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Non-Insured Health Benefits: Vision Care Benefit Update Saskatchewan Association of Optometrists AGM June 8, 2019 Andrea Reynoldson, Director, NIHB-SK Kelly Ulrich, Manager, NIHB-SK
Non-Insured Health Benefits: Vision Care Benefit Update Saskatchewan Association of Optometrists AGM June 8, 2019 Andrea Reynoldson, Director, NIHB-SK
Kelly Ulrich, Manager, NIHB-SK
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Presentation Overview
• NIHB Vision Care Benefit • AFN-NIHB Joint Review • Upcoming changes to the NIHB Vision Care Benefit
– Eyewear bundles – Coverage frequency
• Vision Care Provider Agreement
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Vision Care Benefit: New Approach to Corrective Eyewear
• Vision Benefits covered under the Non-Insured Health Benefits (NIHB) Program include: – Eye examinations (e.g. general and follow-up eye and vision examinations) – Corrective eyewear: Frames (e.g. regular eye glass frames); Lenses (e.g. unifocal, bifocal, high index, polycarbonate); Contact lenses; and Exceptions (reimbursement amount or frequency) based on medical need.
• Today’s update is regarding a new approach to NIHB coverage of corrective eyewear. This approach will be in effect on June 29, 2019.
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AFN-NIHB Joint Review
• A joint review of the NIHB program, conducted in partnership between the Assembly of First Nations (AFN) and the First Nations and Inuit Health Branch (FNIHB).
• The Steering Committee is made up of equal representation of First Nations and FNIHB representatives. The group is collectively guided by an Elder.
• The overall objective of the review is to identify and implement actions that: – enhance client access to benefits, – identify and address gaps in benefits, – streamline service delivery to be more responsive to client needs, and – increase program efficiencies.
• Includes in-depth benefit by benefit review, and has resulted in extensive changes and investments in the NIHB program since 2015.
• Feedback gathered over a 3 year period through multiple channels, including Regional Roundtables, Navigator networks, direct client/provider online surveys.
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AFN-NIHB Joint Review
• In order to respond to calls for action identified through the Joint Review, the NIHB Program will be implementing a new approach to corrective eye wear coverage under the NIHB Vision Care Benefit.
• The new approach is intended to make it easier for clients to understand their vision care coverage under NIHB, as well as to provide clients with more choice when seeking eyewear.
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Vision Care Benefit - New Approach: Key Changes
1. ‘Bundled’ approach - under the new approach, there will be two key coverage amounts:
Item Criteria for Approval Maximum Eligible Amount
Standard coverage amount
• Coverage for clients with a prescription under ±7.00 in both eyes
• About 95% of clients • Minimum prescription strength will
continue to apply
• Claimed cost for one or more prescription items, up to combined total of $275, as per Frequency Guidelines
• Additional amounts added for medically necessary tints and coatings
High Index coverage amount
• Coverage for clients who require a correction whose minimum power in a meridian is ±7.00 in at least one eye
• About 4% of clients
• Claimed cost for one or more prescription items up to combined total of $415, as per Frequency Guidelines
• Additional amounts added for medically necessary tints and coatings
The allowance can be used towards the purchase of many items and features that are currently exclusions, such as non-prescribed tints, coatings, photochromic lenses, prescription eyewear used for sports or work, a second pair of glasses and contact lenses. Clients with very complex (and therefore high cost) prescriptions will continue to be considered on an exception basis, over these coverage amounts.
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Vision Care Fee Schedule - SK (June 29, 2019): Eyewear
B. Corrective eyewear, either: Total invoiced cost up to, see note 1:
Standard amount (includes scratch resistant cost), or $275.00 High index amount, per published requirements (includes scratch resistant and antireflective coat) $415.00
C. Exception contacts, if client qualifies per published requirements Total invoiced for costs related to fitting and supply of
exception contacts, usual and customary charge, up to
Exception contact lens, amount may be applied only to costs related to contact lenses (assessment/fitting, dispensing, supply).
$450.00
D. Add ons (per published requirements), if the client qualifies, the item must be dispensed. Add the $ indicated to standard/high index amount (B)
or early replacement lens amount (C ) if client qualifies
for this item UV, medically necessary +$10.00/lens Tints, medical necessary, per tint +$10.00/lens Flex frame, add to bundle allowance if client qualifies (added to amount in B only) +$50.00
E. Repairs, exception basis Per invoiced usual and customary charge, up to
Minor repairs (once every two years for clients 18+, once per year for client under 18) $25.00 Major repairs (once every two years for clients 18+, once per year for client under 18) $125.00
F. Early lens replacement (only costs related to supply and dispensing of replacement lenses can be claimed—no frame), exception basis, per published policy
Per invoiced usual and customary charge, up to
Standard (includes scratch resistant coat), or $75.00/lens High index (includes scratch resistant and antireflective coat) $145.00/lens G. Postage: Actual charges, when required (receipt required if priority post or registered mail is used).
Note: 1. Total cost of the following can be claimed against the amount in (B): lenses(any type of prescription eyewear meeting published minimum strength requirements, any glass/plastic lens material, photochromic), frame, markup, case, dispensing fees, scratch coating, client chosen tints/coatings, lens treatments/hardening, oversize, grooving, edging, any costs associated with add, cylinder, sphere, prism, antireflective coating, dispensing in client own frame, contact lens assessment/fitting.
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Vision Care Benefit - New Approach: Fee Comparison
Current Fee Schedule – Average Cost
New Fee Schedule – Bundle Amount
Single Vision $171.75 $275
Bifocal $205.03 $275
High Index - Single Vision $185.29 $415
High Index - Bifocal $222.30 $415
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Vision Care Fee Schedule - SK (June 29, 2019) Diagnostic Services
Diagnostic Services
A. Diagnostic Services
Routine Eye Exam $65.09
Repeat Routine Exam $65.09
Partial Eye Exam $40.26
Single Procedure $30.71
Tonometry $14.82
Visual Fields $36.29
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Vision Care Benefit – New Approach: Key Changes
2. Frequency of coverage will be changed to a calendar year basis. o The frequency of coverage will be changed to a calendar year basis (e.g. two
years, not 24 months). Frequency guidelines will remain unchanged. Age Group Frequency
Clients aged 0-17 years Once per calendar year
Clients aged 18-64 Once every two calendar years
Clients aged 65+ Once per calendar year
3. Unspent balances will be available for future eyewear purchases o NIHB will track any unspent balance of the coverage amount. The
residual value will be available to the client until the end of the calendar year (or two year) cycle.
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Vision Care Benefit – New Approach: Implementation
• Client Update available online mid-June • Updated Vision Care Framework and Benefit List to be published online • Provider update – distributed mid-June • Implementation of a National Vision Health Advisory Committee
– The committee will include vision health professionals, First Nations & Inuit members and the AFN and ITK.
• Clients can confirm their residual balance after implementation by contacting our Regional Office at 1-866-885-3933
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Vison Care Provider Agreement
• The NIHB Program initiated a national provider enrolment process in March 2015
• The process ensures that all providers have a clear understanding of NIHB Program policies and procedures
• Existing vision care providers enrolled under this new process by completing a Provider Agreement
• Providers enrolled since March 2015 have completed a Provider Agreement at the time of enrollment
• Providers are encouraged to refer to the Provider Agreement for the Terms and Conditions of the NIHB Program
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NIHB Saskatchewan Toll-Free Line: 1-866-885-3933
To subscribe to NIHB Program Updates: https://www.canada.ca/en/indigenous-services-canada/services/non-
insured-health-benefits-first-nations-inuit/subscribe-updates.html
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Andrea Reynoldson Director, Non-Insured Health Benefits
First Nations & Inuit Health Branch, Saskatchewan Region Indigenous Services Canada [email protected] Kelly Ulrich Manager, Non-Insured Health Benefits First Nations & Inuit Health Branch, Saskatchewan Region Indigenous Services Canada [email protected]
