Non-Insured Health Benefits

NIHB Eligibility Criteria

(Non Insured Health Benefits – Eligibility Criteria)

Health Canada, First Nations, and Inuit Health criteria for eligibility to access the NIHB Program:

Registered First Nations individuals (Please Note: You must register your child with the Indian Registrar (DIAND) within the first year of birth, or they may not be eligible for NIHB Benefits after they turn 1 year of age)

• Children up to one year of age of Registered individuals
• Must be registered or eligible for registration with a provincial/territorial health insurance plan (OHIP)
• Resident of Canada

Benefits Outside of Canada

(Non-Insured Health Benefits Coverage)

The NIHB Program will cover the cost of benefits outside of Canada if you are attending school, employed or require approved medical treatment outside of Canada. The following items are covered as a benefit and include:

Private health insurance premium costs (for approved students, migrant workers and their legal dependents) will be reimbursed with proof of attendance at recognized institution or place of employment

Medical Transportation (for eligible clients when medically referred and approved by provincial or territorial health care plan) may be covered, click here for more information.

To ensure you are eligible for a benefit, and do not end up with out-of-pocket expenses for a service that was provided to you by one of the NIHB Service Providers, please ask the Service Provider if:

• They bill directly to NIHB
• If the service is an eligible benefit within the NIHB Program

If you still have further concerns and/or questions in regards to your eligibility for a service provided under the Non-Insured Health Benefits please call the NIHB Client Information Line at: 1-800-640-0642; and for information on Dental: 1-888-283-8885.

NIHB Areas of Coverage

Drugs

The NIHB Drug Benefit List (DBL) provides a listing of the drugs eligible under the NIHB Program. This list in not an all inclusive list, your pharmacist will be able to provide you with what is covered under the NIHB benefits. Examples of covered drug benefits are:

• Rescription Drugs
• Over-the-Counter (OTC) Drugs
• Open Benefit Drugs
• Limited Use Drugs
• Chronic Renal Failure Medications/Supplements
• Palliative Care Medications/Supplements

IF YOU HAVE BEEN TO THE PHARMACY AND HAVE BEEN TOLD TO PAY AS THE DRUG IS NOT COVERED, PLEASE ASK THE PHARMACIST TO FORWARD THE PRESCRIPTION TO THE DRUG EXCEPTION CENTRE FOR PROCESSING.

This process has to take place before an appeal for coverage can be done.

Ontario Drug Benefits (ODB)

If the drug is NOT listed on the ODB formulary:

The primary physician can send a request to the Ministry of Health and Long Term Care (MOHLTC) to cover the cost of the drug

The Ministry will review the request and let the physician know of the decision
The physician will then contact the client

For more information, click here.

Dental

The NIHB Dental Policy Framework (2005) and the NIHB Provider Guide for Dental Benefits (2009) define the terms, conditions, policies and benefits under which the NIHB Program will cover dental services. This is not an all inclusive list, your dentist will have a complete list.

For more information, click here.

Eye & Vision Care

All eye & vision care services requires prior approval to ensure client eligibility. Your eye & vision care provider will have a complete list. Examples of covered eye & vision care benefits are:

Eye Exams

• One routine eye exam ($43.80) every 2 years – ages 19 to 64 (OHIP covers exams for those 20 years & under and 65 years & over)

Eye Glasses

• Under 18 years – 1 pair every 12 months18 years and over -1 pair every 24 months
• Frames ($50 contribution paid toward frames- Effective May 1, 2011)

Other items that may be covered, but require medical justification include:

• Contact lenses with one back-up pair of glasses
• Polycarbonate lenses for monocular clients

For more information, click here.

Medical Supplies & Equipment (MS&E)

Eligibility

• All items require a written prescription from a Physician, Nurse Practitioner, or other NIHB recognized licensed prescriber
• Some items require prior approval
• Frequency limitations may apply
• Exceptions may be considered on a case by case basis with written medical justification
• Consideration is given to renting versus purchasing equipment if that is a viable option based on the client’s condition

Categories

• Audiology (hearing aids)
• Bathing and Toileting Aids
• Environmental Aids (dressings)
• Lifting and Transfer Aids
• Miscellaneous Supplies
• Mobility Aids (walkers, wheelchairs)
• Orthotics and Custom Footwear
• Oxygen and Respiratory Supplies and Equipment
• Pressure garments (stockings, socks)
• Prosthetics (eye, breast, limb)
  Urinary Supplies and Devices (catheter, incontinence)

Ontario Assistive Devices Program (ADP)

The ADP program is through the (MOHLTC) and is available to all Ontario residents ADP will cover up to 75% of cost for medical equipment and supplies.

The ADP and NIHB programs have eligibility criteria and guidelines that need to be followed. Once these criteria and guidelines are met the two programs will be utilized to best meet the needs of the individual. Your health care professional/service provider will have the complete list of criteria and guidelines and should coordinate benefits between the two programs to ensure that you have maximum coverage.

NIHB program will cover the 25% fee of eligible and approved NIHB items

Please Note: If the item is fully covered under a public/private health care plan, NIHB will not approve coordination of benefits, nor requests for co-payment to upgrade the quality of the item

For more information, click here.

Medical Transportation

or in the community of residence.

• Diagnostic tests and medical treatments covered by a provincial plan
• Access to Non-Insured Health Benefits (approved vision care, dental, mental health)
• Ambulance services above OHIP coverage will be invoiced to the client – the client may contact the service provider with the 10-digit status number, and the provider will bill the NIHB Program directly

Long distance medical travel may include travel to the health services listed below.
(Prior approval is required through First Nations and Inuit Health):

• Access to alcohol, solvent, drug abuse and detox treatment
• Access to Traditional Healers
• Assistance with meals and accommodation based on the established regional rates
• Escorts (approved as per the Framework)

Signed and dated confirmation of attendance and original receipts must be submitted for reimbursement.

In emergency situations, post approval may be granted (if consistent with the Framework)

For more information, click here.

Short-term Crisis Intervention/Mental Health Counselling

Medical or self-referral

Mental Health Professional must be an approved, registered provider with Health Canada
Prior approval is required (which will be submitted by your Mental Health Professional)
Up to 2 hours will be covered for the development of an assessment treatment plan
Approval for up to 15 one hour sessions (with a possible 5 hour maximum extension)

For more information, click here.

Other-Chiropractic Care

NIHB will fund clients up to a maximum of $150.00 per fiscal year (April 1 to March 31) for the chiropractic sessions

• A medical doctor / nurse practitionerës referral is required.
• Clients may submit their original prescription and receipts to the Regional office for reimbursement

Please Note: The client is responsible for payment of the co-payment portion, previously known as the OHIP share (Average cost is $75.00 for an initial assessment and $45.00/ treatment)

For more information, click here.

Client Reimbursement

When a client does pay directly for goods or service, they may seek reimbursement from the NIHB Program. Requests must be made on a Client Reimbursement Form, within one year from the date of service or date of purchase. Requests for reimbursement of eligible benefits must also include:

• Recipients name, address, status number, First Nation and date of birth
• Original receipt with cost breakdown
• Copy of prescription

Click here for the Client Reimbursement Form.

Appeals

EVERYONE HAS THE RIGHT TO APPEAL A DENIED BENEFIT!

When coverage for a benefit through the Non-Insured Health Benefits (NIHB) Program has been denied, the client or parent/guardian of the client has the right to appeal the decision

There are three levels of appeal available which only the client or parent/guardian can initiate. In order for a case to be reviewed as an appeal, a letter from the client or parent/guardian, accompanied by supporting information from the provider or prescriber must be submitted to the Non-Insured Health Benefits Program

APPEAL PROCESS for Dental, Eye & Vision Care, Medical Supplies & Equipment, Medical Transportation, and Short-term Crisis Intervention Mental Health Counselling

There are 3 levels of appeal under the NIHB Program:

Level I – Director NIHB / Ontario Region
Level II – Regional Director
Level III – Director General, NIHB

***Supporting and new medical documentation is required at each level.

APPEAL PROCESS for Drugs and Orthodontics

There are 3 levels of appeal under the NIHB Program:

Level I – Director, Benefit Review Services
Level II – Director, Benefits Management
Level III – Director General, NIHB

***Supporting and new medical documentation is required at each level.

For more information, click here.