Guide for Medical Supplies and Equipment Benefits: Non-Insured Health Benefits

September 13, 2018

This guide provides information on the Indigenous Services Canada (ISC) Non-Insured Health Benefits (NIHB) Program and its policies that are relevant to medical supplies and equipment (MS&E) benefit coverage. It explains the extent and limitations of the NIHB Program’s MS&E benefits by describing the important elements of each associated policy. It also lists website addresses to provide quick access to related forms and more detailed Program information.


Table of contents

For lists of MS&E eligible benefits covered in home or ambulatory care settings please refer to the MS&E Benefits Lists.

Refer to the Medical Supplies and Equipment (MS&E) Claims Submission Kit (PDF) available at Express Scripts Canada, for the process to submit claims for payment of goods and services rendered to eligible clients.

 

1.0 Medical supplies and equipment (MS&E) general policies

1.1 Introduction

Indigenous Services Canada (ISC)'s Non-Insured Health Benefits (NIHB) Program is a national program that provides eligible registered First Nations and recognized Inuit coverage for a range of medically necessary health benefits when these benefits are not otherwise covered through private or provincial/territorial health insurance plans or social programs.

NIHB Program benefits include prescription drugs and over-the-counter (OTC) medications, dental and vision care, medical supplies and equipment (MS&E), mental health counselling, and transportation to access medically required health services that are not available on reserve or in the community of residence.

As MS&E policies and procedures evolve, the guide is updated accordingly and providers are advised of these changes through the NIHB's newsletters and broadcast messages distributed by Express Scripts Canada, clients are advised through the Program Updates.

Providers are advised to read and retain the most current version of the guide as well as Newsletters to ensure continued compliance with their Express Scripts Canada Provider Agreement for the NIHB Program. In the event of contradiction between versions of the guide, the provisions of the Indigenous Services Canada (formerly Health Canada) web-posted information will prevail.

Items covered through the MS&E benefit are intended to address NIHB clients' medical needs in relation to basic activities of daily living (ADL) such as eating, bathing, dressing, toileting, and transferring.

MS&E benefits are covered in accordance with the mandate of the NIHB Program. Coverage for specific MS&E benefits is based on policies and guidelines established by ISC. These decisions are based on the judgement of recognized health professionals consistent with the best practices of health services delivery and evidence-based standards of care. This applies to open benefits (items that do not require a prior approval) on the NIHB Program's MS&E benefits list as well as items that require prior approval.

NIHB will cover the cost of items that meet Program coverage criteria. As such, providers must not charge NIHB clients a co-payment or extra bill for any item the Program is extending coverage.

Please note that some MS&E items require prior approval for reimbursement. In order to avoid delays and ensure claims are reimbursed, items requiring prior approval should only be dispensed after the approval is granted by the appropriate FNIHB regional office. Refer to Section 1.4: Prior Approval Requirements for additional details.

1.2 Types of MS&E benefits

1.2.1 Open benefits

Open benefits are medical equipment and supplies listed on the MS&E Benefits List that can be dispensed by providers without obtaining a prior approval.

Prior to dispensing an open benefit that has a replacement guideline; providers are reminded to contact the Express Scripts Canada Provider Claims Processing Call Centre at 1-888-511-4666 to confirm the client eligibility. Once eligibility has been confirmed, providers may submit claims directly to Express Scripts Canada for payment.

Providers are required to keep the following information on file:

  • Prescription or recommendation from an NIHB-recognized prescriber
  • Manufacturer product code number, make/model of the equipment
  • Assessment or recommendation report from a health professional, if available

1.2.2 Limited use

Limited use (LU) items require specific criteria for coverage under the NIHB Program; for benefits in this category, prior approval must be given and specific criteria must be met to be eligible for coverage.

1.2.3 Exceptions

Exceptions are items that are not listed on the MS&E Benefits List. NIHB may provide coverage on a case-by-case basis as long as the item is not an exclusion of the Program. A request for an exception requires a written medical justification and a completed prior approval request form. MS&E providers should refer to section 1.4 of this guide and follow the same prior approval requirements to request coverage for exception items.

1.2.4 Exclusions

Exclusions are items that are not listed on the MS&E Benefits List and cannot be considered for coverage or appealed under the NIHB Program. General exclusions include:

  • items used exclusively for sports, work or school;
  • items for cosmetic purposes;
  • experimental equipment and/or experimental therapy;
  • therapy treatment (e.g. Occupational Therapy, Physiotherapy, Speech Therapy, Chiropractic and Massage Therapy)
  • therapy equipment (e.g. treadmills, exercise balls);
  • household items/products; and
  • home renovations (e.g. ramps, stair lifts).

Specific exclusions are also listed under each MS&E sub-benefit area.

1.3 Prescription requirements for MS&E items

The following are prescription/written recommendation requirements to establish eligibility for any MS&E benefit:

  • The Provider must obtain and have possession of the prescription/written recommendation before services are provided to the client. Therefore, the prescription/written recommendation must be dated prior to the provider service date for the claim to be eligible for payment;
  • Unless otherwise indicated in the guide, a prescription/written recommendation is required for both the initial and replacement items;
  • A prescription/written recommendation that is not dated will be deemed invalid;
  • Unless otherwise indicated, a prescription/written recommendation is valid for one year from the date that it is written; and
  • Pre-populated prescription/form by service providers to prescribers is not acceptable.

Prescription (Rx)/recommendation must contain the following information:

  • prescription/written recommendation dated and signed within the past 12 months;
  • prescriber's licence number;
  • prescriber's hand-written signature (a stamped or electronic prescriber signature is not accepted, unless the provider has obtained permission from the regional office to use this format);
  • client's full given name and surname as detailed in the Medical Supplies and Equipment (MS&E) Claims Submission Kit (PDF), section 4.0 Client Identification and Eligibility; and
  • item or service being prescribed/recommended.

The Program will only accept a prescription/written recommendation that is written for a specific client.

Please note: a written recommendation should include the same information as a prescription.

Where the prescription is in the form of a referral to another health professional, it must include the specific type of assessment required. For example:

  • Prescription from a physician or nurse practitioner addressed to an occupational therapist (OT) requesting an assessment and recommendations for a wheelchair.

Regardless of the form used, all information indicated above should be provided.

Faxed prescriptions/written recommendations require a fax header with the date sent and the sender's coordinates.

1.4 Prior approval process

To request a prior approval, the MS&E provider completes the following steps:

  • obtains client's written prescription, recommendation or referral from a physician, nurse practitioner, or an NIHB-recognized health professional (further details provided in the sub-benefit sections of this guide);
  • when the benefit is for a palliative care or a hospital discharge client, checks the appropriate box appearing at the top of the prior approval (PA) form and specifies the date of discharge;
  • obtains and confirms client's identification information (refer to section 1.17 - Client Eligibility);
  • obtains a copy of any third-party coverage (e.g. workers' compensation board, private insurance etc.);
  • indicates the date of service (if one-time item), or service period (for multiple dispenses);
  • ensures that all the required fields of the PA form are completed to avoid delays in the review of the request. The form should be completed by the provider. (Note: The Program does not reimburse fees to prescribers/recommenders related to completing PA Forms);
  • obtains all relevant medical information, documents or report to support the request (consult the benefit guide sections for the prior approval forms as well as the list of additional supporting documents that may be required when submitting requests); and
  • submits the above information along with the prior approval form to the NIHB regional office.

Note: Prior approval requests for First Nations residing in British Columbia who are eligible under the First Nations Health Authority (FNHA) should be submitted to:

First Nations Health Authority (FNHA)
757 West Hastings Street, Suite 540
Vancouver, British Columbia
V6C 3E6
Toll-free: 1-800-317-7878
Fax: 1-888-299-9222

For NIHB clients residing in British Columbia, who are not eligible under the FNHA, please contact the Alberta NIHB regional office for assistance.

The NIHB Program reserves the right to request additional information if deemed necessary to adjudicate prior approval requests.

1.5 Special authorization

A special authorization (SA) is an approval that may be provided for items required on a long-term basis that have a set price and recommended replacement guideline.

Claims against the SA are submitted directly to Express Script Canada for the approved duration without requiring a PA. When a SA is provided, a PA number should not be included in the claim to avoid rejection.

1.6 Recommended replacement guidelines

The NIHB Program's recommended replacement guidelines are based on the usual and customary medical needs of clients and customary device lifespan. For individual items, refer to the recommended replacement guidelines in the MS&E Benefits List. Requests exceeding these guidelines may be considered on a case-by-case basis when supported by clinical rationale from a recognized health professional.

Items that have recommended replacement guidelines are not to exceed a three-month supply at a time. This applies to items with or without prior approval. Providers are encouraged to speak with the client first to determine if additional items are required rather then automatically dispensing renewals. For renewals, the client must contact the provider to request the item(s) rather than the provider dispensing items automatically.

Early replacement of equipment and devices will only be considered if a substantial unanticipated change has taken place in a client's medical condition (e.g. substantial change in weight and/or growth), or if the equipment or device has deteriorated during the course of a normal use and cannot be repaired in a cost effective manner. When requesting coverage for an early replacement, information documenting the change in the client's medical needs is provided at the time of the request.

Note: Coverage for early replacements will not be provided if items are damaged as a result of misuse, carelessness or negligence.

1.7 Coupons and promotions

When accessing benefits through the NIHB Program, eligible clients may not directly or indirectly benefit from special promotions or incentives offered by providers. This includes but is not limited to: coupons, discounts, points programs or rebates in the form of cash and/or goods. To the extent permitted by such promotions and applicable law, coupons, discounts, or rebates, should be applied to the NIHB claim. As a result, the amount claimed through the NIHB Program is the residual amount after application of the promotion.

1.8 Rentals

When an MS&E item is rented, the rental agreement can be for a period of up to three months and is not to exceed the cost of purchasing the item. The rental agreement must include equipment maintenance and repair as the NIHB Program does not cover these costs. The rental agreement must also include a clause stipulating that should the purchase of the item become an option, the amount spent on the rental will be deducted from the purchase price.

1.9 Repairs

Under the NIHB Program, only the most recently purchased item qualifies for the coverage of maintenance and repairs. Repairs are to restore the item's physical condition, allowing for normal wear and tear, and include a warranty according to industry standards.

Please note that repairs are eligible for coverage only when the warranty has expired. A prior approval is required for all repairs and, if more cost effective, the item should be replaced instead of repaired. A prescription is not required for repairs.

Note: Repairs will not be covered if items are damaged as a result of misuse, carelessness, or negligence

1.10 Warranties

For MS&E items with warranty coverage, as a minimum, the warranty coverage must specify that during the duration of the warranty:

  • repairs and services are the responsibility of the provider, manufacturer, or service designate free of charge to the Program; and
  • in situations where there are repeated technical failures, the item, device or components will be replaced by the provider at no cost to the NIHB Program.

MS&E providers are expected to serve as the client's advocate to request that the manufacturer or manufacturer's service depot honour the warranty on the item.

1.11 Coordination of benefits

When an NIHB-eligible client is covered by another public or private health care plan, claims must be submitted to the client's other health care/benefits plan first. The NIHB Program will then coordinate payment with the other payer on eligible benefit(s). Claim submissions involving coordination of benefits with a third-party health care plan may be submitted manually or electronically.

Manual claims are to be accompanied by a copy of the Explanation of Benefits form supplied by the other public or private health care plan to confirm that all other health coverage has been exhausted. If the client no longer has alternate health coverage, the client or the provider should contact the NIHB regional office so that the client's file can be updated.

If the other plan refuses to coordinate with the NIHB Program, the provider may submit the item or service for coverage under the NIHB Program by providing the NIHB regional office a copy of the health care plan message indicating refusal to coordinate.

In situations where the NIHB Program is coordinating benefits on eligible MS&E items as a secondary payer with another health care plan/program, NIHB will respect the prescribing requirements of the other plan/program. The NIHB Program criteria for coverage will continue to apply.

When the cost of an MS&E item is fully covered through a public/private health care plan, the coordination of benefits will not be required or accepted by the Program. As such, the NIHB Program will not approve requests for a co-payment to upgrade an item.

1.12 Claims submission

After signing an MS&E Provider Agreement with the claims processor for the NIHB Program, providers are advised to read and retain a copy of the Medical Supplies and Equipment (MS&E) Claims Submission Kit (PDF). This Kit outlines provider accountability and obligations when submitting claims for payment. The Kit is located on the Express Scripts Canada website.

1.13 Terms and conditions of services

To be eligible for payment of services rendered, providers must adhere to all of the criteria and policies in this guide and Medical Supplies and Equipment Benefits lists, Medical Supplies and Equipment Claims Submission Kit, and the Provider Agreement for Medical Supplies and Equipment.

It is the provider's responsibility to verify client eligibility for a benefit and to ensure that items are covered under the NIHB Program by seeking prior approval.

The provider is also responsible to keep all information supporting the benefit requested (e.g. the prescription, medical assessment, order sheet, invoice from the manufacturer, explanation of benefits, etc.), regardless of the type of benefit (whether an open benefit, prior approval required or an exception benefit).

Quick Links

1.14 Unclaimed MS&E items

A partial reimbursement may be requested for custom-made or special-order items in situations where the client:

  • does not pick up the item;
  • is unable to use the item; or
  • is deceased.

In such cases, the custom-made item:

  • is dismantled and an invoice is submitted to the NIHB Program for the custom-made parts that cannot be reused, as well as for professional fees incurred for the creation of the item.

In cases, where the item is a special order:

  • an invoice is submitted for any re-stocking fees and shipping costs associated with returning the item to the manufacturer.

Contact the NIHB regional office to initiate this process. In cases where the client does not pick up the item, the provider should make a reasonable effort to contact the client. Each submission will be reviewed on a case-by-case basis.

1.15 Balance billing

Providers are required to seek payment for eligible NIHB MS&E benefits solely from Express Scripts Canada. Therefore, providers shall not bill, charge, collect a deposit from, seek compensation from, condition the provision of services on payment from, or have any recourse against any client or person acting on behalf of the client.

The only exception to this policy is when a provider must charge a client upfront in a co-ordination of benefits situation or when an item is not covered by the NIHB Program.

Additional information can be found in Section 5.3 of the Medical Supplies and Equipment Provider Agreement (PDF) on the Express Scripts Canada's NIHB Claims Services Provider Website.

1.16 Acronyms

ABG
Arterial Blood Gas
ADL
Activities of Daily Living
Bi-CROS
Bi-Lateral Contralateral Routing of Offside Signals
BOCPD
BOC Pedorthist registered with Pedorthic Footcare Association (PFA) - Canadian Chapter.
BTE
Behind-the-Ear
CBCPO
Canadian Board for Certification of Prosthetists and Orthotists
CIRNA
Crown-Indigenous Relations and Northern Affairs
CO(c)
Certified Orthotist
CP(c)
Certified Prosthetist
CPAP
Continuous Positive Airway Pressure
(C.Ped)
Certified Pedorthist registered with Pedorthic Footcare Association (PFA) - Canadian Chapter.
CPed(c)
Canadian Certified Pedorthists
CPO(c)
Certified Prosthetist Orthotists
CROS
Contralateral Routing of Offside Signals
DPM
Doctor of Podiatric Medicine
DPodM
Chiropodist (Diploma in Podiatric Medicine)
ESS
Epworth Sleep Scale
FNIHB
First Nations and Inuit Health Branch of Indigenous Services
HICPS
Health Information and Claims Processing Services
ISC
Indigenous Services Canada
ITC
In-the-Canal
ITE
In-the-Ear
MS&E
Medical Supplies and Equipment
NIHB
Non-Insured Health Benefits
OT
Occupational Therapist
OTPQ
Ordre des technologues professionnels du Québec
PSG
Polysomnograph
PT
Physiotherapist

1.17 Client eligibility

To be eligible for NIHB Program benefits, a person must be a Canadian resident and have the following status:

  • registered Indian according to the Indian Act; or
  • Inuk recognized by one of the following Inuit Land Claim organizations: Nunavut Tunngavik Incorporated, Inuvialuit Regional Corporation, Makivik Corporation. For an Inuk residing outside of their land claim settlement area, a letter of recognition from one of the Inuit land claim organizations and a birth certificate are required; or
  • a child, less than 18 months of age, whose parent is an eligible client; and
  • is currently registered or eligible for registration, under a provincial or territorial health insurance plan; and
  • is not otherwise covered under a separate agreement (e.g. a self government agreement) with federal, provincial or territorial governments.

Please note that the following individuals may be excluded from the NIHB Program, contact the Regional Office for more information:

  • First Nations and Inuit who are not residents in Canada;
  • First Nations and Inuit individuals incarcerated in a federal, provincial/territorial or municipal corrections facility; or
  • First Nations and Inuit individuals who are in a provincially/ territorially funded institutional setting which provides its residents with supplementary health benefits as part of their care, such as nursing homes.

Health benefit requests for these individuals should be submitted to the appropriate organization.

To facilitate verification, MS&E providers should provide the following client identification information in each claim:

  • surname (under which the client is registered);
  • given names (under which the client is registered);
  • date of birth (yyyy/mm/dd); and
  • client identification number.

It is recommended that providers ask clients to present their identification card upon each visit to ensure that client information is entered correctly and to protect against mistaken identity.

For recognized Inuit clients, one of the following identifiers is required:

  1. Government of the Northwest Territories health plan number, which begins with the letter "T" and is followed by seven digits. This number is valid in any region of Canada and is cross-referenced to the First Nations and Inuit Health (FNIH) Regional Office client identification number.
  2. Government of Nunavut health plan number, which is a nine-digit number starting with a "1" and ending with a "5". This number is valid in any region of Canada and is cross-referenced to the FNIH Client identification number.
  3. FNIHB Client Identification Number (N-Number), which begins with the letter "N" and is followed by eight digits. This is a client identification number issued by the First Nations and Inuit Health Branch at ISC (formerly Health Canada) to recognized Inuit clients.

For registered First Nations clients, one of the following identifiers is required:

  1. Crown-Indigenous Relations and Northern Affairs (CIRNA) registration number, which is a 10-digit number. Also known as the Treaty or Status number, this registration number is the preferred method of identifying First Nations clients.
  2. Band Number and Family Number, where applicable.
  3. FNIHB Client Identification Number (B-Number), which begins with the letter "B" and is followed by eight digits.

For children under 18 months of age who are not yet registered with Crown-Indigenous Relations and Northern Affairs (CIRNA) or applicable Inuit associations, providers must communicate with the FNIHB regional office.

Information can also be found in the Medical Supplies and Equipment Claims Submission Kit at Express Scripts Canada website (PDF).

1.18 Privacy statement

ISC's NIHB Program has a responsibility to protect personal information under its control in accordance with the Privacy Act and its related Treasury Board privacy policy and directives and is responsible for ensuring the personal information collected is limited to that which is necessary to administer the Program.

For more information on applicable privacy practices, please contact the Department's Privacy Management Division.

1.19 Appeal process

A denial of benefit can be appealed by the client or the provider on behalf of the client. Please note that the items identified as exclusions or insured services cannot be appealed. Refer to appeal process online or contact the NIHB regional office for information.

Quick Link

1.20 Audit program

The NIHB provider audit program ensures that the NIHB Program is accountable for the expenditure of public funds. The Health Information and Claims Processing Services (HICPS) contractor performs this audit function by verifying paid claims against records to confirm that the claims have been billed in compliance with the terms and conditions of the NIHB Program.

Detailed information about audit procedures and the responsibilities of providers for these audits are included in the Medical Supplies and Equipment (MS&E) Claims Submission Kit.

Quick Link

1.21 Contact information

For NIHB regional office information, please visit our Contact the Non-Insured Health Benefits Program web page.

 

2. General medical supply and equipment benefits

2.1 General medical supply and equipment benefit categories

The general medical supplies and equipment (MS&E) benefit categories are:

  • bathing and toileting aids;
  • catheter supplies and equipment;
  • dressing aids;
  • feeding aids;
  • gender affirming items;
  • incontinence supplies and equipment, such as diapers, and liners;
  • lifting and transfer aids;
  • low vision aids;
  • miscellaneous supplies and equipment;
  • mobility aids, such as walking aids, walking aids accessories, wheelchairs, wheelchair cushions and wheelchair parts;
  • ostomy supplies and devices; and
  • wound dressing supplies, such as adhesive tapes, dressing strips and bandages.

2.2 Prescriber and provider requirements

General MS&E benefits must be prescribed by:

  • a physician, nurse practitioner, or an NIHB-recognized health professional
  • an optometrist (for low vision aids) or a Certified Ophthalmic Technician/Medical Technologist (OMT) working under the Stanton Territorial Health Authority (STHA) in Northwest Territories and Nunavut

General MS&E benefits must be dispensed by:

2.3 Prior approval requirements

For a list of general MS&E items that require prior approval, please refer to the MS&E Benefits List.

To initiate the prior approval process, the NIHB General MS&E Prior Approval Form along with the following supporting documentation are required by the regional office:

  • the prescription or referral form and any other information the provider/prescriber may have to support the request; and
  • additional information required as listed in section 2.4 of this guide.

Quick Link

2.4 General MS&E benefit policies

A. Criteria and required information

Requests for specific MS&E items are adjudicated according to the following criteria:

a. Breast pumps:

For breast pump claims, providers must indicate the infant's date-of-birth on the prescription.

  • Manual breast pump:

    Manual breast pumps will be covered with a prescription from an NIHB-recognized health prescriber (physician, nurse practitioner or registered midwife) for the birth of each child. Prior approval is not required. Refer to the MS&E Benefits List section 1.3.3 for the maximum price for manual breast pump.

  • Electric breast pump, rental:

    Electric breast pump rentals are considered for coverage when a mother or infant presents medico-physical complications hindering the normal physiological process of breast feeding. Medical documentation is required to support the request.

    Note: The Program may consider other breast pump coverage when the mother or infant presents with medico-physical complications hindering the normal physiological process of breast feeding. Medical documentation is required to support the request.
b. Catheter supplies and equipment requiring prior approval:

Information concerning the client's diagnosis, a justification for the use, the type and the quantity of catheter supplies and equipment are required as part of the request for coverage. Recommended replacement guidelines are available in the MS&E Benefits List 1.7.1.. Requests exceeding the recommended replacement guidelines require a medical justification.

c. Dressings:
  1. Items requiring no prior approval:

    For selected dressings, no prior approval is required when the maximum annual quantity or price per unit is not exceeded. If maximum quantities or prices are exceeded a prior approval is then required, please refer to the following section (ii).

  2. Items requiring a prior approval must include the following:

    The client's diagnosis and a wound/ulcer assessment from a nurse or physician. The assessment should include the following information:

    • wound site and size (indicate in mm or cm);
    • tunneling (direction & depth);
    • wound bed;
    • wound border;
    • peri-wound skin condition;
    • exudate amount;
    • exudate type;
    • wound odour;
    • wound care treatment with type/size of dressings being used;
    • frequency of dressing changes; and
    • anticipated healing time.

Refer to the MS&E Benefits List section 1.8.3 for the dressing supplies price file.

d. Feeding pump:

Medical documentation that establishes the client's inability to receive feeding through gravity is required to request coverage.

e. Gender affirming items:

These items are covered as an open benefit (i.e. not requiring prior approval). However, providers will need to apply for prior approval if the request exceeds the recommended pricing and/or frequency guideline.

Providers are required to keep the following information on file:

  • a prescription/recommendation from a physician, nurse practitioner or licensed psychologist indicating a diagnosis of gender dysphoria.
  • a prescription will be required for the initial benefit request only.
f. Incontinence supplies:

1. Disposable diapers and pull-up briefs:

NIHB provides coverage for incontinence items, which can be either one type of product or a combination of different products, for three months at a time.

The first time a client applies for prior approval for incontinence supplies, the prior approval form must indicate whether the client has a permanent or temporary need for incontinence supplies. Clients who have a permanent condition may be approved for up to two years of incontinence supplies rather than the standard one year.

When a client has been approved for a two year period, the provider will receive an SA that allows the provider to bill Express Scripts Canada directly without contacting the NIHB regional office to get approval for dispenses during the approved period.

Please note: Clients with a temporary condition will continue to require an annual prescription. Providers will need to apply for prior approval if the request exceeds the recommended replacement guideline.

The following information is required when requesting coverage:

  • medical diagnosis of the cause(s) for the incontinence;
  • type of incontinence (urine/stools or both);
  • when the incontinence occurs (day/night or both);
  • type of incontinence supplies needed;
  • size of the incontinence supplies requested (does not apply to children's sizes or liners);
  • quantity of incontinence supplies needed; and
  • any other supporting information (e.g. temporary or permanent condition).

Note: A medical justification is required for quantities in excess of 450 incontinence items per three month period.

2. Pant (brief) mesh, washables
NIHB provides coverage for washable mesh pants (briefs).

3. Disposable underpads
NIHB provides coverage for disposable underpads for regular bowel care routine.

4. Reusable underpads
NIHB provides coverage for a maximum of two reusable underpads to protect the mattress during the first year of the request, and one mattress underpad per subsequent year.

Refer to the MS&E Benefits List section 1.7.2 for the incontinence supplies price file.

g. Lift, hydraulic (powered):

Request for coverage must include an Occupational Therapist (OT)/Physiotherapist (PT) report summarizing the client's:

  • medical, physical status and functional level (e.g. mobility);
  • transfer status; and
  • justification as to why a standard hydraulic lift will not meet the client's need.
h. Manual wheelchairs:

A manual wheelchair is covered as an open benefit (i.e. not requiring prior approval):

A prior approval will not be required for a manual wheelchair in the event that the price of the wheelchair does not exceed the maximum regional price (see regional prices on the Express Script Canada web site) and the suggested replacement guidelines are respected.

Providers will be required to keep the following information on file:

  • Prescription from a physician or nurse practitioner;
  • Manufacturer's product code #, Make/model of the equipment; and
  • Occupational therapy or physiotherapy assessment report or recommendation if available.

Providers must ensure the client meets the following conditions for a manual wheelchair:

  • The client is not a full-time wheelchair user (since full-time wheelchair users require a more advanced chair);
  • The client is not transferring to a long term care facility; and
  • The client is not in palliative care (as NIHB will fund a rental if this is available).

Manual wheelchair requiring a prior approval.

A prior approval is required for a manual wheelchair if the price of the wheelchair exceeds the regional price limit, or if the suggested replacement guidelines are not met, or if the client does not meet the requirements under the manual wheelchair covered as an open benefit.

Providers must submit the following information:

An OT/PT report explaining how the wheelchair will meet the client's functional needs is required. The report should include the client's:

  • medical, physical, and functional status, including the client's mobility;
  • transfer status; and
  • height and weight.

Note: clients with an above-the-knee or below-the-knee amputation automatically qualify for coverage of a manual wheelchair.

i. Power wheelchairs:

NIHB provides coverage for power wheelchairs for use in a home or in another ambulatory care setting.

The provider must submit an OT/PT report explaining how the wheelchair will meet the client's functional needs. The report should include the client's:

  • medical, physical, and functional status, including the client's mobility (include information regarding how the wheelchair will be used to complete basic activities of daily living (ADL) such as eating, bathing, dressing, and toileting);
  • transfer status; and
  • height and weight.

B. Exclusions

The general exclusion policy (section 1.2.4) continues to apply. The following items are excluded from the general MS&E benefit and are not considered for coverage or appeal under the NIHB Program:

  • environmental protection devices and supplies (e.g., masks, air cleaners, filters, UV protection garments and lotions, etc.);
  • permanently fixed equipment;
  • equipment with a rated capacity that would be unable to bear the client's weight;
  • lift chairs;
  • scooters; and
  • topical or hyperbaric oxygen treatment.

C. Services included in price

The following services are to be included in the price of the requested MS&E items:

  • initial assessment to determine the type of item required;
  • manufacturing of device;
  • dispensing of the item, which includes the adjustment, fitting; and
  • follow-up visit(s).

2.5 General MS&E benefits list

Visit the General medical supplies and equipment benefits list for more information.

 

3. Audiology benefits

3.1 Audiology benefit categories

The audiology benefit categories are:

  • hearing aid, bone conduction, conventional analog;
  • hearing aid, CROS/BiCROS;
  • hearing aid, programmable analog;
  • hearing aid, digital entry level; and
  • hearing aid services, fees, repairs and supplies.

3.2 Prescriber/provider requirements

Audiometric tests and audiology equipment and supplies must be prescribed/recommended by:

  • a physician;
  • a nurse practitioner;
  • an audiologist; or
  • a hearing instrument practitioner Footnote 1

Audiometric tests must be performed by:

  • an audiologist;
  • an audio-prosthetist;
  • a hearing instrument practitioner; or
  • other NIHB-recognized audiology provider.

Audiology equipment and supplies may be provided by:

  • an audiologist; or
  • a HIP or hearing aid dispenser.

Batteries may be provided by:

  • an audiologist;
  • a HIP or hearing aid dispenser; or
  • medical supply and equipment providers, and pharmacies.

3.3 Prior approval requirements

All audiology benefits require prior approval, including testing and new/replacement hearing aids. The only exceptions are for batteries and accessories which do not require a prior approval.

To initiate the prior approval process, the NIHB Hearing Aid and Hearing Aid Repair Prior Approval Form along with the following supporting documentation are required by the regional office:

  • prescription or referral form signed by a physician, nurse practitioner, or audiologist for the audiometric test and hearing aid equipment and supplies;
  • results of most recent audiometric test (six months or less);
  • other related information the provider, physician, nurse practitioner, or audiologist may have to support the request;
  • a copy of an explanation of benefits (EOB) form from any third-party coverage available to the client (e.g., workers’ compensation board, private insurance, etc.); and
  • details of the hearing aid device as described in section 3.4 of this guide (Audiology Benefit Policy).

In the case of a replacement aid, the following is required:

  • results of most recent audiometric test (six months or less);
  • the current hearing aid information (e.g. model number, extra features).

In the case of repairs, the following information is required:

  • manufacturer name;
  • model number or name;
  • date fitted; and
  • serial number.

Once the provider has dispensed the hearing aid, the provider completes the following steps:

  • signs section 7 of the NIHB Hearing Aid and Hearing Aid Repair Prior Approval Form;
  • includes a reference to the original PA number;
  • attaches a copy of the manufacturer’s invoice; and
  • submits the form and supporting documents to the NIHB regional office for processing.

By signing the NIHB Hearing Aid and Hearing Aid Repair Prior Approval Form, the provider attests that the client has received the device and is satisfied with the equipment, repair, and instructions provided.

Providers are to retain a copy of the submitted forms and documentation for audit purposes.

Quick Link

3.4 Audiology benefit policies

A. Medical guidelines and required information

To request hearing aids and/or replacement of hearing aids, the following documentation and information are required:

  • a recent audiogram (less than six months old);
  • the manufacturer’s name;
  • the model and size of the requested aid; and
  • information on any previous NIHB coverage and/or repairs for audiology items.

B. Exclusions

Please note that the general exclusion policy (section 1.2.4) continues to apply. The following items are excluded from the audiology benefit and are not considered for coverage or appeal under the NIHB Program:

  • items used exclusively for education/school;
  • surgical implants;
  • hearing protectors used in work-related situations; and
  • therapy treatment, such as speech therapy.

C. Warranties

All hearing instruments and/or devices must carry, at a minimum, a two-year warranty on repairs and one-year ‘loss and damage replacement’ coverage for one occurrence per aid. Warranties that go beyond these provisions must extend the same benefits to NIHB clients. All items must have a 90-day return privilege at no cost to the hearing aid provider.

D. Follow-up

After the client has had an opportunity to try their device(s) for a maximum of ninety (90) days, further evaluation and follow-ups may be required. If requested by the client, the following services are to be provided:

  • appropriate reinforcement of information, instructions, and retraining on the device, if necessary Footnote 2;
  • any modifications to improve the comfort of the device;
  • any modifications to the electroacoustic characteristics of the device based upon reactions and experiences of the client;
  • any adjustments or changes to amplification levels due to client reactions to enhance client benefit from the device; and
  • other further adjustments.

Follow-up after warranty has expired

After-care services are services that take place when the dispensing fee services under the manufacturer’s warranty have expired (minimum of two years), or when services are not covered by the manufacturer’s warranty.

Most after-care services will involve:

  • adjustments to the client’s fitting, including earmold repairs or replacements which may be necessary from time to time, undertaken as part of the general after-care services. These adjustments may be invoiced according to the fee schedule; and
  • advice to the client outside a formal appointment, regarding their fitting or their hearing loss which is accommodated by the clinic and/or service provider.

E. Repairs

Repairs are to restore the hearing aid to its original level of performance. While a prescription is not needed for repairs, prior approval is required for all billable hearing aid repairs.

Out-of-office and in-office hearing aid repairs are not subject to service fees while the item is under warranty by the manufacturer, unless the out-of-office repair results in a charge not covered by the warranty.

Out-of-office hearing aid repairs that incur a charge by the manufacturer (after the original manufacturer’s warranty has expired), should include a warranty period on the repair. A replacement should be considered when more economical than a repair.

Warranty on repairs

Repair warranty periods must be consistent with the current Canadian Auditory Equipment Association-NIHB agreement:

  • repairs carried out on a hearing aid during the product purchase warranty period are guaranteed for a maximum of 12 months after repair or until the original product warranty expires, whichever comes first;
  • all repairs and remakes carried out on a hearing aid after the warranty period expires will be subject to a maximum cost outlined in the pricing grid and will carry a 12-month warranty if the hearing device is less than five years old;
  • charges for repairs and remakes can only be billed after the warranty period, 24 months for new aids and 12 months after the repair or remake of an aid; and
  • a remake includes the provision of a new shell for the aid and replacement of required existing electronic components to ensure that the aid has been returned to the equivalent operating standard of a new aid.

Repair timeline

If same-day repairs cannot be completed, a loaner hearing aid should be provided free of charge if requested by the client. A Behind The Ear (BTE)-type hearing aid is acceptable as a loan hearing aid for In The Ear (ITE) and In The Canal (ITC) hearing aids. If the hearing aid is not repaired at the point of service and needs to be sent to another location to be repaired, the device should be returned to the client promptly. Batteries and repair services must be available at the point of service during regular business hours. The provider should have at least one permanent business location with the capacity to repair devices.

3.5 Audiology benefits list

Visit the Audiology Benefits List.

 

4. Limb and body orthotics benefits

4.1 Limb and body orthotics’ categories

The limb and body orthotics’ categories are:

  • head, torso and/or spine orthoses;
  • limb orthoses for lower and/or upper extremities; and
  • orthotic supplies.

The classes are defined as:

Off-the-shelf (Class I):

An orthosis that a client can purchase and fit themselves, including items that are typically purchased at a pharmacy. The device requires very minimal alterations – such as just bending a metal stay to contour better to the limb and could be done by hand. These products would be sized small, medium, large or from a sizing chart. These items can be provided by a general MSE provider.

 

Custom-fitted (Class II):

This is an orthosis that is more complex than a class 1 item. It requires expertise either for fit or assessment. The item may require more significant alteration to fit the client, including the use of heat or tools. The item may be selected from a wide range of stock, and be referred to as ‘off-the-shelf’; however, expertise is required to select the orthosis that would best meet the client’s needs. For example, Class II off the shelf knee orthosis requires very little customizing due to the way the braces are fabricated, however expertise is required to ensure that the brace is suitable for the client. An improperly fit item could have more serious consequences, including skin breakdown or aggravating joint/ligament issues. For these reasons, NIHB eligible providers of class 2 braces are certified Orthotists or certified Prosthetist Orthotists and for upper extremity only, Certified Hand Therapists.

 

Custom-made (Class III):

An orthosis, regardless of where it is manufactured, that is made based on individual client measurements, cast or, or digital measurement. NIHB eligible providers of these items are certified Orthotists or certified Prosthetist Orthotists and for upper extremity only, Certified Hand Therapists.

4.2 Prescriber/provider requirements

Limb and body orthotics must be prescribed by:

  • Class I (off-the-shelf): physician or nurse practitioner; or
  • Class II (custom-fitted) and Class III (custom-made): physician.

Limb and body orthotics must be provided by:

Class I (off-the-shelf):

  • a limb and body orthotic provider or a NIHB-recognized MS&E provider (e.g. pharmacy or MS&E provider).

Class II (custom-fitted) and Class III (custom-made):

  • a certified orthotist (CO(c));
  • a certified prosthetist orthotist (CPO(c));
  • a “technicien en orthèses et prothèses (TOP)” certified by the Canadian Board for the Certification of Prosthetists and Orthotists (CBCPO) or by “l’Ordre des technologues professionnels du Québec (OTPQ)” (Quebec only); or
  • a Certified Hand Therapist (CHT) who is a registered occupational therapists and physiotherapists certified by the Hand Therapy Certification Commission, Inc. (HTCC) for upper limbs only.

4.3 Prior approval requirements

Prior approval is required for all limb and body orthotic devices. To initiate the prior approval process, the NIHB Orthotics-Custom Shoes-Prosthetics-Pressure Garments Prior Approval Form (PDF) along with the following supporting documentation must be submitted to the regional office:

  • the prescription (if required as per the replacement process for orthotics in 4.4) or referral form signed by the appropriate health professional;
  • detailed assessment from the provider;
  • any other information the provider, physician or nurse practitioner may have to support the request;
  • a copy of an explanation of benefits (EOB) form from any third-party coverage available to the client (e.g., workers’ compensation board, private insurance, etc.); and
  • additional required information described in section 4.5 of this guide.

4.4 Replacement process for limb and body orthotics

The original prescriptionFootnote 3 may be used for a replacement request if this is the same provider when the:

  • limb or body orthotic was initially covered by the NIHB Program
  • item addresses a permanent medical condition; and
  • replacement is within the recommended replacement guideline.

A new prescriptionFootnote 3 is required for a replacement when the:

  • item addresses a temporary condition (defined as a condition that lasts less than 12 months);
  • client changes providers;
  • client’s medical condition changes; or
  • request is for an early replacement.

Quick link

4.5 Limb and body orthotics benefit policies

A. Criteria and required information

In addition to the supporting documents described in section 4.3, the following are the criteria for coverage and supporting information required to authorize the limbs and body orthotics:

a) Custom thoracolumbar sacral orthoses

Orthotics for spinal fractures often need to be fitted while the client is in an acute care setting. The following information is required to support the request for coverage:

  • the diagnosis;
  • date of fracture; and
  • the date of surgery, if applicable.

B. Exclusions

The general exclusion policy (section 1.2.4) continues to apply. The following items are excluded from the limbs and body orthotics benefits and are not considered for coverage or appeal under the NIHB Program:

  • therapy treatment and/or therapy equipment, such as, but not limited to:
    • electrospinal orthosis;
    • neurostimulators;
    • direct passive movement devices; and
    • electromagnetic stimulators for osseous growth.

C. Services included in price

The following services are to be included in the price of the item:

  • initial assessment to determine the type of benefit required;
  • casting of the body part for the manufacturing of the device;
  • manufacturing of device;
  • dispensing of the benefit, which includes the adjustment, fitting; and
  • follow-up visit(s).

D. Warranty

The manufacturer/provider warranty must include:

  • breakage guarantee for six months and no charge for necessary adjustments to a custom-made orthoses for a period of three months after the final fitting except when there has been a change in the client’s medical condition that would prevent a satisfactory fit;
  • breakage guarantee for two months and no charge for necessary adjustments to a customized orthoses/pre-fabricated for a period of 30 days after the final fitting except when there has been a change in the client’s medical condition which would prevent a satisfactory fit.

4.6 Limb and body orthotics benefits list

Visit the Limb and Body Orthotics Benefits List.

 

5. Custom-made shoes and custom-made foot orthotics benefits

5.1 Custom-made shoes and custom-made foot orthotics categories

  • custom-made shoes;
  • custom-made foot orthotics; and
  • modifications to stock footwear.

5.2 Prescriber/provider requirements

Custom-made shoes, custom-made foot orthotics and modifications to stock footwear must be prescribed by a:

  • physician;
  • nurse practitioner; or
  • podiatrist (Doctor of podiatric medicine (D.P.M) only).

Custom-made shoes, custom-made foot orthotics and modifications to stock footwear must be provided by a (according to their provincial/territorial scope of practice):

  • a certified orthotist (CO(c));
  • a certified prosthetist orthotist (CPO(c));
  • a “technicien en orthèses et prothèses (TOP)” certified by the Canadian Board for the Certification of Prosthetists and Orthotists (CBCPO) or by “l’Ordre des technologues professionnels du Québec (OTPQ)” (Quebec only);
  • chiropodist (DPodM) registered with provincial / territorial regulatory bodies;
  • podiatrist (D.P.M. only) registered with provincial or territorial regulatory bodies;
  • Canadian-certified pedorthist (C.Ped(C)); or
  • Certified Pedorthist (C.Ped) or BOC Pedorthist (BOCPD) registered with Pedorthic Footcare Association (PFA) - Canadian Chapter.

5.3 Prior approval process

Prior approval is required for custom-made foot orthotic for one foot, custom-made shoes, or modifications to stock footwear.

To initiate the prior approval process, the NIHB Orthotics-Custom Shoes-Prosthetics-Pressure Garments Prior Approval Form along with the following supporting documentation must be submitted to the NIHB regional office:

  • the prescription or referral form signed by the appropriate health professional;
  • detailed assessment from the provider, including requirements for custom-made shoes and custom-made internal footwear devices as specified in section 5.4 of this guide;
  • any other information the provider, physician, nurse practitioner, or podiatrist (D.P.M) may have to support the request;
  • a copy of an explanation of benefits (EOB) form from any third-party coverage available to the client (e.g., workers’ compensation board, private insurance, etc.); and
  • additional required information described in section 5.4 of this guide.

Quick Link

5.4 Custom-made shoes and custom-made foot orthotics benefit policies

A. Criteria and required information

In addition to the supporting documents described in section 3.4.3, the following are the criteria for coverage and information required to authorize the custom-made shoes and foot orthotics benefits.

a. Custom-made shoes

The following information is required for coverage:

  • measurements of the feet;
  • photographs of the feet (preferred) and/or templates/drawing/tracing of the contour of the feet;
  • prescriber type (i.e. physician, nurse practitioner, or podiatrist (D.P.M only));
  • the provider’s qualification(s);
  • the client’s diagnosis and biomechanical/medical assessment;
  • an explanation as to why the client’s needs cannot be met by off-the-shelf orthopaedic footwear;
  • the casting technique (e.g. plaster of Paris slipper cast);
  • manufacturing technique, material used, and design of shoes;
  • name of the laboratory; and
  • warranty details.

b. Custom-made foot orthotics

The following information must be kept on the client file or provided when a PA is required:

  • diagnosis and client’s symptoms;
  • biomechanical/medical assessment;
  • type of device (e.g. accommodative or functional);
  • casting technique:
    • NIHB-accepted casting techniques are: plaster of Paris slipper cast; foam box; contact digitizing (Amfit); STS slipper casting, and full-3D optical scanning (e.g. Cast CAD);
  • manufacturing technique and material used;
  • name of the laboratory; and,
  • warranty details.

B. Exclusions

The general exclusion policy (section 1.2.4) continues to apply. The following items are excluded from the custom-made shoes and custom-made foot orthotics benefits and are not considered for coverage or appeal under the NIHB Program:

  • foot products manufactured only from 2D with extrapolation laser or optical scanning, or computerized gait and pressure analysis systems;
  • pre-fabricated foot orthotics and internal footwear devices;
  • off-the-shelf and orthopaedic/therapeutic footwear (e.g. pair of shoes, running shoes, boots, summer sandals, etc.)

C. Services included in price

The following services are to be included in the price of the item:

  • initial assessment to determine the type of benefit required;
  • casting of the body part for the manufacturing of the device;
  • manufacturing of device;
  • dispensing of the benefit, which includes the adjustment, fitting; and
  • follow-up visit(s).

D. Warranty

The manufacturer/provider warranty must include:

  • no charge for necessary adjustments to custom-made foot orthotics for a period of three months after the final fitting, except when there has been a change in the client’s medical condition that would prevent a satisfactory fit; and
  • no charge for repairs to custom-made shoes for a one year period.

5.5 Custom-Made Shoes and Custom-Made Foot Orthotics Benefits List

Visit the Custom-made shoes and Custom-Made Foot Orthotics Benefits List

6. Oxygen equipment and supplies benefits

6.1 Oxygen equipment and supplies benefit categories

The oxygen equipment and supplies benefit categories are divided into:

  • oxygen systems and equipment; and
  • oxygen supplies.

6.2 Prescriber/provider requirements

For NIHB Program coverage, home oxygen equipment and supplies are to be prescribed by:

  • a physician;
  • nurse practitioner; or
  • physician assistant (applies to Manitoba only).

Oxygen must be provided by an oxygen provider enrolled with NIHB with appropriate health care staff including regulatory affiliations:

  • registered respiratory therapist (RRT);
  • registered nurse (RN); or
  • licensed practical nurse/registered practical nurse when within their scope of practice in their province/territory (LPN, RPN).

6.3 Prior approval requirements

Prior approval is required for all home oxygen equipment and supplies benefits.

To initiate the prior approval process, the NIHB home oxygen and respiratory equipment and supplies benefits approval form along with the following information are required by the regional office:

  • prescription detailing the oxygen flow (litres per minute) and usage (numbers of hours per day);
  • specify whether the request is for a new application or a renewal for home oxygen;
  • expected dates of service (e.g. May 01, 2018 to July 31, 2018);
  • any other information the provider/physician or nurse practitioner may have to support the request;
  • a copy of an explanation of benefits (EOB) form from any third-party coverage available to the client (e.g., workers’ compensation board, private insurance, etc.); and
  • required information described in section 6.4 of this guide.

Quick Link

6.4 Oxygen equipment and supplies benefit policies

General information

  • Home oxygen may be considered for coverage by the NIHB Program once the client’s condition is stabilized and treatment regimen is optimized.
  • Coverage is authorized for the primary residence only, with the exception of additional oxygen requirements due to travel for the purpose of attending a medical appointment.
  • While supplemental oxygen for the purpose of attending medical appointments is assessed on a case-by-case basis, it is expected that the client will use the oxygen concentrator when possible.
  • NIHB covers oxygen portability away from the primary residence for the purpose of completing essential activities in the client’s home and community, e.g.; shopping for groceries or personal items … (up to 12 cylinders per month).
  • With medical justification, NIHB will consider additional portability on a case by case basis.

Testing information

  • Arterial blood gas (ABG) and its requirements:
    • ABGs are to be completed at rest on room air.
    • An arterial blood gas (ABG) result obtained during an acute exacerbation is not accepted.
    • NIHB will consider waiving the ABG requirement in situations where a client lives in a fly-in zone or area that is away from a centre able to perform an ABG.
    • If an ABG is not available, detailed oximetry strips are required and must be submitted with the prior approval request.
  • Oximetry testing and its requirements:
    • The oximetry test is performed on room air and on supplemental oxygen to confirm that a client’s medical condition improves when supplemental oxygen is administered.
    • The test results must include the flow rate, the oxygen saturation, the pulse, the distance walked and the level of shortness of breath (using the BORG scale).
    • Each printout or manually completed form must record at least 5 continuous minutes of monitoring. In situations where testing cannot be completed an explanation should be provided.
    • A NIHB’s oximetry testing form with instructions has been created as an optional tool for providers.
    • Note that for Portable oxygen concentrator (POC) and for oxygen conserving device (OCD) requests the oximetry testing should be completed using the requested item.

QUICK Link

NIHB oximetry instruction and testing form (PDF)

Criteria and requirements to authorize oxygen equipment and supplies:

A. Applying for initial 3 month funding period:

The client must meet one of the following:

Initial medical indications and testing requirements:

  Medical Indication Criteria Testing Requirements Documentation
i

- a PaO2 of 55 mmHg or less

- oximetry that demonstrates sustained desaturation (SpO2 less than 89% for 2 continuous minutes)

- ABG

- if unable to obtain an ABG, then an oximetry at rest and on exertion is required

- Prescription including diagnosis, flow rate and hours of use per day

- Funding period (start and end dates)

- RRT/RN/RPN/LPN (if available for initial)

ii

- a PaO2 of 60 mmHg or less with evidence of cor pulmonale, pulmonary hypertension and/or secondary polycythemia

- oximetry that demonstrates sustained desaturation (SpO2 less than 89% for 2 continuous minutes)

- ABG

- if unable to obtain an ABG, then an oximetry at rest and on exertion is required

- Prescription including diagnosis, flow rate and hours of use per day

- Funding period (start and end dates)

- RRT/RN/RPN/LPN (if available for initial)

- Documentation provided by a physician stating the qualifying disease process

iii

- a PaO2 between 56 and 59 mmHg with exercise limitation due to hypoxemia with significantly greater exercise capability and/or significantly decreased shortness of breath on oxygen compared to room air

- oximetry that demonstrates sustained desaturation (SpO2 less than 89% for 2 continuous minutes)

- ABG and oximetry at rest and on exertion

- Prescription including diagnosis, flow rate and hours of use per day

- Funding period (start and end dates)

- RRT/RN/RPN/LPN (if available for initial)

iv

- nocturnal hypoxemia when nocturnal oxygen desaturation is less than 89% for 30% of the night and sleep disordered breathing is ruled out

- ABG and an overnight oximetry

- Prescription including diagnosis, flow rate and hours of use per day

- Funding period (start and end dates)

- RRT/RN/RPN/LPN (if available for initial)

V

- New York Heart Association Stage IV Heart Disease ** (Severe)

- oximetry that demonstrates sustained desaturation (SpO2 less than 89% for 2 continuous minutes)

- oximetry at rest only

- Prescription including diagnosis, flow rate and hours of use per day

- Funding period (start and end dates)

- RRT/RN/RPN/LPN (if available for initial)

- Documentation provided by a physician to support New York Heart Association Stage IV Heart Disease

** Defined as: unable to carry-on any physical activity without discomfort. Symptoms of CHF are present at rest (severe CHF). Any activity increases symptoms, or is symptomatic at less than ordinary levels of activity or may or may not be asymptomatic at rest.

Note: For Palliative care oxygen criteria please see Section D.

B. First renewal requirements for a 9 month funding period:

The client must meet one of the following:

  Medical Indication Criteria Testing Requirements Documentation Required
i

- a PaO2 of 55 mmHg or less

- oximetry that demonstrates sustained desaturation (SpO2 less than 89% for 2 continuous minutes)

- ABG

- if unable to obtain an ABG, then an oximetry at rest and on exertion is required

- Prescription including diagnosis, flow rate and hours of use per day

- Funding period (start and end dates)

- RRT/RN/RPN/LPN

ii

- a PaO2 of 60 mmHg or less with evidence of cor pulmonale, pulmonary hypertension and/or secondary polycythemia

- oximetry that demonstrates sustained desaturation (SpO2 less than 89% for 2 continuous minutes)

- ABG

- if unable to obtain an ABG, then an oximetry at rest and on exertion is required

- Prescription including diagnosis, flow rate and hours of use per day

- Funding period (start and end dates)

- RRT/RN/RPN/LPN

iii

- a PaO2 between 56 and 59 mmHg with exercise limitation due to hypoxemia with significantly greater exercise capability and/or significantly decreased shortness of breath on oxygen compared to room air

- oximetry that demonstrates sustained desaturation (SpO2 less than 89% for 2 continuous minutes)

- ABG and oximetry at rest and on exertion

- Prescription including diagnosis, flow rate and hours of use per day

- Funding period (start and end dates)

- RRT/RN/RPN/LPN

iv

- nocturnal hypoxemia when nocturnal oxygen desaturation is less than 89% for 30% of the night and sleep disordered breathing is ruled out

- overnight oximetry

- Prescription including diagnosis, flow rate and hours of use per day

- Funding period (start and end dates)

- RRT/RN/RPN/LPN

V

- New York Heart Association Stage IV Heart Disease

- oximetry that demonstrates sustained desaturation (SpO2 less than 89% for 2 continuous minutes)

- oximetry at rest only

- Prescription including diagnosis, flow rate and hours of use per day

- Funding period (start and end dates)

- RRT/RN/RPN/LPN

C. Renewal requirements at 1 year from start and subsequent yearly renewals for a 12 month funding period:

Note: ABGs are no longer required but will be accepted.

The client must meet one of the following:

  Medical Indication Criteria Testing Requirements Documentation Required
i

- a PaO2 of 55 mmHg or less

- oximetry that demonstrates sustained desaturation (SpO2 less than 89% for 2 continuous minutes)

- ABG or oximetry at rest and on exertion

- Prescription including diagnosis, flow rate and hours of use per day

- Funding period (start and end dates)

- RRT/RN/RPN/LPN

ii

- a PaO2 of 60 mmHg or less with evidence of cor pulmonale, pulmonary hypertension and/or secondary polycythemia

- oximetry that demonstrates sustained desaturation (SpO2 less than 89% for 2 continuous minutes)

- ABG or oximetry at rest and on exertion

- Prescription including diagnosis, flow rate and hours of use per day

- Funding period (start and end dates)

- RRT/RN/RPN/LPN

iii

- a PaO2 between 56 and 59 mmHg with exercise limitation due to hypoxemia with significantly greater exercise capability and/or significantly decreased shortness of breath on oxygen compared to room air

- oximetry that demonstrates sustained desaturation (SpO2 less than 89% for 2 continuous minutes)

- ABG and oximetry at rest and on exertion

- Prescription including diagnosis, flow rate and hours of use per day

- Funding period (start and end dates)

- RRT/RN/RPN/LPN

iv

- nocturnal hypoxemia when nocturnal oxygen desaturation is less than 89% for 30% of the night and sleep disordered breathing is ruled out

- overnight oximetry

- Prescription including diagnosis, flow rate and hours of use per day

- Funding period (start and end dates)

- RRT/RN/RPN/LPN

V

- New York Heart Association Stage IV Heart Disease

- oximetry that demonstrates sustained desaturation (SpO2 less than 89% for 2 continuous minutes)

- oximetry at rest only

- Prescription including diagnosis, flow rate and hours of use per day

- Funding period (start and end dates)

- RRT/RN/RPN/LPN

D. Criteria and requirements for palliative care home oxygen:

General information

  • NIHB defines palliative as a client having been diagnosed with a terminal illness or disease which is expected to be the primary cause of death within six months or less.
  • NIHB’s palliative care home oxygen funding period covers up to six months of palliative oxygen. Following this six month period, a client will be considered a regular recipient of oxygen coverage, and therefore regular testing requirements will apply.

The client must also meet one of the following:

  Medical Indication Criteria Testing Requirements Documentation Required
i

- a PaO2 of 60 mmHg or less

- oximetry that demonstrates sustained desaturation (SpO2 less than 92% for 2 continuous minutes)

- ABG or oximetry at rest

- Prescription including diagnosis, flow rate and hours of use per day

- Funding period (start and end dates)

- RRT/RN/RPN/LPN

ii

- When the above testing does not meet the criteria, and dyspnea is present that cannot be improved with medication and/or comfort analgesia

- ABG or oximetry at rest

- Information supporting this criteria provided by a physician, nurse practitioner or palliative care team member (i.e. Registered Nurse)

E. Exclusions

The general exclusion policy (section 1.2.4) continues to apply. The following items are excluded from the oxygen benefit and are not considered for coverage or appeal under the NIHB Program:

  • oxygen for therapy treatment and/or therapy equipment, such as:
    • pain relief (e.g., migraines, cluster headaches, chronic fatigue syndrome);
    • topical or systemic hyperbaric treatment; and
    • oxygen for angina in the absence of documented chronic hypoxemia.
  • oxygen benefits for outings while the client is an in-patient in an acute or long-term hospital setting;
  • oxygen to run nebulizers/compressors; and
  • oxygen on a “stand-by basis” (PRN).

F. Provider services to support oxygen equipment and supplies

To support oxygen therapy the provider is required to offer the following services:

  • complete set-up within 24 hours of authorization (with the exception of ferry and remote site transportation limitations);
  • equipment delivery, safety and care, and client education on use;
  • a respiratory therapist or nurse visit within 72 hours, after three months, and every six months thereafter to ensure optimum oxygen therapy (i.e. review prescription, review use of equipment, educate client on condition); and
  • removal of equipment within 72 hours of being informed that it is no longer required.

6.5 Oxygen equipment and supplies benefits list

Visit the Oxygen Equipment and Supplies Benefits List.

 

7. Pressure garments and pressure orthotics benefits

7.1 Pressure garments and pressure orthotics benefit categories

Pressure garments and pressure orthotics’ benefits are organized in the following categories:

  • Compression garment and lymphedema compression device:
    • custom-fitted graduated compression garment;
    • custom-made graduated compression garment; and
    • lymphedema compression device sequential extremity pump for lymphedema
  • Hypertrophic scar management:
    • custom-fitted pressure garment;
    • custom-made pressure garment;
    • customized pressure orthosis; and
    • custom-made pressure orthosis.

7.2 Prescriber/provider requirements

Prescribers:

For compression garments of 20mmHg to 30mmHg, and 30mmHg to 40mmHg, as well as lymphedema compression devices:

  • a physician;
  • a nurse practitioner; or
  • a registered midwife (in the case of a pregnancy).

Compression garments over 40mmHg, and all hypertrophic scar pressure garments:

  • a vascular surgeon;
  • an orthopedic surgeon; or
  • an oncologist, internist, pediatrician, plastic surgeon, physiatrist or general surgeon.

Providers:

To be considered for NIHB coverage, compression garments and lymphedema compression devices must be provided by:

  • an NIHB enrolled pharmacy/MS&E provider with staff certified as a compression garment fitter.

Hypertrophic scar pressure garments must be provided by;

  • an NIHB enrolled pharmacy/MS&E provider with staff certified as compression garment fitter or certified burn scar garment fitter.

7.3 Prior approval requirements

Prior approval is required for all pressure garment and pressure orthotic benefits.

To initiate the prior approval process, the NIHB orthotics-custom shoes-prosthetics-pressure garments prior approval form along with to the following supporting documentation are required by the regional office:

  • prescription indicating the required compression;
  • any other information the provider/physician, nurse practitioner or registered midwife may have to support the request; and
  • the required information as described in section 7.4.

Quick Link

7.4 Pressure garments and pressure orthotics benefit policies

A. Required information

The following information and criteria are requirements for coverage of pressure garments and pressure orthotics benefits:

a) Compression stocking/sleeve 20-30, 30-40mmHg and high sustained compression bandages 35mmHg

  • client’s diagnosis;
  • prescription indicating the requested compression;
  • qualifications and the title of the fitter;
  • whether the item is custom-fitted or custom-madeFootnote 4; and
  • name of the manufacturer and model of the item.

b) Compression stocking/sleeve 40mmHg and up

  • client’s diagnosis;
  • prescription indicating the requested compression;
  • prescriber’s specialty;
  • qualifications and the title of the fitter;
  • whether the item is custom-fitted or custom-madeFootnote 4; and
  • name of the manufacturer and model of the item.

c) Hypertrophic scar compression garment

  • client’s diagnosis and date of onset;
  • site and extent (i.e. percentage of body affected);
  • qualifications and the title of the fitter; and
  • name of the garment’s manufacturer.

d) Sequential extremity pump and accessories

  • client’s diagnosis and cause of lymphedema;
  • site of the lymphedema;
  • qualifications of the fitter; and
  • name of the manufacturer and model of the item.

A sequential extremity pump can be rented on a trial basis for one month before final purchase; however, the rental fee will be applied to the purchase price.

B. Exclusions

Please note that the general exclusion policy (section 1.2.4) continues to apply. The following items are excluded from the pressure garments and pressure orthotics benefit and are not considered for coverage or appeal under the NIHB Program:

  • compression garments for short-term treatment such as pre- and post-surgery;
  • pre- and post-medical treatment; and
  • post-traumatic edema.

C. Services included in the price

The following services must be included in the cost of the item to be considered for coverage:

  • initial assessment to determine type of benefit required;
  • measuring body part to manufacture the device in precise measurement;
  • manufacturing the device;
  • dispensing the benefit, including adjustment and fitting; and
  • follow-up visits, as per professional/industry standards.

7.5 Pressure Garments and Pressure Orthotics Benefits List

Visit the Pressure Garments and Pressure Orthotic Benefits List.

 

8. Prosthetics benefits

8.1 Prosthetics benefit categories

The prosthetics benefits list covers:

  • breast prostheses;
  • eye (ocular) prostheses;
  • lower and upper limb prostheses; and
  • prosthetics supplies, repairs, parts, and labour.

8.2 Prescriber/provider requirements

a. Breast prostheses

Prescribed by:

  • a physician
  • a nurse practitioner

Provided by:

  • a certified mastectomy fitter enrolled with the Program
  • a provider enrolled with the Program who has a certified mastectomy fitter on staff

b. Ocular (eye) prostheses

Prescribed by:

  • an ophthalmologist

Provided by:

  • a member of the National Examining Board of Ocularists (NEBO) certified ocularist.

c. Limb prostheses

Prescribed by:

  • a physician

Provided by:

Limb prosthesis:

  • certified prosthetist CP(c)
  • certified prosthetist orthotist CPO(c)
  • technicien en orthèses et prothèses (TOP) certified by the Canadian Board for Certification of Prosthetists and Orthotists (CBCPO) or certified by l’Ordre des technologues professionnels du Québec (OTPQ) (Quebec Only)

Stump socks for a prosthesis:

  • an enrolled NIHB Pharmacy or recognized Medical Supplies and Equipment (MS&E) provider; or

Stump shrinkers:

  • an NIHB enrolled Pharmacy; or
  • an enrolled MS&E provider who has a certified compression fitter on staff.

Note: A new prescription is required should an early replacement be needed due to a change in medical condition. Refer to replacement guideline period.

8.3 Prior approval requirements

Prior approval is required for all prosthetic benefits, with the exception of eye prosthesis polishing.

To initiate the prior approval process, the NIHB orthotics-custom shoes-prosthetics-pressure garments prior approval form along with the following supporting documentation are required by the regional office:

  • prescription if required as per replacement policy 8.4;
  • medical diagnosis;
  • any other information the provider/physician or nurse practitioner may have to support the request;
  • copy of an explanation of benefits (EOB) form from any third-party coverage available to the client (e.g., workers’ compensation board, private insurance, etc.); and
  • additional required information as described in section 8.5.

Quick Link

8.4 Replacement process for prosthetics

An original prescriptionFootnote 5 may be used for a replacement request when submitted by the same provider if:

  • prosthetic was initially covered by the NIHB Program,
  • item requested addresses the same medical condition as the original item,
  • the client’s medical condition remains the same, and
  • the replacement is within the recommended replacement guideline.

A new prescriptionFootnote 5 is required for a replacement when the:

  • client changes providers;
  • client’s medical condition changes; or
  • request is for an early replacement.

Refer to the Prosthetics Benefits list for recommended replacement guidelines.

8.5 Prosthetics benefit policies

A. Criteria and Required Information

The following information is required for prosthetics benefit coverage:

a. Breast prosthesis

  • date of surgery (initial request only);
  • left, right or bilateral mastectomy;
  • manufacturer and model number of the breast prosthesis and brassiere; and
  • name of the certified mastectomy fitter.

Note: breast prosthesis is to be dispensed within six (6) weeks from the date of the surgical procedure.

b. Eye prosthesis/scleral shell

  • diagnosis and/or medical reason for the request; and
  • date of the onset.

c. Limb prosthesis-definitive:

  • the date of surgery (initial request only);
  • materials to be used;
  • a detailed assessment (with measurements, when applicable);
  • whether an in-house or external laboratory will be used to manufacture the device;
  • a detailed quote/breakdown of components for the prosthesis; and
  • previous NIHB coverage for devices and repairs.

d. Limb prosthesis preparatory

  • the date of surgery;
  • the materials to be used;
  • a detailed assessment (with measurements, when applicable);
  • whether an in-house or external laboratory will be used to manufacture the device; and
  • a detailed quote/breakdown of components for the prosthesis.

B. Exclusions

The general exclusion policy (section 1.2.4) continues to apply. The following items are excluded from the prosthetic benefit and are not considered for coverage or appeal under the NIHB Program:

  • Breast prosthesis:
    • temporary or swim prosthesis;
    • silicone implants used in breast reconstruction;
    • breast prosthesis for failed breast reconstruction, when the client has not had a mastectomy or lumpectomy;
    • breast prosthesis for cosmetic augmentation; and
    • silicone nipples.
  • Limb prosthesis:
    • electric and myoelectric prosthesis;
    • a second prosthesis for the same amputation site; or
    • early replacement of a prosthetic that has been used beyond manufacturer specifications (e.g. for weight lifting, or sports).
  • Testicular implants
  • Wigs and hairpieces

C. Services included in the price

The following services must be included in the cost of the item to be considered for coverage:

  • initial assessment to determine type of benefit required;
  • casting of the body part to manufacture the device;
  • manufacturing the device;
  • dispensing, including adjustment and fitting; and
  • follow-up visit(s), as per professional association guidelines.

D. Warranty

  • For breast prosthesis, the warranty must guarantee that the prosthesis will remain satisfactory for fit and defects for a minimum of two years.
  • For eye prosthesis, the warranty must guarantee no charge for necessary adjustments for the initial three months following the final fitting, and a one-year warranty against discoloration and separation of materials. An exception can be made when the client's medical condition changes and prevents a satisfactory fit.
  • For limb prosthesis, the warranty must guarantee against breakage for six months and no charge for necessary adjustments for three months after the final fitting provided that the individual's size or medical condition has not changed significantly.

8.6 Prosthetics benefits list

Visit the Prosthetic Benefits List.

9. Respiratory equipment and supplies benefits

9.1 Respiratory equipment and supplies benefit categories

The respiratory equipment and supplies benefit categories are:

  • breathing apparatuses and supplies;
  • respiratory secretion clearance; and
  • tracheostomy supplies and equipment.

9.2 Prescriber/provider requirements

Respiratory equipment and supplies benefits must be prescribed by a:

  • paediatrician for an apnea monitor;
  • medical specialist such as a respirologist, sleep specialist, or a specialist in internal medicine for a bi-level device, oximeter, or volume ventilator;
  • physician or a nurse practitioner for a continued positive airway pressure (CPAP), auto-continuous positive airway pressure (APAP), and bi-level positive airway pressure (BPAP) system; or
  • physician or nurse practitioner for a compressor, flutter valve, high humidity compressor, peak flow meter, pep mask, percussor, or drainage board.

These items are to be provided by an:

  • NIHB enrolled Medical Supplies and Equipment (MS&E) provider or appropriate health care staff with regulatory affiliations (e.g. registered respiratory therapist/registered nurse familiar with training in managing respiratory conditions).

Please note: No prescription is required for the replacement of accessories (e.g., mask, breathing circuit tube, nasal pillow and cushion for the mask) for a positive airway pressure system that is approved for coverage by the NIHB Program for the lifetime of the positive airway pressure system.

9.3 Prior approval requirements

Prior approval is required for all respiratory equipment and supplies benefits.

To initiate the prior approval process, the NIHB home oxygen and respiratory equipment and supplies benefits approval form along with the following documentation are required by the regional office:

  • prescription from a recognized provider as described in section 9.2;
  • any other medical information the provider/physician or nurse practitioner may have to support the request; and
  • required information as described in section 9.4.

Quick Link

9.4 Respiratory equipment and supplies benefit policies

A. Criteria and required information

The following criteria and information is required when requesting respiratory benefit coverage:

Positive airway pressure (PAP) systems

  • Prescription from a physician or a nurse practitioner
  • Clinical information including:
    • Age, height and weight, BMI, sleepiness scale (ESS);
    • Symptoms of sleep disordered breathing and associated risk factors.
  • Results from a sleep study (one of the following):

    • Level 1 - Standard Polysomnograph (PSG)

      Full baseline and treatment PSG or split night PSG demonstrating diagnosis and response to PAP.

      It is recognized that Level 1 PSG testing may not be readily available in some regions. In such cases, level 2 or level 3 can be accepted with the additional clinical information as outlined below.

    • Level 2 - Comprehensive portable PSG

      Sleep study includes apnea/hypopnea index, saturation, heart rate, and body position with baseline and treatment results obtained during two separate nights.

    • Level 3 - (e.g. Stardust)

      Minimum requirements include recording of ventilation (at least two channels of respiratory movement of respiratory movement and airflow), ECG or heart rate, and oxygen saturation with baseline testing and with prescribed treatment testing results which are obtained during two separate nights.
  • Exception to PAP testing criteria
    • The NIHB Program will consider other testing methods on an exception basis, such as when a diagnostic PSG or other diagnostic testing is the accepted testing or standard of care in a given province/territory.
  • Rental (Up to three months)
    • Once a diagnosis has been established, the provider may choose to submit the diagnostic testing with interpretation and a prescription for the PAP therapy to NIHB for one month of rental funding in order to complete PAP titration testing at home. Subsequently, up to two additional months of rental can be requested to determine PAP compliance.
  • OR
    • Once a diagnosis has been established, the provider may choose to submit the diagnostic testing with interpretation, a prescription and prescribed treatment testing results to NIHB for a three month of rental funding to determine PAP compliance.
    • An interface and headgear purchase may be covered for the trial period.
    • Before the purchase of the PAP system is considered, the provider must confirm that the client is compliant with the usage via a downloaded PAP system usage report.
  • Note: The rental fee of the PAP system is to be deducted from the purchase price.
  • Purchase
  • The purchase of a PAP system may be covered if:
    • the data collected from the overnight oximetry while on the PAP system demonstrates significant improvement in the sleep condition;
    • the readout from the PAP system demonstrates that the client is compliant with therapy; and
    • physician interpretation of the treatment study confirms requirement.

B. Exclusions

Please note that the general exclusion policy (section 1.2.4) continues to apply. The following items are excluded from the prosthetic benefit and are not considered for coverage or appeal under the NIHB Program:

  • respiratory benefits for outings while the client is an in-patient in an acute or long-term hospital setting;
  • custom-made masks for ventilation; and
  • incentive spirometer or volumetric exerciser.

C. Services included in the price

Items:

  • Rental: Positive pressure system with integrated heated humidifier, circuit (tubing), and all other necessary accessories such as filters or connectors.
  • Purchase: Positive pressure system with integrated heated humidifier.

Services:

  • Product ordering and delivery from manufacturer to provider;
  • Initial product set up and mask fitting;
  • Instruction on the effective use, care and maintenance of the system;
  • All ongoing care including follow-up appointments and calls to monitor effectiveness, support compliance and make necessary adjustments (such as mask re-fit);
  • Report generation;
  • Correspondence with NIHB as part of coverage process; and
  • Correspondence with other health care professionals (physician, sleep lab) as necessary

D. Warranty

Vendor must honour manufacturer’s warranty.

9.5 Respiratory equipment and supplies benefits list

Visit the Respiratory Equipment and Supplies Benefits List.

Report a problem or mistake on this page
Please select all that apply:

Thank you for your help!

You will not receive a reply. For enquiries, contact us.

Date modified: