exempt; i.e., it must be a service that:
* is rendered by a registered or licensed nurse;
* falls within the scope of nursing services; and
* is rendered to an individual within a nurse-patient relationship.
Regardless of whether an activity may be characterized as a nursing service, the supply of that service must meet all of the criteria of section 6 of Part II of Schedule V to the ETA in order to be exempt.
Rendered by a registered or licensed nurse
For purposes of the ETA, a registered or licensed nurse is an individual who meets certain prescribed standards of education, clinical competence and registration or licensing requirements. Generally speaking, the jurisdiction to regulate health professions, including nurses, is provincial. By reference to the requirement that only the services of registered or licensed nurses are exempt, the ETA incorporates the qualifications necessary to practise the nursing profession in the provinces.
Accordingly, the GST/HST legislation provides that only the nursing services rendered by nurses that are registered or licensed by a provincial regulatory body in respect of the nursing profession will be exempt. In order to practise as a nurse in [the province], an individual must be registered with […].
Scope of nursing services
Based on a review of the […] standards for the nursing profession as well as the activities authorized and described by […] as comprising nursing services, we understand that the scope of practice for nursing in [the province] is […]
Registered nurses may work in a wide variety of practice settings and be engaged in a variety of activities for which their particular knowledge and qualifications may be relevant to the recipient of their supplies. In fact, nursing roles and responsibilities are continually evolving and changing. For instance, registered nurses may perform supervisory, administrative, consultant, teaching and researching activities.
However, even where an activity may be recognized as a nursing service or the service provider is a registered or licensed nurse, as further explained below, the activity will not be an exempt supply under section 6 of Part II of Schedule V to the ETA where it does not constitute a nursing service rendered to an individual within a nurse-patient relationship. For instance, a consultative service will not be exempt if there is no established or ongoing relationship between the nurse and a patient and the nurse is not a care provider of the individual. Other activities which the CRA interprets as not involving such services are communicating with communities or populations, managing nursing resources such as staff, facilities and equipment, developing learning resources for nurses and other health care providers, and providing or developing health education for organizations.
Rendered to an individual within a nurse-patient relationship
A registered or licensed nurse establishes and maintains a nurse-patient relationship by using nursing knowledge and skills to render patient care services involving supportive, therapeutic, palliative and rehabilitative services to assist the patient in attaining or maintaining optimal function, such as treating the health problems of a patient, administering medications and performing other interventions.
The CRA interprets this particular criterion as meaning nursing services that involve personal interaction between a nurse and an individual who is a patient where there is an established or ongoing relationship between the nurse and the patient and the nurse is a direct care provider of the patient. Accordingly, when a registered nurse, a registered nursing assistant, a licensed or registered practical nurse or a registered psychiatric nurse renders nursing services to an individual in the capacity of a care provider, i.e., in a professional nurse-patient therapeutic relationship, these nursing services will be exempt.
A “patient”, who is also often referred to in the practice of nursing as “client”, is typically an individual but can also include family members and decision-makers of the individual. A client may also be a family, a group, such as in a therapy session or a community, such as in a public health setting or could include students in an educational setting, staff in an administrative setting and study participants in a research setting.
Regardless of how broad the scope of a nursing practice may be, it is important to clarify that only those clients who are individuals receiving patient care services would fall within section 6 of Part II of Schedule V. In contrast, services rendered by a registered nurse to communities in a public health setting, students in an educational setting, staff in an administrative setting, and study participants in a research setting would not fall within this particular exempting provision.
Health Promotion Consultant
According to the information you provided to us, you, as a health promotion consultant, focused on health promotion strategies. These strategies demand for the client to take responsibility for behaviour change, while acknowledging the importance and impact of social and environmental determinants on a person’s or community’s ability to make those changes.
As a health consultant, you would provide certain interventions which supported health promotion work with vulnerable or at-risk populations […]
The interventions you provided include health teaching or health promotion, communicating with individuals, families, groups, communities and populations, collaborating with care providers, directly or indirectly influencing the practice of care providers and/or policy, developing learning resources for nurses or other care providers and collecting health data.
More specifically, you developed, […] programs. These programs were developed to support information and awareness related to, for example, […] and lifestyle risk factors, […] These programs were for the most part to be delivered by health care providers such as nurses.
Furthermore, you developed training resources for nurses to use […]
Accordingly, in light of the above and of the CRA’s interpretation of section 6 of Part II of Schedule V to the ETA, it is our view that the supply of services as described above rendered by a health promotion consultant would not fall within the exemption if the service is not rendered to an “individual” within a “nurse-patient relationship”.
However, whether a particular supply of any consulting service rendered by a registered nurse constitutes a nursing service rendered to an individual within a nurse-patient relationship will have to be determined on a case-by-case basis. Where a particular supply of a consulting service is a nursing service rendered by a registered or licensed nurse to an individual within a nurse-patient relationship, this supply will be exempt pursuant to section 6 of Part II of Schedule V to the ETA if made after February 26, 2008. The facts of each contract for a consulting service would need to be evaluated in order to determine if the conditions set out in the exempting provision are met.
The foregoing comments represent our general views with respect to the subject matter of your request. These comments are not rulings and, in accordance with the guidelines set out in GST/HST Memorandum 1.4, Excise and GST/HST Rulings and Interpretations Service, do not bind the Canada Revenue Agency with respect to a particular situation. Future changes to the ETA, regulations, or our interpretative policy could affect this interpretation.
If you require clarification with respect to any of the issues discussed in this letter, please call me at 613-954-4395. Should you have additional questions on the interpretation and application of GST/HST, please contact a GST/HST Rulings officer at 1-800-959-8287.
Yours truly,
Art Blommesteijn
Health Care Sectors Unit
Public Service Bodies and Governments Division
Excise and GST/HST Rulings Directorate
FOOTNOTES
1. To be exempt under section of Part II of Schedule V, a supply made before February 27, 2008 has to be a supply of a nursing service rendered by a registered nurse, a registered nursing assistant, a licensed or registered practical nurse or a registered psychiatric nurse, where the service is rendered to an individual in a health care facility or in the individual’s place of residence; the service is a private-duty nursing service; or the supply is made to a public sector body.
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