Millbrook FN: NIHB 2015 Summary of Benefits

Jun 17, 2016

NIHB Pharmacy Benefit:

The objective of the NIHB pharmacy benefit is to provide eligible clients with access to pharmacy benefits and services in a fair, equitable and cost-effective manner that will contribute to improving the overall health status of First Nation and Inuit clients, recognizing their individual health needs and the context of health service delivery; and provide coverage for a range of drug benefits and services based on professional judgment, consistent with the current best practices of health services delivery and evidence-based standards of care. Clients are required to access any public or private health or provincial/territorial programs for which they are eligible prior to accessing Non-Insured Health Benefits.

There are several types of pharmacy categories, these are:

• Open Benefits: items listed on the NIHB Drug Benefit List (DBL) that do not have established criteria or prior approval requirements
• Limited Use: items that have quantity or frequency limitations – prior approval must be given
• Exceptions: items not listed as benefits on the DBL and not exclusions. Requests may be considered on a case-by-case basis with written medical justification. Items not listed as benefits on the DBL and are not available through the exception process. Exclusion items cannot be appealed.

Medical Supplies and Equipment (MS&E) Benefits

The NIHB Program provides a limited range of medically necessary health-related goods and services to eligible clients. The client first obtains a prescription from an NIHB recognized health care professional prescriber. The client submits the prescription to an NIHB-recognized provider. In most cases the provider will have to obtain prior approval from a Health Canada regional office before providing the prescribed item.  For items requiring preapproval, the client must then contact the NIHB Regional Office where they will be put in touch with an enrolled “Provider” who will submit documentation to NIHB to support the request. Then, it is the vendors (enrolled in the program) who submit the request along with the approval form to NIHB (rather than the client dealing with NIHB directly).

The NIHB MS&E benefits are set out in the MS&E Benefit List and include specific eligible items generally within the following categories audiology equipment (e.g. hearing aids); bathing and toileting aids; catheter supplies and equipment; incontinence supplies and equipment, such as diapers and catheters; lifting and transfer aids; medical equipment (e.g. wheelchairs and walkers); medical supplies (e.g. bandages and dressings);  orthotics and custom footwear;  ostomy supplies and devices; oxygen and respiratory supplies and equipment; pressure garments; prosthetics; and protectors.

What is not covered?

For general MS&E benefits, exclusions include but are not limited to scooters (considered a mode of transportation for outdoor use only); hospital beds, mattresses and bedding (considered household items and beyond the scope of NIHB Program. Costs for household items are the responsibility of the Client); permanently fixed equipment (e.g., grab bars, ceiling tracks for lifts, stair lifts, etc. that are fixed to a wall/ceiling); lift chairs (considered household furniture. Costs for household items are the responsibility of the Client); pressure relief mattresses and alternating air pressure overlay pads powered or non-powered (which are beyond the scope of NIHB Program); and environmental protection devices and supplies (e.g., masks, air cleaners, filters, UV protection garments and lotions, etc. which are beyond the scope of NIHB Program).

NIHB Medical Transportation Benefit:

The Medical Transportation benefit is provided to eligible NIHB clients to access medically necessary health services that cannot be obtained on the reserve or in the community of residence, when access would otherwise be denied (exceptions may be granted, with justification and NIHB approval, to meet exceptional needs).  The NIHB Medical Transportation Policy Framework defines the policies and benefits under which the NIHB Program will fund.  Access to medical transportation benefits requires approval in advance by the Health Canada regional office, except in emergency situations.

Medical Transportation benefits may be provided to help community members to access the following types of services:

• Provincial/territorial insured medical services (e.g. doctors’ appointments, hospital care, health programs); eligible Non-Insured Health Benefits approved by the NIHB Program; and alcohol, solvent, drug abuse and detox treatment pre-approved by the NIHB Program.
• If community members are eligible NIHB clients, the following conditions apply:
• The medical service is not available locally;
• The community member has used up all other transportation benefits available from other federal, provincial/territorial or private programs;
• Travel is to the nearest appropriate health facility only;
• The most economical and efficient means of transportation is used, taking into consideration the urgency of the situation and medical condition; public transport is not available;
• Transportation to health services is coordinated to ensure maximum cost-effectiveness; and benefits are pre-approved by the Health Canada regional office or can be approved after the fact if there is medical justification and it meets NIHB Program criteria.

In cases where a client is required to travel repeatedly on a long term basis to access medical care/treatment, medical transportation benefits are provided for up to four months. During this time, an assessment will be conducted involving the treating physician, other relevant health professional(s) and the client to determine the provision of further benefits, taking into consideration the client’s medical condition. The NIHB Program will cover eligible travel costs for medical or non-medical escorts in certain circumstances:

Medical Escort: When a physician / RN is needed to monitor the condition of the client’s health during travel.

Non-Medical Escort: A non-medical escort may be covered at the request of a health professional. Examples of situations that may require a Non-Medical Escort: the client has a physical/mental disability such that he or she cannot travel without help; is medically incapacitated; is a minor and needs to be accompanied; requires legal consent by a parent or guardian; or requires a translator, if translation services are not available at the health facility.

Assistance with a kilometre allowance, meals and accommodations may be provided while in transit to access medically necessary health services according to rates and limitations established by the benefit criteria.

Certain types of travel, benefits and services will NOT be provided as benefits under the NIHB Program under any circumstances and are not subject to the NIHB appeal process. These include assistance with compassionate travel; appointments for clients in the care of federal, provincial or territorial institutions (e.g., incarcerated clients); court-ordered treatment/assessment, or as a condition of parole, coordinated by the justice system; appointments while travelling outside of Canada, other than as outlined in Section 1 travel for clients residing in an off-reserve location where the appropriate health services are available “locally”; travel for the purposes of a third-party requested medical examination; the return trip home in cases of an illness while away from home other than for approved travel to access medically necessary health services; travel only to pick-up new or repeat prescriptions or vision care products; travel to access health related services that are not identified in section 1.3, unless coordinated; payment of professional fee(s) for preparation of doctor’s note /document preparation to support provision of benefits; and transportation to adult day care, respite care and/or interval/safe houses.

Dental benefits:

Coverage for dental services is determined on an individual basis, taking into consideration the current oral health status, recipient history, accumulated scientific research, and availability of treatment alternatives.

The NIHB Program’s dental benefit covers:

• Diagnostic services like examinations or x-rays;
• Preventive services like cleanings;
• Restorative services like fillings;
• Endodontics such as root canal treatments;
• Periodontics or the treatment of gums;
• Prosthodontics including removable dentures;
• Oral surgery including the removal of teeth;
• Orthodontics to correct irregularities in teeth and jaws; and
• Adjunctive services, which include additional services like sedation.

Dental services must be provided by a licensed dental professional such as a dentist, dental specialist, or denturist.  Dental providers must comply with the NIHB Dental Benefits Guide. Eligible recipients access the dental benefit as follows:

• Recipients must make an appointment with a dental provider who will complete an examination, establish a treatment plan, and discuss the services required with the recipient;
• The dental provider will indicate what is covered by the NIHB Program (certain services may need prior approval);
• If the dental provider doesn’t know whether the service is covered by the NIHB Program, they can obtain that information by contacting the Health Canada regional office, or the National Dental Predetermination Centre (NDPC) for those regions which have been centralized, and asking the dental benefits staff what is and is not covered.

The NIHB Program requires the following standard documentation and information for the review of any predetermination and post-determination (post-approval) request:

• Predetermination/post-determination request on one of the following forms: Standard Dental Claim Form, ACDQ Dental Claim and Treatment Form, computer generated form, or NIHB Dental Claim Form (Dent-29).
• Comprehensive treatment plan from the treating and/or referring dentist/specialist, indicating all completed treatment and pending treatment needs including restorative, periodontal, prosthodontic, endodontic, orthodontic and surgical services.
• Current conventional or digital radiographs (within last twelve months): a. Periapical and bitewing radiographs: – must be of good diagnostic quality (i.e., size, resolution, contrast); and – must be mounted and labelled with the date of service, client name and provider name. b. A panoramic radiograph may be submitted in addition to, but not in place of bitewing and periapical radiographs. Please note: if duplicate radiographs are submitted they must identify the right or left side of the client’s mouth. When submitting enlarged digital radiographs, of any type, dental providers are requested to print a measurement scale on the radiograph to facilitate the assessment.
• Notation of all missing teeth.
• Periodontal charting, and/or Periodontal Screening and Recording (PSR), and/or Periodontal assessment.
• Periodontal tooth specific measurements (6 sites/tooth), where applicable. Please refer to the appropriate policy in this guide.
• All pertinent clinical findings/notes supporting the predetermination request.
• At Health Canada’s request, other documentation may be required.

Note: It is mandatory for dental providers to maintain a client chart/record documenting and supporting the services provided, claimed and paid by the NIHB Program.

Eye and Vision Care Benefits:

The benefits covered are eye examinations, when they are not insured by the province/territory, eyeglasses that are prescribed by a licensed vision-care provider such as an optometrist or optician; eyeglass repairs; eye prosthesis (an artificial eye); and other vision care benefits depending on your specific medical needs.

In order to obtain this benefit you must obtain a prescription by a licensed vision care professional such as an optometrist or an ophthalmologist, take the prescription to a recognized vision provider, such as an optician or an optometrist; and the provider must obtain pre-approval of the benefit by calling or faxing the Health Canada regional office.

The NIHB Program will cover an eye exam every 24 months for a person 18 years and over, every 12 months for a person younger than 18 years, and when there is a change or correction in vision.

However, if you have diabetes (or another medical condition) you may be eligible for a complete eye exam every 12 months.

It is common medical practice for eye examinations to be performed every two years for healthy individuals with no underlying conditions. The NIHB Program may cover follow-up examinations when medically necessary, for example in cases with an underlying medical condition, such as diabetes.

Eyeglass repairs are covered by the NIHB Program under the following conditions:

• The total cost of the repair cannot exceed the cost to replace the eyeglasses; and
• only one major repair and one minor repair are covered within the eyeglasses replacement time frame (12 or 24 months).
• Please note that replacement frames or sets of lenses are not eyeglass repairs. Replacements or repairs as a result of misuse, carelessness or negligence are not covered by the NIHB Program.

The following is a list of some (but not all) excluded items under the Eye and Vision Care program:

• Vision care goods and services covered by provincial/territorial health insurance plans
• esthetic products; vision exams required for a job, drivers license or to engage in sports activity; safety glasses for sport, leisure or work use; implants (e.g. punctual occlusion procedure); and laser surgery

There is an appeal process when a benefit has been denied; a client, parent, legal guardian or representative may initiate an appeal when an eligible benefit has been denied by the NIHB Program.

For a case to be appealed, a signed note or letter from the client, parent or legal guardian, accompanied by supporting information from the service provider or prescriber (e.g. doctor) must be submitted to the NIHB Program. There are three levels of appeal available.

Information on the appeal process is available on the Health Canada Website or contact the Health Canada regional office.

NIHB Short-Term Crisis Intervention Mental Health Counselling (STCIMHC) Benefit

The NIHB Program’s STCIMHC benefit is intended to provide coverage for mental health counselling to address crisis situations when no other mental health services are available and/or being provided. This benefit is intended to support the provision of immediate psychological and emotional care to individuals in significant distress to stabilize their condition, minimize potential trauma from an acute life event, and, as appropriate, transition them to other mental health supports.

In order for clients to access a Mental health counselling provider, the provider must be approved by the NIHB program; they are approved by providing proof they are registered with a legislated professional regulatory body and eligible for independent practice in the province/territory in which the service is being provided. Eligible mental health providers include:  Psychologists and Social Workers, with clinical counselling orientation; or Mental health counsellors with education and training comparable to psychologists or social workers, in Nova Scotia this includes Counselling Therapists who are registered with the NS College of Counselling Therapists.

In exceptional circumstances, other mental health counselling providers who do not meet these requirements may be accepted subject to the following conditions:

• There are no other mental health counselling providers enrolled with the NIHB Program in the vicinity and access to services is limited; or
• Where there is an emergency situation such that the health and safety of the client or other persons is at immediate risk.

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