Please note that the following document, although correct at the time of issue, may not represent the current position of the Agency. / Veuillez prendre note que ce document, bien qu'exact au moment émis, peut ne pas représenter la position actuelle de l'Agence.
XXXXX
XXXXX
XXXXX
Excise and GST/HST Rulings Directorate
Place de Ville, Tower A, 15th floor
320 Queen Street
Ottawa ON K1A 0L5
Case Number: 106653
Business Number: XXXXX
August 9, 2010
Dear XXXXX:
Subject:
GST/HST INTERPRETATION - Nurse Case Manager Services
Thank you for your XXXXX concerning the application of the Goods and Services Tax (GST)/Harmonized Sales Tax (HST) to the services you provide as a Nurse Case Manager. We apologize for the delay in responding.
HST applies at the rate of 15% in Nova Scotia, 13% in New Brunswick, Newfoundland and Labrador, and Ontario, 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
You would like to know whether the services you provide to your clients as a Nurse Case Manager are exempt supplies of nursing services under the ETA.
We are unable to provide you with a ruling in accordance with GST Memorandum 1.4, Excise and GST/HST Rulings and Interpretations Service. A GST/HST ruling is a written statement the Canada Revenue Agency (CRA) provides to a client that sets out the CRA's position on how the relevant provisions of the legislation apply to a clearly defined fact situation of the client. The CRA will issue a ruling only when the person requesting the ruling has provided all the relevant facts of a transaction or series of transactions.
As we have not been provided with a signed copy of a contract or agreement for a specific transaction and as your question relates to interpretative issues involving the meaning of the expressions "nursing service" and "nurse-patient relationship" which are not defined in the ETA, for your assistance, we are providing the following interpretation.
Summary
You advised that you are a Registered Practical Nurse (RPN) who works independently as a Nurse Case Manager (sole proprietor). You work with individual clients who have sustained an acquired brain injury or spinal cord injury. Your work entails visiting the clients and their families in their homes as well as in the community. You are responsible for facilitating a rehabilitation team in order to maximize the client's functional independence. The individual client or the client's family may hire you. You are compensated on a fee-for-service basis and may invoice third party insurers, the client's family or a lawyer. You provided copies of the following documents for our review:
• Fact Sheet: An Introduction to the Nursing Act, 1991, College of Nurses of Ontario;
• Fact Sheet: Am I Practicing Nursing? College of Nurses of Ontario:
• Statement: What is an RPN?, Registered Practical Nurses of Ontario;
• Table of Rates and Fees for health care professionals issued by the Financial Services Commission of Ontario;
• XXXXX; and
• An invoice issued to a third party insurer for services rendered.
The services you render as a Nurse Case Manager include the process of assessment, organizing, monitoring, health education, counselling, planning, health promotion, communication, collaboration, implementing, coordinating, and advocacy for your client. Your time involves direct and indirect contact with the client and the client's family, either in the client's home or in the community. You are involved in constant collaboration with other treating health care professionals, which could include family physicians, neurologists, psychologists, physiotherapists, occupational therapists and speech-language pathologists. You also advised that the nursing role is continually changing and that registered nurses may engage in a variety of activities beyond the traditional nursing structure.
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. 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 is also 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 iFootnote 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.
Please note that for purposes of the GST/HST generally, exempt status applies to the supply and not to the supplier. Thus the tax status of a particular supply is not based solely on a person's qualifications and knowledge but rather is determined on the factual context in which the supply is made. With respect to your query each supply (as provided for under each contract) would be evaluated to determine if it is a nursing service rendered by a registered or licensed nurse to an individual within a nurse-patient relationship. This evaluation would include an analysis of the terms and conditions of the relevant contract or agreement for the supply to determine whether the supply satisfies the criteria of section 6 of Part II of Schedule V. There criteria are discussed below.
Rendered by a registered or licensed nurse
The ETA does not regulate or define nursing services; rather this criterion is linked to the provincial regulation of the nursing profession. 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 other 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.
Therefore, 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.
Since the services in question are supplied in Ontario, we considered the manner in which nursing services are regulated by the laws of that province. We understand that nurses in Ontario are regulated under the Nursing Act, S.O. 1991, c. 32, and the Regulated Health Professions Act, S.O. 1991, c. 18. In that province, only members of the College of Nurses of Ontario (the College) can use the titles of Registered Nurse, Registered Practical Nurse, or any variation, abbreviation or equivalent in another language. As noted above, these requirements are applied in the ETA by reference to these specific titles in the exempting provision.
Scope of nursing services
This criterion describes a service rendered by a registered or licensed nurse that falls within the domain of nursing practice. The College has been delegated the authority under the Regulated Health Professions Act for the regulation and registration of individuals who are qualified to practice the nursing profession in Ontario. As noted previously, to practise as a nurse in Ontario a person must be currently registered with the College. You advised that the College has set standards for the nursing profession and registered nurses are expected to observe these standards.
Based on a review of these standards as well as the activities authorized and described by the College as comprising nursing services we understand that the scope of practice for nursing in Ontario is the promotion of health and the assessment of, the provision of care for, and the treatment of, health conditions by supportive, preventative, therapeutic, palliative and rehabilitative means in order for a patient to attain or maintain optimal function. Nurses are authorized to perform various controlled acts when rendering nursing care to their patients. Core nursing services generally focus on the diagnosis and treatment of health problems of a patient, administration of medications and other interventions.
Our research indicates that registered nurses may also work in a wide variety of practice settings, be engaged in a variety of activities for which his or her particular knowledge and qualifications may be relevant to the recipient of his or her supplies, and that nursing roles and responsibilities are continually evolving and changing. For instance, registered nurses may perform supervisory, administrative, consultant, teaching and researching activities. These activities are not intrinsic to the nursing profession as unregulated providers also engage in these activities. Thus these activities are not naturally nursing services. Further review of the standards and guidelines of the regulatory bodies that govern the nursing profession would be required to determine the extent such activities are recognized by those bodies as services that fall within the domain of nursing.
You advised that the College has set guidelines for registered nurses to determine whether they are practicing nursing. These guidelines are set out in the Fact Sheet entitled Am I Practicing Nursing? Registered nurses complete a checklist to determine if they are practicing nursing when engaged in a particular activity. These questions include whether the activity involves the nurse applying nursing knowledge, skill and judgment and whether the nurse has a direct or indirect effect on the recipient of a health care service in Ontario. As well, there is a list of activities registered nurses would check involving assessment, planning, intervening, evaluating, and other activities, and a list of various settings in which registered nurses undertake these activities, such as in an acute care hospital, a long-term care facility, independent practice, educational institution, and a government agency.
It is important to note that even where an activity may be recognized as a nursing service or the service provider is a registered or licensed nurse, as explained below, the activity will not be an exempt supply under section 6 of Part II of Schedule V 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. In addition, not all the activities on the College's checklist would involve services rendered to an individual within a nurse-patient relationship. Some of these activities that would not involve such services are communicating with communities or populations, managing nursing resources such as staff, facilities and equipment, developing learning resources for nurses or other health care providers, and providing or developing health education for organizations.
Rendered to an individual within a nurse-patient relationship
A "patient" can denote an individual who is experiencing an illness that requires acute or chronic care. This criterion refers to nursing services that create a therapeutic nurse-patient relationship with an individual. A registered or licensed nurse establishes and maintains a therapeutic nurse-patient relationship by using nursing knowledge and skills to render patient care services, such as treating the health problems of a patient, administering medications and performing other interventions. Thus this criterion in section 6 of Part II of Schedule V is describing a nursing service rendered by a registered or licensed nurse that is a patient care service involving supportive, therapeutic, palliative and rehabilitative services to assist the patient in attaining or maintaining optimal function.
We understand that people receiving services from health care providers are often referred to as "clients" rather than "patients" and this is also the case for nursing services. The College states that the term "client" better represents the diverse practices of nurses than "patient". In its Ethics Practice Standard, the College describes a "client" as a person with whom a nurse is engaged in a professional therapeutic relationship. The College explains that in most circumstances the client is an individual but a client could 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. Clients could also include students in an educational setting, staff in an administrative setting, and study participants in a research setting.
Regardless of the reference to "client" rather than "patient", it is important to note that only those clients who are individuals and as noted above only those nursing services that are patient care services involving supportive, therapeutic, palliative and rehabilitative services to assist a patient in attaining or maintaining optimal function fall within the scope of section 6 of Part II of Schedule V. Thus 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., care involving personal interaction with a patient in a professional nurse-patient therapeutic relationship, these nursing services will be exempt.
Case management services
We understand that case management is the collaborative process of organizing and coordinating resources and services in response to individual health care needs and is provided in multiple settings, such as acute care settings (e.g., hospitals) and in community settings (e.g., home care). Case management is usually directed toward a selected client population such as clients with head injuries. Activities of case management include assessing, planning, arrangement of services, implementing, coordinating, monitoring, and evaluating the plan of care as well as options and services required to meet a client's health services needs.
Case management is also described as coordinating care and advocating for individuals and patient populations to reduce cost and resource use and provide improved quality of health care and achieve desired outcomes. Based on the needs of the client and in collaboration with service providers, the case manager links clients with appropriate providers and resources throughout the continuum of health care settings and ensures that the care provided is safe, effective, timely, and efficient. Case management activities also include managing, teaching, negotiating and collaborating with multidisciplinary groups.
Case management services could be an area of speciality practice within a given health care profession or they may be provided by unregulated providers. Generally speaking, case managers must possess the appropriate education, skills, knowledge, and experience required to render appropriate services and adhere to ethical, legal, and regulatory standards or guidelines of their health care profession. Case managers have the ability to legally and independently practice without the supervision of another licensed professional.
One of the emerging roles of registered nurses is case management. Our research indicates that the regulatory bodies of the nursing profession have identified registered nurses as having a role as case managers because they have the skill, expertise and capacity to support and enhance the care of an individual across the continuum of health care services. A nurse case manager is usually a registered nurse in a health practice setting who takes a leadership role in coordinating the case management process.
The focus and core of registered nursing practice generally is to provide care to clients while the primary role of nurse case managers is to coordinate and facilitate care. Nurse case managers work with clients to assess their health needs, coordinate ongoing care and they may act as an advisor and advocate throughout an individual's recovery. Nurse case managers provide physical assessment of the individual and chronic disease management and they work collaboratively as a member of an interdisciplinary team and act as a clinical resource for the interdisciplinary team by providing information based on nursing theory and practice related to clients with complex health care needs. As regulated health professionals, registered nurses are required to use their nursing knowledge, skills and judgement when engaged in case management activities even though they may not be providing direct care to patients.
The information you provided and our research indicates a case management service may, in some circumstances, constitute a nursing service rendered by a registered or licensed nurse to an individual within a nurse-patient relationship. Whether a particular supply of any supervisory, administrative or case management 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 case management 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 if made after February 26, 2008. You will have to evaluate the facts of each contract for a case management service to determine if the conditions set out in the exempting provision are met. Please note that case management services that are not rendered within a nurse-patient relationship or that are rendered by unregulated providers are taxable supplies.
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, you can call Brian Olsen at 613-954-4289. 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,
Chantal Desrosiers
Municipalities and Health Care Services Unit
Public Service Bodies and Governments Division
Excise and GST/HST Rulings Directorate
i 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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