Access to NonInsured Health
Benefits
(NIHB)
Outline
• Overview of each service
• Different strategies to help your client access the NIHB Program
• Appeal process
• Health care liaison agent
• Joint review of the NIHB Program and future changes
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Drug benefits
• Drug Exception Centre (DEC) – Ottawa
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Analyzes and authorizes drugs and appeals
Serves all FN across Canada
Open from 8:00 a.m. to 6:00 p.m. from Monday to Friday
Can only be contacted by physicians and pharmacists
• Exclusion of FN by the RAMQ drug insurance plan
• List of drugs covered by NIHB compared to the RAMQ
• Emergency supply (7 days)
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Drug classification
Drug categories
Examples
Acetaminophen, Ibuprofen, Gravol, Penicillin,
No
Codeine, Fentanyl, Lyrica, Pantoloc, Concerta
Yes
Biphentin, Synvisc, Strattera, Oxyneo
Yes
Daxas, Sativex, Victoza, Ultram
Yes
Health Canada requires that the
client file an appeal request to
review whether the drug
reimbursement will be approved
Yes
In order to ensure that the drug is
in fact an exclusion
1- Included on the list
Heparin, Prozac
Open benefits (covered
without restriction)
2- Limited use
3-Exceptions
4- Not covered
5-Exclusions
Should the pharmacist contact the
DEC for authorization to charge?
Imovane, cough syrup with codeine, antiobesity agent, vaccines related to travel
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Prescription path – RAMQ
Patient
Prescribing physician
Sends a single
authorization form
Pharmacy
RAMQ
The RAMQ authorizes the
prescription number
The client obtains his/her
drug
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Prescription path – NIHB
Prescribing physician
The patient brings
his/her prescription
The physician sends
the form to the Drug
Exception Centre
The pharmacy must
submit an
authorization request
The Drug Exception
Centre sends a
specific form for each
exception or limited
use drug
Drug Exception
Centre in Ottawa
Analysis
Authorized
The client
obtains his/her
drug at no cost
Not authorized
•Get the prescription changed
•Pay for the prescription
•Initiate an appeal process
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Drug access problems
• The pharmacist does not contact the DEC
• The physician does not return the duly completed form
• The access criteria for exception drugs are not known
• Poor synchronization of the computer systems
Express Script Canada: 1-888-511-4666
• Newly statued people (McIvor, Descheneaux decision)
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Dental care
• Centralized in Ottawa since 2013 – Dental Predetermination Centre
• Customer service: 1-885-618-6291
• Fast authorization for basic care (cleaning, fillings)
• For care that requires pre-authorization, everything is done by mail
(dent-29 form, x-rays, periodontal chart, etc.)
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Dental care access problems
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Very cumbersome administration+++
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A lot of mailing back and forth (missing information)
• Many dentists no longer serve the FN clientele or seek payment in
advance for services
• Insufficient reimbursement from Health Canada
• Important to make the client accountable for their choice of dentist
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Orthodontic services
• Centralized in Ottawa –
Orthodontic Review Centre: 1-866-227-0943
• Postal delivery only (treatment plan, molds, x-rays, etc.)
• Orthodontic policy lacks precision
Criteria: malocclusion associated with a functional disability
• Low rate of treatment approval
• Many orthodontists no longer serve First Nations or ask them for
payment in advance or to take care of the predetermination steps
themselves
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Medical supplies and equipment
(MSE)
• Predominantly regional administration (preauthorization)
• Request processing centre: 1-877-483-1575
• Lots of MSE require preauthorization (forms, tests, occupational
therapy assessments, etc.)
• Suppliers collaborate fairly well but complain about the
administrative burden
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MSE access problems
• Often exclusions from the program (grab bars, adaptive footwear,
etc.), nothing to be done
• Prescribers are unaware of the criteria for each MSE
• Incomplete preauthorization file (test results, forms)
• Unfamiliarity with provincial health programs
(Tool: guide developed by the Office des personnes handicapées du
Québec (OPHQ))
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Medical transportation (MT)
• In Quebec: administered by the FN communities
• Contribution agreement
• Offers a certain amount of flexibility
• Health Canada provides training on the framework
• Tool: decision tree
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MT access problems
• Double escorts
• Stay for an indefinite duration
• Obligation to access the nearest professional
• Border communities
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Vision care
• Authorization and billing using a single form
Access problems
• Insufficient reimbursement rate
• Eye drops
• Additional testing authorizations for diabetics or other diseases
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Appeal process
• Three levels of appeal for all services
• Sent by mail or fax
• Signed letter from the client asking for a review of their file
• Medical justifications from the prescriber
www.cssspnql.com
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Drug appeal process
• Almost always for exception drugs
• In the explanatory note:
• Diagnosis
• Why is it the best treatment for the client?
• Special medical condition?
• Treatments previously tried
• Side effects
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Dental appeal process
• Dental Predetermination Centre: 1-855-618-6291
• The dentist must return the entire predetermination file by mail
with an additional explanatory note.
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Orthodontic appeal process
• The orthodontist must mail the same file as during the
predetermination (treatment plan, molds, etc.)
• Additional note from a specialist assigned to the file can be a good
idea (maxillofacial surgeon)
• Files are analyzed once per month
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MSE appeal process
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The same documents as for the predetermination must be sent
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Make sure that the file is complete (tests, etc.)
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Analysis on a case by case basis
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Navigator (liaison agent)
• Supports the community workers:
• Appeal process (letter drafting)
• Information on access to the program (how can the
services be accessed?)
• Contacts the professionals
• Contacts Health Canada
• Identifies recurring access issues
• Direct support for clients when referred
• Develops tools (e.g.: Guide to procedures for accessing health services
(GPS))
• Advocates on behalf of FN in disputes
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NIHB joint review
• 2012: Chiefs’ Assembly resolution
• 2014: Commitment from the Minister of Health, Rona
Ambrose
• 2015: Start of the work (national process)
• 2016: Participation of the provinces (regional process)
• 2017: Development of recommendations
• 2017-2018: Implementation plan
The FNQLHSSC is committed to keeping you informed of any
changes that are made to the program.
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Examples of recommendations
Drugs:
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Automatic approval for exception renewals
Make public the criteria for exception drugs
Allow for retroactive reimbursement (appeal process)
Change the computer note that states “not covered” in
the billing system of the pharmacists
• Infant formula
• Test strips for diabetics
• Drugs for cancer and diabetes
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Examples of recommendations
MSE:
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HC must follow up with suppliers to complete the client file
Include the ambulatory clientele in the wound care project
VAC pump rental reimbursement
Authorize nurses to prescribe and justify any overflow for
incontinence supplies
• Walking boots
• Compression stockings
• Set MSE
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Examples of recommendations
Dental:
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Decentralization of the predetermination services
Standardized form
Computerize the systems (electronic delivery)
Denture renewal every 5 years
Crown: allow coverage of new materials and ease the
eligibility criteria
• Reimburse all the amounts set out in the ACDQ grid
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Examples of recommendations
Medical transportation:
• Automatically assign an escort for elders (over age 60)
• Allow community nurses to prescribe two escorts when
the situation warrants it
• Reimburse MT for all care and services that are part of
the provincial service offer
• Allow FN to consult a professional who complies with
Health Canada’s rates in cases of overcharging even if
that professional is not the closest to them
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Questions or comments?
Jessie Messier
418-842-1540, ext. 2705
[email protected]
www.cssspnql.com
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