Presentation on theme: "Non-Insured Health Benefits (NIHB) Program"— Presentation transcript:
1 Non-Insured Health Benefits (NIHB) Program Program OverviewQalipu Mi’Kmaq First Nations BandSeptember, 2011Newfoundland Community Information sessions1
2 NIHB Overview Objective of the NIHB Program/What is NIHB Who is Eligible? When does my eligibility start?NIHB Program Benefits:Pharmacy (e.g. insulin and glucose test strips )Medical Supplies & Equipment (e.g. lancets and syringes)Dental ServicesVision CareMedical TransportationShort-term Crisis Mental Health CounsellingOut of Country InsuranceClient ReimbursementAppeal ProcessQuestions2
3 What is NIHB?National program administered by Health Canada, First Nations and Inuit HealthSupplements 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 DentalOther 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)
4 Eligibility for NIHBAn eligible recipient must be identified as a resident of Canada AND one of the following:a Registered Indian according to the Indian Actan Inuk recognized by one of the Inuit Land Claim organizationsan 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 income4
5 When am I Eligible for benefits? Individuals will become eligible for Non-Insured Health Benefits when they are:officially registered with Aboriginal Affairs and Northern Development Canada (AANDC) as status Indians following the formation of the Band by the federal Cabinet, andhave an AANDC registration number that will be provided after formation of the Band.To be eligible to submit claims, you must:have received confirmation from AANDC of your registration,confirm with the NIHB regional office that services/benefits are eligible under the program (suggest doing so prior to making any appointment), andkeep 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……).5
6 Before Calling NIHB for Service: Please have on hand the following information for NIHB to create a client record:Qalipu Band Number (034……)Name of Client or person to be accessing servicesDate of birthAddress and phone number
8 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 NIHBIf 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)
9 “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.
10 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 stripsAll pharmacy benefits require a prescription from a physician, nurse practitioner, dentist or other authorized prescriberFor drugs and products that are insured, there is 100% coverage (no copay or deductible)
11 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
12 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 neededLimited Use Drugs: these are drugs that can be covered when coverage criteria are met; your physician will need to provide informationException Drugs/Non-Benefit Drugs: these are not insured, however can be considered for coverage in exceptional circumstances with supporting information from your physician
13 Accessing BenefitsWhen 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 pharmacistYour pharmacy will be advised (by fax) of the coverage decisionSpeak to your pharmacist about insured alternatives
14 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.
15 Generic MedicationsNIHB 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.
16 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).
17 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:If you need assistance finding a pharmacy that will bill NIHB directly, please contact the Regional Office at
19 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 footwearPressure garmentsProstheticsOxygen therapyRespiratory therapy (e.g. CPAP machine)
20 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 diallingc) Medical Diagnosis: may be required for such items as wheelchairsSome 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. $ for orthotics)
22 NIHB Dental ServicesCoverage 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.22
23 NIHB Dental FactsNIHB 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.23
24 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.24
25 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.25
26 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).26
27 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.27
28 ExclusionsThere are a number of items that are Excluded from the NIHB Benefits List, and cannot be considered for an exception:ImplantsVeneersBleachingSports Mouth Guards28
29 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 at29
30 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.30
32 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 advance32
33 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 ageNew lenses if prescription changes at least 0.5 diopters before eligibility dateEyeglass 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 conditions33
34 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: $ $62.05Frame Dispensing: $ $39.83Lens: $ $54.00Lens Dispensing: $ $70.76$ $226.64* rates as of October 2010Children 17 and under are entitled to Scratch Resistant CoatingAny additional costs are the client’s responsibility
35 Examples of Exclusions The following is a list of some (but not all) of the excluded items and therefore, not subject to appeal:Vision care goods and services covered by provincial/territorial health insurance plansVision exams required for a job, drivers license or to engage in sports activitySafety glasses for sport, leisure or work useImplants (e.g. punctual occlusion procedure)Foldable cataract lens (soft)Refractive Laser surgeryContact Lens for aesthetic purposesContact Lens SolutionProgressive / Tri-focal LensesSunglassesPhotochromic / photochromatic lensesTreatments with investigational / experimental statusReplacements as a result of misuse, carelessness or client negligence
37 Accessing the MT Benefit To assist clients in accessing medical services that are not provided in the local areaAll travel must be pre-approved by the Non-Insured Health Benefits (NIHB) Regional officeWhen 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
38 What Travel is Covered? Travel is covered: for services that are located farther than 35kms round trip from their hometo the nearest appropriate health professional or facilityin the most efficient and economical modeto 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)38
39 Non-Medical Escorts Travel expenses may be covered for ONE escort The escort MUST be prior approved by NIHBThe “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 requestMay 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 client39
40 Medical Transportation Benefits 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.Accommodationsdistance 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 differenceIf 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.MealsMeals may be covered if the time away from home for the appointment is more than six hoursBreakfast is not covered for same day trips unless medical justification is providedMeals may be provided for trips less than six hours if there is medical justification provided40
41 Rates Transportation: The private rate of mileage is $0.18/km Accommodations:Private rate: $13.50/night/adultMeals:Adult: Breakfast $6.00, Lunch $9.00, Supper $ Children under 12 years of age receive half the adult rate.
42 Exclusions 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 housesAppointments while travelling outside of CanadaWhere the appropriate services are available locallyTravel 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 travelTravel 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 completion42
43 Short-term Crisis Intervention Mental Health Counselling
44 Short-term Crisis Intervention Mental Health Counselling Provides a bridge to provincial services, initial12 hours, assessed on a case by case basis.NIHB covers (first 3 hours):initial assessmentdevelopment of a treatment planprofessional mental health therapist feestravel costsAcceptable providers: Counselling must be provided by therapists registered with a regulatory body from the disciplines of clinical psychology or clinical social work (Masters level).
45 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
47 Payment of Non Insured Health Benefits outside of Canada The NIHB Program provides some benefits outside of CanadaWhat 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 travel47
49 Client ReimbursementTwo different forms: One for Vision, MS&E, Pharmacy, Dental and one for Medical transportationComplete and sign the appropriate formProvide an original or a copy of the prescription from your Doctor or Nurse PractitionerAttach 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 insurerAny supporting medical documentation (if available)Reimbursement form can be found: or
50 Client Reimbursement (continued) Short-Term Crisis Intervention Mental Health CounsellingPlease contact the NIHB Regional Office (Halifax) for approval prior to seeking counselling services at5050
52 Appeal ProcessWhen 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 OttawaAll appeal requests must be received in writing with the client’s signature.
53 Appeal Process (continued) Information to be included with your letter of appeal:The condition for which the benefit is being requestedThe diagnosis and prognosis; including what other alternatives have been triedRelevant diagnostic test resultsJustification for the proposed treatment and any additional supporting information
54 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.
55 CONTACT INFORMATIONFor more information on Non-Insured Health Benefits please visit our website at:Atlantic Region’s NIHB Toll Free Number: