Non-Insured Health Benefits (NIHB) Program

Program Overview

Qalipu Mi’Kmaq First Nations BandSeptember, 2011Newfoundland Community Information sessions

NIHB Overview

1. Objective of the NIHB Program/What is NIHB 2. Who is Eligible? When does my eligibility start?3. NIHB Program Benefits:

• Pharmacy (e.g. insulin and glucose test strips )• Medical Supplies & Equipment (e.g. lancets and syringes)• Dental Services• Vision Care• Medical Transportation• Short-term Crisis Mental Health Counselling• Out of Country Insurance

4. Client Reimbursement 5. Appeal Process6. Questions

What is NIHB?

• National program administered by Health Canada, First Nations and Inuit Health

• Supplements what you already receive from the province using your MCP card and other provincial plans like other Canadians (MD visits, hospital services)

• Some eligible benefits are managed by Ottawa such as Pharmacy, Medical Supplies and Equipment and Dental

• Other eligible benefits are managed at the Regional office such as Medical Transportation, Vision, Short Term Crisis Intervention Mental Health Counselling and Out of Country Insurance. All Regions offer these benefit areas but there will be differences in what is paid for based on regionally negotiated agreements (e.g. glasses)

Eligibility for NIHB

An eligible recipient must be identified as a resident of Canada AND one of the following:

• a Registered Indian according to the Indian Act• an Inuk recognized by one of the Inuit Land Claim

organizations• an infant of less than 1 year of age, whose parent is an

eligible recipientClients should also be registered (or eligible for registration) with their provincial Department of Health.

Available to all clients regardless of income

When am I Eligible for benefits?

• Individuals will become eligible for Non-Insured Health Benefits when they are:i. officially registered with Aboriginal Affairs and Northern Development

Canada (AANDC) as status Indians following the formation of the Band by the federal Cabinet, and

ii. have an AANDC registration number that will be provided after formation of the Band.

• To be eligible to submit claims, you must:i. have received confirmation from AANDC of your registration,ii. confirm with the NIHB regional office that services/benefits are eligible

under the program (suggest doing so prior to making any appointment), and

iii. keep receipts for eligible benefits/services rendered between the date of band creation and the date on your Confirmation of Registration letter from AANDC that includes your Qalipu Band # (034……).

Before Calling NIHB for Service:

Please have on hand the following information for NIHB to create a client record:

1) Qalipu Band Number (034……)

2) Name of Client or person to be accessing services

3) Date of birth

4) Address and phone number

Pharmacy

How to Access Pharmacy Benefits

Your band ID (10 digits) is used by the pharmacy to bill NIHB electronically.

A pharmacy must be a provider with NIHB to bill NIHB directly (electronically), ask your pharmacy if they are set up to bill NIHB

If you pay for your medication you can submit your receipt for reimbursement, however the pharmacy may not be aware if the drug is insured by NIHB or may charge more than is reimbursed by NIHB (you may not be reimbursed the full amount)

“Coordination of Benefits”

If you have access to another drug plan, that plan should be billed first and then NIHB (NIHB would be the secondary insurer).

Your pharmacy can help coordinate payment of prescription claims through electronic billing.

What Pharmacy Benefits are Insured?

Prescribed drugs that are:-on the national NIHB drug benefit list or approved for coverage (formulary is available online) -benefits include some over-the-counter medications and some drug-related supplies such as diabetic test strips

All pharmacy benefits require a prescription from a physician, nurse practitioner, dentist or other authorized prescriber

For drugs and products that are insured, there is 100% coverage (no copay or deductible)

Pharmacy

What is not covered (examples):

Household products (including regular soaps and shampoos); Cosmetics; Anti-obesity drugs;Herbal or alternative therapies, including glucosamine and evening primrose oil;

megavitamins; Drugs with investigational/experimental status; Vaccinations; Hair growth stimulants; Fertility agents and impotence drugs; Selected over-the-counter products such as cough and cold medications;Infant formula; Drugs that are excluded from the benefit list

Types of Benefits in the NIHB Program

• Open Benefits : these drug can be billed by the pharmacy when they receive your prescription with no prior approval needed

• Limited Use Drugs: these are drugs that can be covered when coverage criteria are met; your physician will need to provide information

• Exception Drugs/Non-Benefit Drugs: these are not insured, however can be considered for coverage in exceptional circumstances with supporting information from your physician

Accessing Benefits

• When the system does not pay a claim for your prescription, and it is an eligible benefit (e.g. limited use drug with criteria), your pharmacy should call the Drug Exception Center (DEC) (8:30am to 6:30pm NDT/NST)

• DEC is located in Ottawa; they will send any necessary forms to your physician and provide any relevant information to your pharmacist

• Your pharmacy will be advised (by fax) of the coverage decision• Speak to your pharmacist about insured alternatives

What about drugs I am on now? Will they be covered?

Full benefit drugs:

NIHB will pay when billed by the pharmacy.

Drugs that are not open benefits: e.g. limited use drugs:

Your pharmacy should contact the DEC so the correct forms can be sent to your physician as necessary; a two year printout of your pharmacy claims may also be required (with your consent) as some medications can be approved based on this history.

Generic Medications

NIHB covers the cost of the ‘lowest cost alternative’; the best price for the same drug, which is usually the generic version of a drug.

Coverage for a higher cost product can be provided if you have an allergy or adverse reaction to the other (generic) versions of a medication; your physician would need to provide information.

Other important points

NIHB will pay up to 100 days supply for most medications.

For most long term chronic medications, only one dispensing fee will be provided to your pharmacy every 28 days.

In some cases, there is a maximum amount you are able to have covered in a specified time period, without getting special approval for more (e.g. smoking cessation products, diabetic test strips).

Other important points (continued)

NIHB has agreements with pharmacy providers regarding how much can be billed and how drugs are priced. Extra charges (e.g. for higher dispensing fees than allowed by NIHB) should not be passed onto you.

You have up to one year to submit official pharmacy receipts for payment. A reimbursement form is available online: http://www.hc-sc.gc.ca/fniah-spnia/alt_formats/fnihb-dgspni/pdf/nihb-ssna/form-reimburse-rembourse-eng.pdf

If you need assistance finding a pharmacy that will bill NIHB directly, please contact the Regional Office at 1-800-565-3294.

Medical Supplies & Equipment (MS&E)

Medical Supplies & Equipment (MS&E)

What is covered:

• Medical supplies (e.g. bandages, dressings)• Medical equipment (e.g. wheelchairs, walkers)• Audiology benefits (e.g. hearing aids, repairs)• Orthotics and custom footwear• Pressure garments• Prosthetics• Oxygen therapy• Respiratory therapy (e.g. CPAP machine)

How do I access MS&E Benefits?

You must have the following information:a) prescription from recognized prescriber ( Medical Doctor /Nurse

Practitioner)b) You may need prior approval for the item from NIHB before

purchasing. Have your pharmacy/provider check with NIHB Regional office by dialling 1-800-565-3294

c) Medical Diagnosis: may be required for such items as wheelchairs

Some items can be approved by NIHB over the phone (diapers) other items will need to be reviewed by consultants at Headquarters (wheelchairs, custom made shoes, issues with frequencies or cost above what we are approved to pay (e.g. $450.00 for orthotics)

Dental Services

NIHB Dental Services

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

Dental services must be provided by a licensed dental professional such as a dentist, dental specialist, or denturist.

Current NIHB rates are 92% of the 2009 Provincial Fee Guide.

NIHB Dental Facts

• NIHB Dental benefits account for approximately 75% of all public funds spent directly on dental services in Canada.

• NIHB has the one of the widest ranges of eligible procedures of any publicly funded dental program in the world.

• NIHB seeks to fund procedures with known health benefits and to help people to maintain a functional dentition throughout life. Some benefits such as scaling and root planning have actually been dramatically increased based on recent evidence to support a strong link between diabetes and cardiovascular disease risk and poor gum health.

Dental - What is covered without Predetermination?

Diagnostic services like examinations or x-rays; Preventive services like cleanings; Restorative services like fillings; Endodontic treatment on anterior and some posterior teeth; Basic oral surgery such as simple extractions of teeth; Emergency treatment for the relief of pain.

While these services do not require predetermination, some of them do have annual frequency limitations. Any exceptions to these limits will require approval from NIHB.

Dental - What is covered without Predetermination?

• Check-up and cleaning: Twice every 12 months for children under 17, once for those 17 and older.

• Emergency exams are covered once in a 12 month period, but exceptions can be made if there is an associated emergency treatment done as well.

• There is no limit on the total number of fillings, but they are limited to 1 per tooth per 12 months (same provider / same office)

• Root Canal treatment on anterior teeth, bicuspids, and first molars can be done as needed (limit of 3 in 3 years).

• Denture repairs: One per denture in any 12 months.• Denture relines: One per denture in any 24 months.

Dental - What is covered with Predetermination?

Major restorative treatment such as crowns; Prosthodontics - complete and partial removable dentures, Oral surgery including the surgical removal of teeth; Orthodontics to correct functional irregularities in teeth and jaws.

These services always require predetermination regardless of payment method (Client/Band reimbursement vs. direct billing to NIHB).

Dental - What is covered with Predetermination?

• Most services that require predetermination are not eligible for post-approval. e.g. after the fact.

• Crowns, Root Canal treatment, Prosthodontics, Periodontal treatment – NIHB Policies include criteria that must be met in order to be approved.

• Dentures are limited to one per arch in any 8 year period.• Surgical extractions may be post-approved, but still have to

meet the predetermination criteria.• Exceptions to frequencies or policy may be made if the

condition leading to the need for treatment is beyond the patients control.

Exclusions

There are a number of items that are Excluded from the NIHB Benefits List, and cannot be considered for an exception:

• Implants• Veneers• Bleaching• Sports Mouth Guards

NIHB Orthodontic Coverage

Since 2002, all NIHB Orthodontic approvals have been issued by the Orthodontic Review Centre in Ottawa. There is no Regional contact for any Orthodontic requests.

The Orthodontic Review Centre can be reached at

1-866-227-0943

NIHB Dental Claim Submissions

Providers seeking direct payment submit their claims directly to Express-Scripts Canada. Submission can be made manually, or electronically. Payment is issued twice monthly.

Clients (or a 3rd Party) seeking reimbursement should submit all documentation to the NIHB Regional Office to ensure all required information is included and claim is processed correctly.

The NIHB Regional Office now has the capability of entering Client Reimbursement Claims electronically, reducing the amount of time clients are waiting for payment.

Vision Care

Vision Care

Access to Services:

• You must be examined by an Optometrist or an Ophthalmologist to obtain a prescription. Prescriptions are to be filled by an Optometrist or an Ophthalmologist.

• If a vision care provider is not registered in the NIHB Atlantic Region database, a vendor code needs to be created (24-48 hours by the NIHB Regional office)

• Clients will be able to receive services from registered providers without having to pay in advance

Vision Care (continued)

What is covered:

• Routine eye exams and standard eyeglasses: (prescribed by Vision Care Provider)

- Every 2 years for clients 18 and older- Every year for clients under 18 years of age

• New lenses if prescription changes at least 0.5 diopters before eligibility date

• Eyeglass repairs- Only one major and one minor repair (not to exceed cost of

glasses)• Contact lenses (if medically necessary)• Eye Prosthesis (artificial eye)• Other eye exams due to medical conditions

Vision Care (continued)

How much does the NIHB Program pay for eye wear?Pricing depends on whether or not prescription is single vision or bi-focal: Single Vision* Bi-

Focal*Frame: $62.05 $62.05

Frame Dispensing: $39.83 $39.83Lens: $36.00 $54.00Lens Dispensing: $55.88 $70.76

$193.76 $226.64* rates as of October 2010

• Children 17 and under are entitled to Scratch Resistant Coating

• Any additional costs are the client’s responsibility

Examples of Exclusions

• Vision care goods and services covered by provincial/territorial health insurance plans

• 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)

• Foldable cataract lens (soft)• Refractive Laser surgery

• Contact Lens for aesthetic purposes

• Contact Lens Solution• Progressive / Tri-focal Lenses• Sunglasses• Photochromic / photochromatic

lenses• Treatments with investigational /

experimental status• Replacements as a result of

misuse, carelessness or client negligence

The following is a list of some (but not all) of the excluded items and therefore, not subject to appeal:

Medical Transportation

Accessing the MT Benefit

• To assist clients in accessing medical services that are not provided in the local area

• All travel must be pre-approved by the Non-Insured Health Benefits (NIHB) Regional office

• When you call in you will need:– your Band number, date of birth, appointment information

(doctor name, phone number, location, date of appointment) and travel information (mode of travel, date of travel)

– 3-5 days notice is required

What Travel is Covered?Travel is covered:• for services that are located farther than 35kms round trip from

their home• to the nearest appropriate health professional or facility• in the most efficient and economical mode• to Insured services under provincial health plans (physician

appointments, hospital care, diagnostic tests, medical treatments)• to alcohol, solvent, drug abuse and detox treatment centers

(includes Health Canada funded NNADAP programs)• Traditional healers (within Region)• for services approved by NIHB (Vision, dental and mental health

providers)

Travel expenses may be covered for ONE escort• The escort MUST be prior approved by NIHB• The “Non-Medical Escort Form” must be completed by a Community

Health Professional (i.e. physician, nurse practitioner, nurse). The form must include the medical details to support the request

• May be covered if one or more of the following criteria apply: • the client is a minor; • a language barrier exists; • the client has a physical/mental disability of a nature or due to a

current medical condition he or she is unable to travel unassisted;• the client is medically incapacitated; • there is a need to receive instructions on specific procedures that

cannot be given only to the client

Non-Medical Escorts

Medical Transportation BenefitsTransportation• Clients can drive themselves or have someone drive them to the medical

appointment. • NIHB may arrange for public transportation (e.g. bus) if possible.• Transportation in St. John’s is provided by the St. John’s Native Friendship

Centre. Alternate arrangements may not be reimbursed.Accommodations• distance must be over 600 km return (unless justification provided)• Clients can request to stay at hotels that direct bill to NIHB. If client

chooses alternate arrangements - responsible for the cost difference• If a person is required to relocate for a period of time to access long term

care, NIHB may assist for a period up to 3 months. Meals• Meals may be covered if the time away from home for the appointment is

more than six hours • Breakfast is not covered for same day trips unless medical justification is

provided • Meals may be provided for trips less than six hours if there is medical

justification provided

Rates

Transportation:• The private rate of mileage is $0.18/km

Accommodations:• Private rate: $13.50/night/adult

Meals:• Adult: Breakfast $6.00, Lunch $9.00, Supper $15.00. Children

under 12 years of age receive half the adult rate.

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 or transportation

to adult day care, respite care and/or interval/safe houses• Appointments while travelling outside of Canada• Where the appropriate services are available locally• Travel for the purposes of a third-party request (e.g. employer requested

medicals)• A return trip home in cases of illness while away from home other than for NIHB

approved travel• Travel to pick-up new/repeat prescriptions or vision products (Exception:

Methadone prescriptions is valid for 4 months only)• Payment of professional fee(s)• An adult that is asked to leave a drug/alcohol treatment program before

completion

Exclusions

Short-term Crisis Intervention Mental Health Counselling

Short-term Crisis InterventionMental Health Counselling

Provides a bridge to provincial services, initial12 hours, assessed on a case by case basis.

NIHB covers (first 3 hours):• initial assessment• development of a treatment plan• professional mental health therapist fees• travel costs

Acceptable providers: Counselling must be provided by therapists registered with a regulatory body from the disciplines of clinical psychology or clinical social work (Masters level).

Short-term Crisis Intervention Mental Health Counselling (continued)

Accessing benefits:

• Currently requires referral to the mental health provider by the client’s physician or nurse practitioner (will change to self referral Sept 2011)

• Approval forms can be obtained from NIHB Regional office

Out of Country Insurance

Payment of Non Insured Health Benefits outside of Canada

The NIHB Program provides some benefits outside of Canada

What is covered?

• The cost of privately acquired health insurance for approved students or seasonal migrant workers and their legal dependants. Prior approval is required.

• Transportation benefits may be provided when eligible recipients are medically referred and approved for treatment coverage outside of Canada by a provincial or territorial health care plan. Prior Approval is required.

• Does not replace need for private insurance for out of country travel

Client Reimbursement

Client Reimbursement

Two different forms: One for Vision, MS&E, Pharmacy, Dental and one for Medical transportation

• Complete and sign the appropriate form• Provide an original or a copy of the prescription from your Doctor or

Nurse Practitioner• Attach original itemized receipts (for Pharmacy: must be official

prescription receipt for medications, not a cash register or debit receipt)• If there is third party coverage (Blue Cross, Sunlife, etc) include a copy

of the prescription, receipts and the coordination of benefits statement from the third party insurer

• Any supporting medical documentation (if available)• Reimbursement form can be found:

http://www.hc-sc.gc.ca/fniah-spnia/alt_formats/fnihb-dgspni/pdf/nihb-ssna/form-reimburse-rembourse-eng.pdfTwo or http://www.Qalipu.com/default.asp

Short-Term Crisis Intervention Mental Health Counselling

•Please contact the NIHB Regional Office (Halifax) for approval prior to seeking counselling services at 1-800-565-3294.

Client Reimbursement (continued)

Appeal Process

Appeal Process

• When coverage of an eligible benefit through the NIHB program has been denied the client or parent/guardian has the right to appeal the decision.

• Appeals can NOT be submitted for EXCLUDED items.

• There are three Levels of Appeal that can be initiated by the client or parent/guardian. Appeals for Drugs and orthodontic services are managed in Ottawa

• All appeal requests must be received in writing with the client’s signature.

Appeal Process (continued)

• Information to be included with your letter of appeal:

• The condition for which the benefit is being requested• The diagnosis and prognosis; including what other alternatives

have been tried• Relevant diagnostic test results• Justification for the proposed treatment and any additional

supporting information

Appeal Process (continued)

• The client or parent/guardian will be notified in writing of the decision.

• If client has not received a written decision within one month of submitting appeal, contact Atlantic Regional office for a status update.

CONTACT INFORMATION

For more information on Non-Insured Health Benefits please visit our website at:

http://www.hc-sc.gc.ca/fniah-spnia/nihb-ssna/index-eng.php

Atlantic Region’s NIHB Toll Free Number: 1-800-565-3294

E-mail: ATLNIHB@hc-sc.gc.ca

THANK YOU

QUESTIONS?