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Non-Insured Health Benefits

 

News Update

January 15, 2015

Qalipu launches pilot to improve Medical Transportation Benefit claims processing service

As of January 2nd, members of the Qalipu Mi’kmaq First Nation (QMFN) from the wards of Gander Bay, Glenwood and Exploits who are living in Atlantic Canada, should see a faster return on their Medical Transportation Benefit claims thanks to a pilot project that will significantly reduce wait times on claim processing.

The Medical Transportation Benefit is an element of the Non-Insured Health Benefits (NIHB), a health plan which all members of QMFN, and other First Nations and Inuit in Canada, are entitled to receive.   The benefit provides financial compensation, based on rates set by Health Canada, for the cost of travel, meals, and accommodations to members with a health condition requiring travel to locations outside their communities to receive necessary medical services.

Members who are eligible for the benefit may submit a claim to have a portion of their costs recovered.  At present, Qalipu members in Atlantic Canada taking advantage of this benefit complete a form and send it to Halifax to be processed by a representative of Health Canada.

“The Halifax office handles claims for all  First Nations and Inuit of Atlantic Canada, not just Qalipu, so members, in the past, have experienced wait times as long as 6-8 weeks.  Qalipu has determined that we can better serve our members by offering this service through our own offices, right here in Newfoundland.”  Says Brendan Sheppard, Chief of the Qalipu Mi’kmaq First Nation.  “The guidelines of the benefit will remain the same however, taking on this role will improve not only the timeliness of claims processing for members, but also allow Qalipu greater independence and fiscal efficiency.”

To test the process of handling, and paying out, these claims in-house, the Qalipu First Nation has begun a three month pilot program focused on managing claims of the Medical Transportation Benefit.  The pilot will allow claims processing for members belonging to the wards of Gander Bay, Glenwood and Exploits who are living in Atlantic Canada, to be completed directly from Qalipu’s Corner Brook office.

Howard Thistle, Non-insured Health Benefits Navigator notes, “For Qalipu, due diligence is important and that means testing the process first.  Following an evaluation of the pilot in April, 2015, we will advise members when we anticipate being able to offer the service to all Qalipu First Nation members living in Atlantic Canada.”

Members of the Qalipu First Nation who are not a part of the wards participating in this pilot project are reminded to continue using the system already in place which means sending their claims to the regional office that corresponds with their location.   Members in the pilot project wards can send their claims to this address: Jody Davis, Qalipu Mi’kmaq First Nation Band, 3 Church Street, Corner Brook, NL, A2H 2Z4

To find more details on who, and what, is covered with this benefit please view the Medical Transport Q&A or contact Howard Thistle, toll-free, at 1-855-675-5743

 


 

What is the Non-Insured Health Benefits Program?

Health Canada provides eligible First Nations people and Inuit with a specified range of medically necessary health-related goods and services when they are not covered through private insurance plans or provincial/territorial health and social programs.

Non-Insured Health Benefits (NIHB) include prescription drugs, over-the-counter medication, medical supplies and equipment, short-term crisis counselling, dental care, vision care, and medical transportation.

 

Who is an Eligible Recipient?

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

An eligible recipient must be identified as a resident of Canada and one of the following:

  • A registered Indian according to the Indian Act;
  • An Inuk recognized by one of the Inuit Land Claim organizations; or
  • An infant less than one year of age, whose parent is an eligible recipient.

When recipients are eligible for benefits under a private health care plan, or public health or social program, claims must be submitted to these plans and programs first before submitting them to the Non-Insured Health Benefits Program.

 

“Nearest Provider”

As one of the principles of the Canada Health Act, individuals can access any appropriate Medicare service, regardless of the location of that service.    However, NIHB provides a finite range of benefits, and may assist with transportation costs for First Nation individuals to travel to the “nearest provider” of a medically necessary service, when that service is only available outside the person’s local home area.    NIHB does not cover transportation costs for individuals to travel to a service provider located within 35 km of their home.

This is an outline of what NIHB means by the “nearest provider”.    If your family physician or GP refers you to a specialist, NIHB considers the nearest provider to be the specialist who has an office closest geographically to your home, who is licensed in NL for that specialty.

As an example, if a GP refers an individual who lives in Deer Lake (52 km from Corner Brook) to a general surgeon, then the nearest provider is one of the 6 physicians who practise as licensed general surgeons in Corner Brook.   If the general surgeon in Corner Brook sees this individual and considers that they need to be assessed by another  more specialised general surgeon in St John’s, then that is considered by NIHB as a ‘tertiary referral’ and the transportation to St John’s would be covered.   However, if the GP refers the individual straight to a general surgeon in St John’s, then NIHB will only cover transportation costs for the individual to travel to see the nearest general surgeon in Corner Brook.  The same principle applies to all groups of specialists.

If a GP says that you need to see a specialist urgently, the ‘nearest provider’ principle still applies. The GP can communicate with the nearest specialist to explain the urgent clinical situation, since specialists arrange to see clients with urgent needs more quickly than those with less urgent medical needs.  However, an individual may always choose to travel further from their home, rather than see the nearest provider.

The same principle applies to tests, investigations and procedures, since not all hospitals and clinics perform the same range of tests, investigations and procedures.

PLEASE NOTE: Regular dental cleanings have to be performed in a Dental clinic with a dentist on staff. NIHB does not cover independent Hygienist ( Hygienist who have their own clinic). This does not Apply to members who live in Alberta.

 

FAQ’S Non Insured Health Benefits

1. If I have an existing Private Insurance and they cover 80% of my Medical expenses would NIHB cover the remaining 20%?

Yes, they would cover the remaining expenses if the item is an eligible benefit under NIHB.

 

2. Should I cancel my private Insurance?

It is suggested that you keep your existing Insurance in case NIHB does not cover expenses that are covered by your existing insurance.

 

3. If I am a seasonal worker will I still be covered by NIHB?

When you become a member of a band you are covered with NIHB the entire time of your membership as a Band Member as long as you are living in Canada and have provincial/territorial health coverage.

 

4. Are Generic Drugs covered as an alternative?

Yes.

 

5. Are Insulin Pumps covered?

Insulin Pumps are an eligible benefit and requests for Insulin Pumps are reviewed on a case by case basis.

 

6. Are orthotics shoes covered?

Only if they are custom made. Due to specific criteria that need to be met by the provider and the prescriber, NIHB should be contacted prior to purchasing custom orthotic shoes to ensure eligibility.

 

7. Are you covered with NIHB if you’re outside the country?

No, you are not eligible to receive benefits through the NIHB program if you are outside of Canada. However, the cost of private health insurance for approved students and seasonal migrant workers may be considered.

 

8. Are medical supplies and equipment covered?

Yes if they are prescribed by a Medical Doctor/Nurse Practitioner and if the item is an eligible benefit.

 

9. If my home needs wheel chair accessibility is this covered?

No, not by Health Canada. You may want to contact Aboriginal Affairs and Northern Development Canada (AANDC) to see if this is covered through their program. Please contact AANDC at 1-800-567-9604.

 

10. Is NIHB covered across Canada?

Yes, NIHB is a National program across Canada. However, there may be differences in the rates paid due to the various agreements negotiated with the various provinces /territories.

 

11. Are private rooms in a Hospital covered?

No, coverage of hospital rooms is done through provincial insurance.

 

12. Is Insurance coverage co-ordinated?

Yes, you submit to your private insurance first then submit the remainder amount to the NIHB. The request will be reviewed and eligible benefits may be reimbursed.

 

General Reimbursement (PDF, 94 KB)
Medical Transportation Reimbursement
(PDF, 33 KB)
Request for Non-Medical Escort (PDF, 87 KB)
Additional Appointments Form (PDF, 21KB)
NIHB – Updated Private Vehicle Kilometric Rates (PDF)
Changes in coverage for Proton Pump Inhibitors (PPIs) (PDF)
Travel Rates Update (PDF)

 

For additional information please access the information below or contact

Non-Insured Health Benefits Navigator (PowerPoint Presentation, 729 KB)
Centralization of Non-Insured Health Benefits (NIHB) Dental Predetermination Services in Ottawa
(PDF)
Newsletter – Opioid Dispensing Frequency – February 2014 (PDF)
Diabetic Test Strips – Update for Clients (PDF)
Non-Insured Health Benefits (NIHB) Program: A Guide for NIHB Clients on Blood Glucose Test Strips (PDF)

 

 

Howard Thistle
NIHB Navigator
Qalipu Mi’kmaq First Nations
45 Spruce Aven
Glenwood, NL  A0G 2K0
Phone: 709-679-5743

Toll Free: 855-675-5743
Email: hthistle@qalipu.ca

ATTENTION

For Members who are experiencing a Medical Emergency after regular work hours and need assistance please contact:

Katie Dicker-Senior Aboriginal Patient Navigator
Health Science Center
Office: 709 777 2199
Fax: 709 777 2210
E-mail: Katie.dicker@easternhealth.ca

Or

Solomon Semigak-Aboriginal Patient Navigator
Health Science Center
Office: 709 777 2110
Fax: 709 777 2210
E-mail: Solomon.semigak@easternhealth.ca