Transcript Non-Insured Health Benefits (NIHB) - Qalipu Mi`kmaq

Non-Insured Health Benefits (NIHB) Program
Program Overview
Qalipu Mi’Kmaq First Nations Band
September, 2011
Newfoundland 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:
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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 Process
6. 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:
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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 recipient
Clients 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:
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officially registered with Aboriginal Affairs and Northern Development
Canada (AANDC) as status Indians following the formation of the Band by
the federal Cabinet, and
have an AANDC registration number that will be provided after formation
of the Band.
To be eligible to submit claims, you must:
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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),
and
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/fnihbdgspni/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:
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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?
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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?
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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:
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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:
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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
$39.83
Lens:
$36.00
$54.00
Lens Dispensing:
$55.88
$70.76
$193.76
$226.64
* rates as of October 2010
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Children 17 and under are entitled to Scratch Resistant Coating
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Any additional costs are the client’s responsibility
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 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
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)
Non-Medical Escorts
Travel expenses may be covered for ONE escort
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The escort MUST be prior approved by NIHB
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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
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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
Medical Transportation Benefits
Transportation
• 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.
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 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
Short-term Crisis Intervention Mental Health Counselling
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 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
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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/fniahspnia/alt_formats/fnihb-dgspni/pdf/nihb-ssna/form-reimburserembourse-eng.pdfTwo or http://www.Qalipu.com/default.asp
Client Reimbursement (continued)
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.
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: [email protected]
THANK YOU
QUESTIONS?