Guide to vision care benefits

Effective date: June 29, 2019

Note to reader:

Indigenous Service Canada's First Nations and Inuit Health Branch and the Assembly of First Nations have undertaken a Joint Review of the Non-Insured Health Benefits (NIHB) program, including the vision care benefit. The objectives of this collaborative process are to enhance client access to benefits, identify and address gaps in benefits, and improve service delivery to be more responsive to client needs. This guide to vision care benefits is an interim measure to clarify policy changes in some areas, and respond to preliminary issues identified through Joint Review discussions to date. Once the ongoing work on the Joint Review is completed, further revisions to this guide are anticipated.

Non-Insured Health Benefits (NIHB) program guide to vision care benefits

Table of contents

1.0 Introduction

1.1 Purpose of the guide

This guide provides information on Indigenous Services Canada's Non-Insured Health Benefits (NIHB) program vision care coverage policies. The purpose of this guide is to outline the terms and conditions, criteria, guidelines and policies under which the NIHB program's vision care benefit operates.

In this guide you will find information regarding:

  • eligible services
  • frequency guidelines
  • benefit coverage and exceptions
  • payments and reimbursement

In the event that this guide does not address questions regarding general policies, processing of payment requests, or specific conditions, NIHB clients or vision care providers may contact the NIHB program's regional offices (Appendix B).

1.2 About the vision care benefit

The NIHB program's vision care benefit provides coverage for eye examinations and corrective eyewear; this includes:

  • eye examinations when they are not insured by the province or territory
  • corrective eyewear (glasses, contact lenses) when prescribed by a vision care professional
  • eyeglass repairs

The program provides eligible clients (Appendix D) with coverage for eligible benefits not available under provincial, territorial or private health insurance (for example, in many provinces and territories, eye examinations may be an insured service for clients based on their age or with certain medical conditions).

1.3 Benefit criteria

Vision care benefits are covered in accordance with NIHB program policies. Eye examinations and eyewear must be provided by a licensed vision care professional in accordance with provincial or territorial legislation and regulations. Providers should obtain prior approval from the NIHB regional office in the province/territory where the service is provided (section 4.2).

Vision care benefits may be eligible for coverage for registered First Nations and recognized Inuit when all of the following criteria are met:

  • the requested item or service is eligible (section 2.0 and 3.0)
  • the prescription is valid (less than two years old)
  • the item or service is prescribed and provided according to established professional standards and applicable provincial/territorial legislation and regulations
  • any provincial, territorial public or private health insurance plans or programs for which the client is eligible have been accessed first

2.0 Eye examination

2.1 Eligible services

Coverage for eye examination within the Frequency Guidelines (section 2.2) falls into three major categories: general examination, follow-up examination, and single tests. Such examinations must be performed by a licensed vision care professional in accordance with provincial or territorial legislation and regulations.

Providers are requested to submit claims directly to the NIHB program so that clients do not pay at the point of service. Clients may call their regional office for a referral and travel support, if eligible, to access providers who bill the program directly in accordance with regional fee guides for eye exams. Reimbursement will not be provided for missed appointments. Please contact your regional office for the eye examination fee guide.

General examination

A general examination usually includes the following, as clinically indicated for the client in the opinion of the treating professional:

  • case history
  • external examination of the eye
  • assessment of visual acuity
  • profile of ocular motility
  • objective and subjective measurement of refraction
  • assessment of binocular coordination
  • assessment of amplitude of accommodation, when required
  • biomicroscopy and assessment of pupillary reflexes
  • tonometry
  • confrontation visual fields
  • direct ophthalmoscopy
  • analysis and diagnosis of findings

Follow-up examination

A follow-up examination is the repetition of one or more tests from the general examination which are needed to assess the condition or progression of the client's oculo-visual condition. Coverage may be approved on an exception basis, based on medical need (for example, findings from general exams, chronic health conditions), and requires prior approval.

Single tests

Clients may be eligible for single eye tests when their ocular or visual condition requires the use of specific additional tests. Coverage may be approved on an exception basis, based on medical need (as above), and requires prior approval. Some examples of single tests include:

  • assessment of visual fields, using visual field analyzer
  • colour blindness test
  • examination of the peripheral retina under pupil dilation
  • gonioscopy of the angle
  • study of oculomotor imbalance
  • study of contrast sensitivity function over at least six spatial frequencies
  • measurement of aniseikonia using an eikonometer or afocal magnifying lenses
  • precise assessment of visual impairment and trial of optical aids
  • assessment of corneal topography using a computerized video-keratoscope
  • electroretinogram measurement or visually evoked potentials
  • trial contact lens and assessment of ocular reaction for clients who meet the criteria for exception contact lenses (section 3.4.3)

All examinations must include recommendations to the patient and, if necessary, a prescription for treatment.

Clients with diagnosed medical conditions affecting the eye

Clients with diagnosed medical conditions affecting the eye, such as diabetes, glaucoma, cataract, age-related macular degeneration, may be eligible for a general examination and additional single tests every year (note that this is covered as an insured service in several provinces).

Coverage may be approved as an exception, based on medical need, and requires prior approval. Details of the client's medical condition must be provided in writing by the prescriber.

2.2 Eye examinations frequency guidelines

Eye examinations Frequency guidelines
General exam under 18 years old – once per calendar year

18 years old or over – once every two calendar years
Follow-up exam reviewed case-by-case
Single test
Clients with diagnosed medical conditions affecting the eye once per calendar year

3.0 Corrective eyewear

3.1 Eligible services

To be eligible for eyewear within the frequency guidelines (section 3.2), the client must obtain a prescription from a licensed vision care professional qualified to do so under applicable provincial or territorial legislation and regulations. The prescription must correct for one or more of the following conditions:

  • refractive error (myopia, hypermetropia and/or astigmatism)
  • presbyopia
  • oculo-motor imbalance

The client's prescription must meet at least one of the following criteria:

  • in at least one eye, require spherical and/or cylindrical correction of at least 0.50 diopter, and/or for presbyopia, have an add power of at least 0.75 diopter
  • require prismatic correction totaling at least 1.00 prism diopter vertically or at least 2.00 prism diopters horizontally

3.2 Corrective eyewear frequency guidelines

Coverage for corrective eyewear (glasses, contact lenses) is provided as follows:

Age group Frequency
Clients under 18 years once per calendar year
Clients 18 years or over once every two calendar years

Frequency of coverage is calculated by calendar year only, not month and date. For example, for a two-year frequency, if a client received coverage for new eyewear at any time in 2019, they will be eligible again on January 1, 2021, unless they qualify for early replacement per section 3.4.6.

3.3 Eyewear coverage amounts

The NIHB program provides clients with two types of coverage amounts: standard and high index. The coverage amount for which the client is eligible is determined by the client's eye examination and resulting prescription.

Any coverage amount that is not used by the client remains available until the end of the frequency period (section 3.2). For example, a client can use the balance of their coverage amount towards the purchase of another pair of glasses. Clients can contact their NIHB regional office to find out their remaining balance.

Providers are encouraged to submit claims directly to the NIHB program. Any additional costs over the maximum eligible amounts are the responsibility of the client. Providers are asked to inform the client if the cost of the eyewear selected exceeds their coverage amount.

Item Criteria for approval
Standard coverage amount
  • coverage for clients with a prescription under ±7.00 in both eyes, and who do not qualify for one of the other coverage amounts
  • client's prescription must address minimum requirements specified in section 3.1
High index coverage amount
  • coverage for clients who require a correction whose minimum power in a meridian is ±7.00 or more in at least one eye

Clients who choose to use their coverage amount towards contact lenses may use the residual amount of the coverage amount towards a back-up pair of glasses. Please note that some clients with exceptional prescriptions may qualify for contact lenses as an exception (refer to section 3.4.3).

Clients with medical needs requiring very high prescription lenses may be considered for additional coverage exceeding the high index amount on an exception basis (see section 3.4.5).

An additional amount for tints and coatings may be added to the standard or high index coverage amount where these items are required because of a medical condition and resulting prescription. Refer to section 3.4.2 for exceptions.

3.4 Exceptions and criteria for approval

For all exception items, a written prescription with medical justification by an ophthalmologist or optometrist is required.

To support the exception request, details of the client's medical condition must be provided in writing by the prescriber. Where relevant, an additional amount may be added on top of the coverage amount (section 3.3) for which a client qualifies.

3.4.1 Exception: Polycarbonate lenses

Polycarbonate lenses may be covered when the client meets the following criteria.

Item Criteria for approval
Glasses with polycarbonate lenses
  • coverage for clients in cases where the client has just one functional eye or for clients who, with the best possible correction, have far visual acuity in the weaker eye which is equal to or less than 6/60 (20/200)

3.4.2 Exception: Tints and coatings

Any client may use their coverage amount towards the purchase of tints or coatings of their choice. However, those with medical justification may qualify for additional amounts on top of the coverage amounts (section 3.3) for these items.

Item Criteria for approval
Tints Tinted lenses must have an average transmission over the visible spectrum of 40 percent, as long as the tinted lenses provide total ultraviolet (UV) protection.

Tints may be authorized for the following conditions:

  • albinism
  • aniridia
  • certain chronic conditions of the anterior segment of the eye causing photophobia
  • prolonged usage of some drugs that cause photosensitivity
Ultraviolet protection Filter Ultraviolet filters may be authorized for the following conditions:

  • aphakia (without intra ocular lens)
  • cataracts
  • retinal degeneration or dystrophy
  • prolonged usage of some drugs that cause photosensitivity
  • where tints are authorized (see above)

3.4.3 Exception: Contact lenses

In some cases, contact lenses may be the most appropriate way to correct vision for a client with certain prescriptions. Clients with one of the following conditions (in the table below) may qualify for additional coverage for both contact lenses and back-up glasses based on detailed medical justification or a prescription from an ophthalmologist or an optometrist.

Note that clients who do not demonstrate one of the conditions (in the table below) may choose to use their standard or high index coverage amount towards the fitting and purchase of contact lenses.

Item Criteria for approval
Exception contact lenses Exception contact lenses may be authorized for one of the following conditions:

  • astigmatism of at least 3.00 diopters in the glasses prescription
  • myopia or hypermetropia of at least 7.00 spherical diopters in the glasses prescription
  • anisometropia or antimetropia of at least 2.00 diopters
  • corneal irregularities
  • optometrist-prescribed treatment of certain ocular pathologies, if authorized by provincial/territorial legislation
  • neurological or arthritic condition which makes it difficult for them to physically handle contact lenses (extended-wear contact lenses)
Back-up glasses for exception contact lens wearers only
  • if a back-up pair of glasses is dispensed, the client qualifies for one Standard or High Index coverage amount based on their prescription (section 3.3) or exception coverage amount (section 3.4)

The exception contact lens coverage amount is to be applied towards the purchase of contact lenses. Additional coverage may be provided towards the purchase of glasses to use as a back-up. The coverage amount specific to the back-up glasses is based on the prescription as noted in section 3.3.

3.4.4 Exception: Flex frames

Where the client is young or has a medical condition (for example, Down syndrome, craniofacial disorders) that makes handling frames difficult, the client may be approved for coverage of flex frames on top of the coverage amounts (section 3.3).

Item Criteria for approval
Flex frames
  • infants and children 4 years and under
  • client has a medical condition that makes handling frames difficult

3.4.5 Exception: High prescription lenses

Where a client's prescription requires corrective lenses with a very high laboratory cost that cannot be managed within the corresponding coverage amount (section 3.3), additional coverage may be considered on an exception basis. A detailed breakdown of costs will be required to support consideration of these claims. Note that, for glasses, the coverage for the frame will be according to the exception frame amount shown in Appendix A.

Item Criteria for approval
High prescription lenses High prescription lenses may be authorized for one of the following:

  • clients under 12 years old whose minimum power in a meridian is greater than 3.00 diopters of hyperopia or requiring bifocals for the management of strabismus
  • a correction whose minimum power in a meridian is greater than +9.00 diopters for hyperopia and -12.00 diopters for myopia in at least one eye
  • astigmatism greater than ±3.00 diopters
  • anisometropia greater than 3.00 diopters between the two eyes

3.4.6 Exception: Early lens replacement due to change in prescription

If a client's prescription changes significantly and replacement lenses are required outside of the regular frequency guidelines, the program will cover the replacement of contact lenses or eye glass lenses (using existing frames) when the client's new prescription demonstrates one of the following criteria in at least one eye:

Item Criteria for approval
Replacement of lenses for glasses
  • a change of at least 0.50 diopter over the sphere, cylinder or addition and the new power meets the eligibility criteria for eye wear (section 3.1)
  • a change in axis greater than 15 degrees for cylinder power up to 2.00 diopters or greater than 10 degrees for a cylindrical power greater than 2.00 diopters
  • a change of at least 1.00 prism diopter vertically or at least 2.00 prism diopters horizontally
  • applies to standard or high index coverage amount (section 3.3) or exception coverage amounts (section 3.4)
Replacement of contact lenses
  • a change of at least 0.50 diopter over the sphere, cylinder or addition and the new power meets the eligibility criteria for eye wear (section 3.1)
  • a change of cylinder axis of more than 10 degrees in a toric contact lens
  • applies to standard or high index coverage amount (section 3.3) or exception contact lenses (section 3.4.3)

When early lens replacement is required because the client's vision is changing, the eye exam must have been done in the preceding three months, to ensure the new eyewear meets the client's current needs.

3.4.7 Exception: Repairs or replacement due to breakage, damage or loss

All frames provided must be of a type that can be repaired and carry a replacement warranty against defective workmanship and materials for a minimum of one (1) year from date of issue.

Repairs to eyewear (minor or major) may be covered after the usual and customary warranties have expired. Coverage is provided in accordance with the fee guide on the condition that the repairs render the eyewear acceptable for wear and that repair costs do not exceed the price of a new frame in the fee guide (Appendix A). Eye glass repair kits will be covered as a client reimbursement under minor repair.

Replacements in the event of breakage, damage or loss may also be considered for coverage with justification and supporting documentation of the incident that caused the need for replacement (such as an incident, insurance, or police report). Replacements resulting from misuse or carelessness will not be considered for adults but may be considered on an exception basis for children.

Item Criteria for approval
Repairs, minor
  • includes repairs to frame, such as nose pads and hinges
  • includes eye glass repair kits
  • prescription is NOT required
Repairs, major
  • includes repairs to frame, such as fronts and frame arms
  • includes replacement of one lens of the same prescription
  • prescription is NOT required
Replacement of entire glasses or contact lenses in the event of breakage, damage or loss
  • for clients 18 years and older, supporting documentation is required of the incident that caused it (such as an incident, insurance, or police report). Supporting documentation not required for clients under 18 years
Frequency Guidelines: Repairs or replacement
Item Frequency
Minor repair
  • under 18 years old – once per calendar year
  • 18 years old or over – once every two calendar years
Major repair
  • under 18 years old – once per calendar year
  • 18 years old or over – once every two calendar years
Replacement of entire glasses or contact lenses
  • under 18 years old – reviewed case-by-case
  • 18 years old or over – reviewed case-by-case; supporting documentation is required of the incident that caused it (such as an incident, insurance, or police report)

3.4.8 Exception: Multifocal eyewear

Most clients who have more than one prescription can have these prescriptions fitted in one frame. Clients who have not previously used multifocal eyewear should attempt full-time wear for a trial period of 3 months. If at that time, the client is unable to adjust to using multifocal eyewear (e.g. bifocals), provided that the client meets the prescription requirements outlined in section 3.1, the client may qualify for:

  • one lens replacement coverage amount (fit new lenses using previously dispensed frame; section 3.4.6)
  • a full coverage amount to fit the remaining qualifying prescription lenses (section 3.3 or 3.4.1) or exception coverage amount (section 3.4)

A client does not have to undergo a trial period if they have already done so in the past, or if there are contra-indications owing to a cervical or ocular mobility abnormality attested to by the optometrist or ophthalmologist.

Multifocal eyewear Criteria for approval
Second pair for client unable to adjust to multifocal after trial period First time users only:

  • client has attempted the glasses for three months
  • in addition to a second coverage amount, client may receive coverage towards the cost of the lens replacement, since the original frame can be reused for one pair (Appendix A)
Two pairs for client who has already tried and been unable to adjust to bifocals/progressives in the past
  • client has undergone trial period in the past
  • client has contra-indications owing to a cervical or ocular mobility abnormality attested to by the optometrist or ophthalmologist

3.5 Ordering eyewear: A note to clients

Clients should be aware that eyewear is custom made. Once the optometrist or optician has made the eyewear, it cannot be used by anyone else. Clients are encouraged to make arrangements with the provider's office to pick up their eyewear. A provider will generally hold eyewear for a maximum of four months from the date of service.

Clients are not obligated to order their eyewear through the same vision care provider who does the exam. If clients choose to have eyewear made elsewhere (such as through a separate optician), they should tell their optometrist or optometric clinic right away, so that the program provides the prior approval to the eyewear provider chosen by the client.

Clients are asked to contact their chosen vision care provider in advance to confirm that the provider is enrolled with NIHB and will bill the program directly. A client is encouraged to ask about the cost of the services and whether the full cost will be billed directly to NIHB, in order to avoid being asked to pay for unexpected costs.

The client is responsible for any cost over the amount covered by the NIHB program. Based on the eyewear selected, clients should ask their provider to confirm the total cost of the eyewear before it is ordered or dispensed.

Some vision care professionals may request that clients sign an agreement, leave a deposit or pay in full when they order eyewear. A client may opt to pay the provider directly and seek reimbursement from NIHB for eligible benefits (refer to section 4.3). However, clients who would like assistance in locating an enrolled vision care provider may contact their NIHB program regional office for assistance.

3.6 Exclusions of the vision care benefit

Exclusions are goods and services which will not be covered by the NIHB program under any circumstances and are not subject to the NIHB appeal process.

Exclusions include:

  • additional eye exams or costs over the coverage eligibility or frequency to obtain employment, a driver's license or to engage in sports activity, or at the request of a third party (e.g. completing a report or medical certificate)
  • eyeglass cleaning kit
  • shampoo
  • any vision items for aesthetic purposes (e.g. non-prescription glasses or cosmetic contacts)
  • contact lens solution
  • replacements for adults as a result of misuse, carelessness or client negligence
  • implants (e.g. punctal occlusion procedure and intraocular lenses)
  • refractive laser surgery
  • treatments with investigational/experimental status
  • vision therapy

3.7 Items covered by other NIHB benefit areas

Eligible clients can obtain ocular prosthesis, scleral shell and low vision aids under the Medical Supplies and Equipment benefit. For more information, please contact your NIHB regional office.

Certain medications used to treat conditions such as Macular Degeneration may be covered under the Pharmacy benefit. For more information, vision care providers or clients may contact the Drug Exception Centre at 1-800-580-0950.

4.0 Payment and reimbursement

All claims for reimbursement of eligible goods and services must be received by the NIHB program within one year from the date of service. In order to be reimbursed, the service or item must be an eligible benefit, and the client must have been eligible at the time the item was provided.

4.1 Delivery and shipping policy

The provider should notify the client that they have four months from the date of service to pick up their eyewear and document their attempts to contact the client in the client's file. In the event that the client does not pick up their eyewear, please refer to Appendix B for more information

In specific circumstances, where the client and provider are in agreement to ship an item to the client, the provider may request payment for shipping costs (including registered mail) in addition to the client's coverage amount. Request for payment of delivery charges should be included in the request for prior approval.

4.2 Prior approval and claims

Providers should obtain prior approval from the NIHB regional office in the province/territory where the service is provided. The regional office will provide a prior approval number for the purpose of billing the claim. Only then should the provider proceed with the fabrication/fitting/dispensing of the item. Prior approval will also ensure that the provider and the client are aware of the amount of coverage that is available, and can select eyewear accordingly.

Prescribers and providers should contact the NIHB regional office for additional information on the prior approval process.

Clients are encouraged to:

  • contact their NIHB regional office to find out their eligible coverage amount
  • inform the prescriber and provider if they have coverage under any other plan
  • inform the prescriber and provider that they are eligible to receive benefits under the NIHB program
  • provide their client identification number

4.3 NIHB program client reimbursement

The NIHB program encourages enrolled providers to bill the program directly for eligible vision care services rendered to NIHB clients (section 3.5).

All requests for client reimbursement must include a completed NIHB Client Reimbursement Form, original receipts and a copy of the optical prescription.

All claims for reimbursement of eligible goods and services must be received by the NIHB program within one year from the date of service. In order to be reimbursed, the service or item must be an eligible benefit, and the client must have been eligible at the time the item was provided.

For additional information, contact the NIHB regional office.

4.4 Coordination of benefits

Clients are required to access any public or private health or provincial/territorial programs for which they are eligible prior to accessing the NIHB program. For example, eye examinations may be an insured service under the provincial or territorial health plan based on a client's age or medical condition. Providers should be aware when a client qualifies for an eye exam under the provincial or territorial health plan.

When an NIHB-eligible client is also covered by another plan, claims must be submitted to the other plan first. The other plan will provide an explanation of benefits (EOB) form that must be sent to the NIHB program. It is the responsibility of the client to inform the provider if they have coverage through a private plan, e.g. employment group plan. For vision care benefits, having coverage under more than one plan enables clients to use both plans when claiming expenses. Clients may use their full NIHB coverage to pay any remaining balance after the other plan has paid.

Where a client is no longer eligible for coverage from another payer, the client or provider can contact the NIHB regional office to update the file.

Appendices

A. Vision care benefit corrective eyewear fee guide

Effective Date: 29 June, 2019

Item Applicable section in guide Maximum eligible amount (up to) Note
Standard coverage amount 3.3 claimed cost for one or more prescription items, up to combined total of $275, as per frequency guidelines (section 3.2)
  • $290 in Atlantic region and $300 in Yukon
  • this amount includes all materials costs, mark up, fitting and dispensing fees
  • additional amounts added for medically necessary tints and coatings (section 3.4.2)
High index coverage amount 3.3 claimed cost for one or more prescription items up to combined total of $415, as per frequency guidelines (section 3.2)
  • $440 in Yukon
  • this amount includes all materials costs, mark up, fitting and dispensing fees
  • additional amounts added for medically necessary tints and coatings (section 3.4.2)
Exceptions
Item Applicable section in guide Maximum eligible amount (up to) Note
Polycarbonate lenses coverage amount 3.4.1 claimed cost for one or more prescription items up to combined total of $325, as per frequency guidelines (section 3.2)
  • $350 in Yukon
  • this amount includes the frames, all materials costs, mark up, fitting and dispensing fees
  • additional amounts added for medically necessary tints and coatings (section 3.4.2)
Exception contact lenses 3.4.3 claimed cost up to a total of $450, as per frequency guidelines (section 3.4.3)
  • this amount includes all materials costs, mark up, fitting and dispensing fees
Minor repair 3.4.7 claimed cost up to $25, as per frequency guidelines (section 3.4.7)  
Major repair 3.4.7 claimed cost up to $125, as per frequency guidelines (section 3.4.7)  
Damage/loss replacement 3.4.7 claimed cost up to standard or high index coverage amount based on their prescription (section 3.3) or exception coverage amount (section 3.4)
  • additional amounts added for medically necessary tints and coatings (section 3.4.2)
Prescription change lens replacement 3.4.6 claimed cost up to standard or high index coverage amount based on their prescription (section 3.3) or amount approved under exceptions (section 3.4) minus the cost of the frame ($125)
  • frame costs are not an eligible expense
  • the same lens material must be dispensed
  • additional amounts added for medically necessary tints and coatings (section 3.4.2)
Prescription change contact lenses replacement 3.4.6 claimed cost up to standard or high index coverage amount based on their prescription (section 3.3) or amount approved under exceptions (section 3.4)  
Exception flex Frames 3.4.4 add $50 to coverage amount or exception lenses
  • flex frame must be dispensed
  • additional costs may be justified upon review
Tints, medically necessary 3.4.2 add $20 per tint ($10/lens) to coverage amount
  • this amount may be claimed only if the tints are dispensed
UV filter, medically necessary 3.4.2 add $20 per filter ($10/lens) to coverage amount
  • this amount may be claimed only if the filter is dispensed
Exception frames 3.4.5 claimed cost up to $125
  • to be used to claim for exception high prescription lenses for glasses (section 3.4.5)
Exception lenses 3.4.5 claimed cost is cost of lenses
  • to be used to claim for exception high prescription lenses (section 3.4.5)
  • the cost of lenses includes lab cost and dispensing fees
Shipping 4.1 shipping cost in addition to coverage amount  
*claimed cost is based on provider invoice/receipt. If a client has other insurance, the client's NIHB eligibility is not reduced. Any balance remaining after another plan has paid may be claimed, up to the client's full NIHB eligible amount. See section 3.3 on unused balances.

B. Unclaimed eyewear

A client has four (4) months from the order date to pick up their eyewear. The provider should document their efforts to communicate with the client in the client's file. In the event that the client does not pick up their eyewear within four months, two options for the provider are proposed:

1) Where the client has ordered glasses, the provider will dismantle the glasses and invoice the NIHB Program only for the lenses and other parts of the glasses which cannot be reused. The frames should go back into the provider's inventory. The lenses should be sent to the regional office. Instead of the client's signature, the provider will indicate that the client did not pick up the glasses within the four month time frame, and submit the signed invoice for payment from the regional office. The regional office will add a note in the client's file stating that the lenses will be held by the regional office until the client claims them, or the frequency period* expires (whichever comes first). Should the client contact the regional office for the lenses, the regional office will make arrangements to have the lenses sent to an eligible provider to be fit into frames and provided to the client. At that time, NIHB will reimburse the provider for the frames for the client's glasses.

*The frequency period refers to the date at which the client will be eligible for new eyewear. For more details on the frequency guidelines, refer to section 3.2.

Based on the provider's professional opinion, if the eyewear does not consist of any reusable parts, the second option should be employed.

2) The provider will mail the glasses or contact lenses to the regional office. The regional office will sign for the eyewear on behalf of the client. The provider will submit an invoice and be reimbursed for the amount approved. The regional office will add a note in the client's file stating that the eyewear will be held by the regional office until the client claims them, or the frequency period expires (whichever comes first). Should the client contact the regional office for the eyewear, the regional office will make arrangements to have the eyewear sent to the client. A note indicating the date that the eyewear was mailed out will be put in the client's file. If the client does not contact the provider within the frequency period, where possible, the eyewear will be sent to a charitable organization for their use.

It is important to note that the NIHB Program will not reimburse providers for any costs for eyewear above the approved amount. For additional information, please contact the NIHB Program regional office in your province or territory.

C. Contact information: NIHB program's regional offices

For additional information, please contact the NIHB program regional office in your province or territory.

D. Privacy statement

Indigenous Services Canada'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, please contact Indigenous Services Canada's Access to Information and Privacy (ATIP) Coordinator. You also have the right to file a complaint with the Privacy Commissioner of Canada if you think your personal information has been handled improperly.

E. Client eligibility

To be eligible for NIHB program benefits, a client must be a Canadian resident and registered or eligible to be registered under a provincial or territorial health insurance plan and have the following status:

  • a First Nations person who is registered under the Indian Act (commonly referred to as a "Indian status"); or
  • Inuk recognized by an Inuit Land Claim organizations; or
  • an infant less than 18 months old whose parent is a registered First Nations person or a recognized Inuk; and
  • Not otherwise covered under a separate agreement (e.g. a self-government agreement such as the Nisga'a and Nunatsiavut agreements) with federal, provincial or territorial governments.

Refer to the client eligibility page or contact the NIHB regional office for information.

F. 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 cannot be appealed. Refer to the Non-Insured Health Benefits appeal procedures or contact the NIHB regional office for information.

G. Provider claims verification program

Verification activities are conducted as part of the NIHB program's need to comply with accountability requirements for the use of public funds and to ensure provider compliance with the terms and conditions of the program. Claim verification activities are administrative in nature. The objectives of the program are to:

  • prevent and detect inappropriate claim/billing practices
  • detect and recover claim/billing irregularities
  • ensure that providers have retained appropriate documentation, meeting both provincial/territorial legislation and regulations as well as program requirements to support each claim
  • validate active licensure of registered providers and prescribers
  • ensure that services paid for were received by eligible NIHB program clients

The NIHB program reserves the right to withhold any future payments to providers pending receipt of monies determined to be paid in error. The program does not focus on professional practice issues. If a practice related issue arises during a review and if the issue cannot be resolved directly with the provider, it may be referred to the respective regulatory body. For additional information, please visit the NIHB vision care benefit web page.

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