Information Booklet

© Her Majesty the Queen in Right of Canada, 2003
Cat. No. H35-4/23-1-2003E
ISBN 0-662-34173-2

Help on accessing alternative formats, such as Portable Document Format (PDF), Microsoft Word and PowerPoint (PPT) files, can be obtained in the alternate format help section.

What's Inside

• The NIHB Program
• Who is an Eligible Recipient
• Objectives of the NIHB Program
• Benefits Provided
  • Drugs
  • Medical Transportation
  • Dental
  • Medical Supplies and Equipment
  • Vision
  • Crisis Intervention Counselling
• Other Information You Should Know
  • Payment of NIHB outside Canada
  • Benefit Criteria
  • Exceptions
  • Exclusions
  • Recommended Replacement Guidelines
  • Coordination of Benefits
  • Client Reimbursement
  • Appeal Process
  • Privacy and Your Consent
• Contact Information

Purpose

The purpose of this booklet is to provide important information about the Non-Insured Health Benefits (NIHB) Program of Health Canada's First Nations and Inuit Health Branch (FNIHB).

The NIHB Program is a national, needs-based health benefit program. The program covers some of the costs of dental or medically required benefits, items and services for eligible First Nations and Inuit.

This booklet explains:

• how to access services
• who to contact when you need information
• what is expected of eligible recipients

Publication authorized by the Minister of Health Canada
This publication can be made available in alternative formats
upon request.

For additional copies, please contact:
NIHB Consent Information Centre
Tel: 1-888-751-5011

This publication is also available on Internet at the following address: www.healthcanada.ca/nihb-consent

Ce document est aussi offert en français sous le titre : Programme des services de santé non assurés -- Livret d'information

The NIHB Program

The NIHB Program is a national health benefit program. It pays for some, or all of the costs of medical, dental and pharmacy services that eligible First Nations and Inuit may need. The program policies and practices follow the 1979 Indian Health Policy and the 1997 NIHB Renewed Mandate.

The program provides a range of health benefits to meet medical or dental needs not covered by provincial, territorial or other third party health plans. Third party health plans are ones usually provided by insurance companies. The benefits and services of the NIHB Program are in addition to provincial and territorial insured health care programs.

Who is an Eligible Recipient?

An eligible recipient is someone who is allowed or entitled to receive benefits such as vision care, drugs or other services from the NIHB Program.

As an eligible recipient you must be identified as a resident of Canada and one of the following:

• a registered Indian according to the Indian Act
• an Innu member of one of the two Innu communities in Labrador (Davis Inlet and Sheshatshiu)
• an Inuk recognized by one of the Inuit Land Claim organizations
• an infant less than age one (1), whose parent is an eligible recipient

Objectives of the NIHB Program

The objectives of the program are to provide benefits to eligible First Nations and Inuit in a manner that:

• is suitable to their unique health needs
• helps eligible First Nations and Inuit to reach an overall health status on par with other Canadians
• is cost effective
• will maintain health, prevent disease and assist in detecting and managing illnesses, injuries, or disabilities

Benefits Provided

Drugs
Medical Transportation
Dental
Medical Supplies and Equipment
Vision
Crisis Intervention Counselling
Provincial health care premiums, where applicable

Drugs (Pharmaceutical Services)

What is covered?

• Prescription drugs listed on the NIHB Drug Benefit List
• Approved over-the-counter medication

Who can prescribe under the NIHB Program?

A doctor or other health professional licensed to prescribe by a province or territory.

Who can provide drug benefits?

Drug benefits must be provided by a registered pharmacist.

How do you access drug benefits?

• Visit your doctor, or any other licensed prescriber who may give you a prescription
• Bring the prescription to a pharmacy or to a nursing station or health centre, who may arrange to have the prescription sent to a local pharmacy

In some cases the pharmacist may have to obtain approval from Health Canada before filling the prescription.

If a benefit is denied you can appeal the decision. Refer to the Appeals section at the end of this booklet for more information.

When does the pharmacist have to obtain approval before billing the NIHB Program for a prescription?

The NIHB Program maintains a comprehensive Drug Benefit List. In most cases the drugs that are prescribed are on the list and the pharmacist can give them to you right away.

In order to provide your prescription drugs, the pharmacist must obtain approval when:

• the drug you have been prescribed is not on the NIHB Drug Benefit List
• the doctor has written 'no substitution' on your prescription
• the drug you have been prescribed is listed as a 'limited use' drug requiring prior approval
• it is a 'maximum allowable' drug

What does your drug plan cover?

It covers the 'lowest cost alternative drug' which is commonly known as a generic drug. The policy of the NIHB Program is to reimburse only the best price alternative or equivalent product in a group of interchangeable drug products.

The NIHB Program will pay for medicine with a higher cost, if the patient has had an adverse reaction to the generic drug.

What is a 'limited use' drug?

Limited use drugs have established criteria which the recipient must meet in order for the NIHB Program to cover the cost.

What does the term 'maximum allowable' mean?

For health and safety reasons maximum quantities have been placed on some drugs. The NIHB Program recognizes that some patients may require more than the maximum allowable quantities of drugs to manage their conditions. Exceptions are considered on a case-by-case basis.

What is the process to obtain approval before billing the NIHB Program for a prescription?

The pharmacist will call the national NIHB Drug Exception Centre. The Centre will request details about the prescription, the prescriber, and the pharmacist.

If required, the Drug Exception Centre analyst will fax a copy of the Exception or Limited Use Drug Request Form to your doctor. Your doctor or licensed prescriber will complete the form stating the exceptional medical need for the drug.

The response will be reviewed and a decision will be made. The decision is communicated to the pharmacist. The decision process may take a few days. The time for approval is dependent on the doctor or licensed prescriber providing the information.

What are your responsibilities?

• Tell the pharmacist if you have coverage under any other plan
• Tell the pharmacist that you are eligible to receive benefits under the NIHB Program
• Provide your nine or ten digit identification number (treaty/status, 'N' or 'B' number), band name and family number or other health care number
• Talk to your pharmacist about your medication and how to take it

For more information about the drug benefit program you can visit the Health Canada web site or contact your FNIHB Regional Office.

Medical Transportation

What is covered?

• Land and water transportation
• Scheduled and chartered airlines
• Road and air ambulance
• Meals and lodging
• Escort and/or interpreter services
• Travel to the nearest health clinic or hospital to receive health services not available in your home community, or not covered by provincial or territorial travel assistance programs

How do you access medical transportation benefits?

• If you live within a First Nations or Inuit community contact your local Health or Band Office, or a local First Nations and Inuit Health Authority for information
• If you live 'off-reserve/outside community' contact your FNIHB Regional Office or the responsible First Nations and Inuit Health Authority for information
• Make your appointment with the nearest appropriate medical/dental professional

If a benefit is denied you can appeal the decision. Refer to the Appeals section at the end of this booklet for more information.

What are your responsibilities?

• Coordinate appointment times to avoid repeat trips
• Get travel approved before you go
• Obtain a confirmation of attendance slip or certification stamp from the provider
• Follow the transportation guidelines provided to you by a local First Nations and Inuit Health Authority or FNIHB Regional Office
• When requesting approval, provide your nine or ten digit identification number (treaty/status, 'N' or 'B' number), band name and family number or other health care number

Dental

Coverage for dental services is determined on an individual basis, taking into consideration the current oral health status, past client history, accumulated scientific research, and availability of treatment alternatives.

What is covered?

• Diagnostic services (examinations, x-rays)
• Preventive services (cleanings)
• Restorative services (fillings)
• Endodontics (root canal treatments)
• Periodontics (treatment of gums)
• Prosthodontics (removable dentures and fixed bridges as an alternate benefit)
• Oral surgery (removing teeth)
• Orthodontics (straightening teeth)
• Adjunctive services (additional services like sedation)

Who can provide dental benefits?

Dental services must be provided by a licensed dental professional such as a dentist, dental specialist, or denturist.

How do you access dental benefits?

• Make an appointment with a dental provider and tell him/her that you are eligible for non-insured health benefits
• The dental provider will examine your teeth and tell you what services you will need
• Ask your dental provider if the service is covered under the NIHB Program (certain services may need predetermination/prior approval)
• Ask the dental provider if he/she will request additional professional fees above those paid by the NIHB Program

If a benefit is denied you can appeal the decision. Refer to the Appeals section at the end of this booklet for more information.

What are your responsibilities?

• Tell the dental provider if you receive benefits under any other health plan
• Tell the dental provider that you are eligible to receive benefits under the NIHB Program
• Give the provider your nine or ten digit identification number (treaty/status, 'N' or 'B' number), band name and family number or other health care number
• Visit the dental provider based on the appointments given
• Always keep your appointments
• Whenever you have a problem with your teeth, call your dental provider

Medical Supplies and Equipment

What is covered?

• Audiology (hearing aid)
• Medical equipment (wheelchair, walker)
• Medical supplies (ostomy, bandage, dressings)
• Orthotics and custom footwear
• Pressure garments
• Prosthetics
• Oxygen therapy
• Respiratory therapy

Who can provide medical supplies and equipment benefits?

Providers differ across the provinces and territories. Check with your local FNIHB Regional Office or a local First Nations and Inuit Health Authority for information.

Who can prescribe medical supplies and equipment benefits?

Medical supplies and equipment must be prescribed by a licensed doctor or medical specialist.

How do you access medical supplies and equipment benefits?

• Visit your doctor who will examine you and may have you see a specialist or request further testing
• Get a prescription from your licensed doctor or medical specialist
• Take the prescription to an approved service provider

If a benefit is denied you can appeal the decision. Refer to the Appeals section at the end of this booklet for more information.

What are your responsibilities?

• Tell the service provider if you have coverage under any other plan
• Tell the service provider that you are eligible to receive benefits under the NIHB Program
• Provide your nine or ten digit identification number (treaty/status, 'N' or 'B' number), band name and family number or other health care number
• Follow all warranty instructions and get the item repaired when necessary
• If you no longer require the item (e.g. wheelchair, walker) contact a FNIHB Regional Office or a local First Nations and Inuit Health Authority to find out if the item can be used by someone else

Vision

What is covered?

• Eye examinations (you should get approval for this ahead of time, in case this is not insured in your province or territory)
• Eyeglasses that are prescribed by a vision care provider
• Eyeglass repairs
• Eye prosthesis (artificial eye)
• Other vision benefits depending on your specific medical needs and according to the agreement negotiated with the association of your province or territory

Who can prescribe vision benefits?

The vision benefit must be prescribed by a licensed vision care professional who has studied a specific program, passed the exams and received a certificate that entitles him/her to work in that field.

Licensed vision care professionals include:

• an optometrist who is licensed to check your vision and to prescribe lenses to correct vision problems
• an ophthalmologist who is a doctor and specializes in diseases of the eye

Who can provide vision benefits?

A recognized provider may be one of the following:

• a licensed optometrist
• an optician (an optician prepares the eyeglasses that have been prescribed)
• an ophthalmologist

How do you access vision benefits?

• Have your eyes examined by an optometrist or ophthalmologist
• Take your prescription to a recognized provider, such as an optician or an optometrist
• The recognized provider will call or fax the local FNIHB Regional Office or the responsible First Nations and Inuit Health Authority for benefit approval

If a benefit is denied you can appeal the decision. Refer to the Appeals section at the end of this booklet for more information.

What are your responsibilities?

• Tell the recognized provider if you receive benefits under any other health plan
• Tell the recognized provider that you are eligible to receive benefits under the NIHB Program
• Give the provider your nine or ten digit identification number (treaty/status, 'N' or 'B' number), band name and family number or other health care number

Crisis Intervention Counselling

Short-term crisis intervention counselling may be provided by a recognized professional mental health therapist when no other services are available to the recipient.

What is covered?

• The initial assessment
• Development of a treatment plan
• Fees and associated travel costs for the professional mental health therapist when it is deemed cost-effective to provide such services in a community

Who can provide crisis intervention counselling?

Crisis intervention counselling must be provided by therapists registered with a regulatory body from the disciplines of clinical psychology or clinical social work, in the province or territory in which the service is provided.

In exceptional circumstances service providers from disciplines other than clinical psychology or clinical social work may be considered.

How do you access crisis intervention counselling?

Call your local FNIHB Regional Office or a local First Nations and Inuit Health Authority. You may be required to use a program in your community.

If a benefit is denied you can appeal the decision. Refer to the Appeals section at the end of this booklet for more information.

What are your responsibilities?

• Identify that you are a recipient of the NIHB Program
• Provide your nine or ten digit identification number (treaty/status, 'N' or 'B' number), band name and family number or other health care number
• Tell the service provider if you have coverage under any other plan
• Attend your scheduled appointments

Other Information You Should Know

Payment of Non Insured Health Benefits outside Canada

The NIHB Program will provide some benefits outside Canada.

What is covered?

• The cost of privately acquired health insurance for approved students or migrant workers and their legal dependents
• Transportation benefits, when eligible recipients are medically referred and approved for treatment outside of Canada by a provincial or territorial health care plan

Who can access the benefits?

• A student following a course of post-secondary training or education from a recognized institution
• A migrant worker
• A legal dependent of a student or migrant worker

What are your responsibilities?

• Ensure that you have been approved by a provincial or territorial health insurance plan to obtain medical treatment in another country before leaving Canada
• Contact your FNIHB Regional Office or a local First Nations and Inuit Health Authority for more information

Benefit Criteria

A benefit is to be considered for coverage when:

• the item or service is on a NIHB Program benefit list or NIHB schedule
• it is intended for use in a home or other ambulatory care settings
• prior approval/predetermination is obtained (if required)
• it is not available through any other federal, provincial, territorial, or private health care program
• the item is prescribed by a physician, dental care provider, or other health professional licensed to prescribe
• the item is provided by a recognized provider

Exceptions

These are items not listed as benefits on one of the NIHB Benefit Lists and are not exclusions under the NIHB Program. They may be considered on a case-by-case basis with written medical or dental justification.

Exclusions

These are items not listed as benefits on one of the NIHB Benefit Lists and are not available through the exception process. These items are therefore not considered for coverage under the NIHB Program. They include items used exclusively for sports, work, education, and cosmetic reasons, are experimental, or are part of a surgical procedure.

Recommended Replacement Guidelines

Guidelines outlining recommended quantity or replacement are based on the average medical needs of recipients. Requests outside these guidelines may be considered on a case-by-case basis.

Coordination of Benefits

When you are covered by another public or private health care plan, claims must be submitted to them first.

Client Reimbursement

Submissions for retroactive coverage must be received by FNIHB on a NIHB Client Reimbursement Request Form, within one year from the date of service or date of purchase.

All requests for reimbursement of eligible benefits must include:

• original receipts with cost breakdown (i.e. dispensing fees, unit cost, and Drug Identification Number (DIN) for drugs)
• a NIHB Dent-29 form and treatment plan for all dental services
• your name, address, identification number (treaty/status, nine or ten digit number, 'N' or 'B' number), band name and family number or other health care number
• a copy of the prescription
• complete client authorization section on the NIHB Client Reimbursement Request Form

To obtain a NIHB Client Reimbursement Request Form, contact your FNIHB Regional Office, or a local First Nations and Inuit Health Authority.

Appeal Process

Recipients may initiate an appeal process when a benefit has been denied through the NIHB Program.

Three levels of appeal are available. Appeals must be initiated by you at each level. There must be supporting information/documentation from your health care provider(s) as required. A written explanation of the decision taken will be provided to you, or to your representative, at each level of the appeal process.

Refer to published NIHB Appeal Procedures available in each region or on the Program's website or contact your FNIHB Regional Office.

Privacy and your Consent

The NIHB Program recognizes an individual's right to control who has access to his or her personal information and the purpose for which that information will be used. When a request for benefits is received, the NIHB Program collects, uses, discloses and retains only the personal information required to process the benefit.

As a program of the federal government, NIHB must comply with the Privacy Act, the Charter of Rights and Freedoms, the Access to Information Act, Treasury Board policies and guidelines including, the Treasury Board of Canada Government Security Policy, and the Health Canada Security Policy.

The Objectives of the NIHB Privacy Code are:

• to set out commitments of the NIHB Program to ensure confidentiality through responsible and secure handling of personal information collected for program delivery, administration and management; and
• to foster transparency, accountability, increased awareness of the NIHB Program's privacy procedures and practices.

The NIHB Privacy Code is based on the ten principles set out in the Canadian Standards Association (CSA), Model for the Protection of Personal Information.

Client Consent

As per Principle 3 of the NIHB Privacy Code, the NIHB Program does not require a signed consent form for day-to-day processing activities and program administration. However, where client safety or inappropriate use of the system may be a concern, the NIHB Program will seek the consent of clients to share their personal information with their health care provider. This consent may be provided verbally or in writing. The NIHB Program may refuse to pay for prescriptions until a patient safety plan is in place.

The NIHB Privacy Code can be found on the Health Canada website, or by contacting your regional NIHB office.

Contact Information

The FNIHB Regional Offices and First Nations and Inuit Health Authority offices listed below can be contacted for detailed information about the NIHB Program. You can also find information about the program by searching the Health Canada web site.

FNIHB Pacific Region

First Nations and Inuit Health Branch
Federal Building
757 West Hastings Street, Suite 540
Vancouver, British Columbia V6C 3E6
Toll free: 1-800-317-7878
In Vancouver: (604) 666-3331

Northern Secretariat (Yukon Region)

First Nations and Inuit Health Branch
Elijah Smith Building
300 Main Street, Suite 100
Whitehorse, Yukon Y1A 2B5
All locations: (867) 667-3942 or 667-3974

Northern Secretariat (NWT and Nunavut)

First Nations and Inuit Health Branch
60 Queen Street, 14th floor
Postal Locator 3914A
Ottawa, Ontario K1A OK9
Toll free: 1-888-332-9222

FNIHB Alberta Region

First Nations and Inuit Health Branch
Canada Place
9700 Jasper Avenue, Suite 730
Edmonton, Alberta T5J 4C3
Toll free: 1-800-232-7301

FNIHB Saskatchewan Region

First Nations and Inuit Health Branch
Chateau Tower
1920 Broad Street, 18th floor
Regina, Saskatchewan S4P 3V2
In Regina: 780-8267, 780-8257, 780-6254, 780-5438 or 780-5566

FNIHB Manitoba Region

First Nations and Inuit Health Branch
Stanley Knowles Federal Building
391 York Avenue, Suite 300
Winnipeg, Manitoba R3C 4W1
Toll free: 1-800-665-8507
In Winnipeg: 983-8886

FNIHB Ontario Region

First Nations and Inuit Health Branch
Emerald Plaza
1547 Merivale Road, 3rd floor
Postal Locator 6103A
Nepean, Ontario K1A OL3
Toll free (From area codes 416 & 905): 1-800-640-0642
All other locations: (613) 952-0093

FNIHB Québec Region

First Nations and Inuit Health Branch
Complexe Guy-Favreau
200 West René Lévesque Boulevard
East Tower, Suite 216
Montréal, Québec H2Z 1X4

Vision care, drugs, medical supplies and equipment:
Toll free: 1-877-483-1575
In Montréal: (514) 283-1575

Medical Transportation:
Toll free: 1-877-583-5973
In Montréal: (514) 283-5973

Crisis Intervention Counselling:
Toll free: 1-877-583-2965
In Montréal: (514) 283-2965

Dental Services:
Toll free: 1-877-483-5501
In Montréal: (514) 283-5501

FNIHB Atlantic Region

First Nations and Inuit Health Branch
Maritime Centre
1505 Barrington Street
15th Floor, Suite 1525 Halifax,
Nova Scotia B3J 3Y6
Toll free (From area codes 902, 506 & 709): 1-800-565-3294
In Halifax: 426-2656

Inuit Tapiriit Kanatami

NIHB Coordinator
170 Laurier Avenue West, Suite 510
Ottawa, Ontario K1P 5V5
(613) 238-8181

Assembly of First Nations

AFN Health Secretariat
1 Nicholas Street, Suite 1002
Ottawa, Ontario K1N 7B7
(613) 241-6789