A Guide for First Nations in Ontario: Navigating the Non-Insured Health Benefits & Ontario Health Programs Benefits

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A Guide for First Nations

in Ontario:

Navigating the Non-Insured Health Benefits & Ontario

Health Programs Benefits

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TABLE OF CONTENTS

INTRODUCTION

... 2

IMPORTANT CLIENT INFORMATION

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ELIGIBLE RECIPIENTS

... 3

QUESTIONS AND ANSWERS

... 3

DENTAL

... 5

ORTHODONTICS

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DRUGS

... 6

MEDICAL SUPPLIES AND EQUIPMENT

... 8

MEDICAL TRANSPORTATION

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VISION CARE

... 12

SHORT-TERM CRISIS INTERVENTION MENTAL HEALTH COUNSELLING

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APPEALS

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CLIENT REIMBURSMENT

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ONTARIO HEALTH PROGRAMS BENEFITS

... 18

ONTARIO ASSISTIVE DEVICES PROGRAM

... 20

GLOSSARY OF TERMS

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INTRODUCTION

The Health Coordination Unit (HCU) and the Ontario Chiefs Committee on Health (OCCOH) both saw the need for this guide to be developed to assist First Nations people living in Ontario to understand the eligible health benefits and services under the federal and provincial programs. This guide is a tool to access Health Canada’s Non-Insured Health Benefits (NIHB) benefits and Ontario’s health program benefits and services and does not necessarily reflect endorsement by Chiefs of Ontario (COO). There have been two versions of the guide produced. The original was followed by this condensed version and provides more information. These two versions are both available on the COO’s website at http://www.chiefs-of-ontario.org/

Health Canada-First Nations and Inuit Health Branch (FNIHB) implements the NIHB Program for eligible First Nations people. There are a number of health programs and services costs that can be covered through the NIHB system. When health issues arise or health costs are a concern, this guide will provide information on what benefits and services can be accessed or covered. There are both resources and limits to be aware of and this guide will help to address some of the needs and problems that arise.

The NIHB Program may provide medically necessary goods and services when they are not covered by provincial or other third party health plans. NIHB Program policy states it is payer of last resort. This means that where there is a duplication of benefits, NIHB clients are expected to access their other health care coverage first. Other health care coverage which may duplicate NIHB benefits, depending upon the nature of the claim, includes the following:

 Employer insurance plan;  Private health care plan; and

 Ontario health and social programs (e.g. Ontario Assisted Device Program, Ontario Works).

In some cases of duplicate coverage, claims must be coordinated between the other insurer and the NIHB Program.

Service providers may ask, on behalf of NIHB, if you have other insurance

coverage. If you are certain that you have another plan which duplicates coverage for the goods or services that you are accessing, then NIHB expects you to tell the service provider. This will result in the claim being submitted to your other insurer first. If there is any portion of the claim that is not covered by your other insurer, you may be required to personally pay the service provider and apply for possible reimbursement from NIHB. If you are unsure whether you have another plan, or whether the other plan provides duplicate coverage for the goods or services that you are accessing, you should tell the service provider that you do not know about other coverage.

These benefits include:  Dental;

 Drugs;

 Medical Supplies and Equipment;  Medical Transportation;

 Vision Care;

 Short-Term Crisis Intervention Mental Health Counselling;  Benefits Outside of Canada; and

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The Ontario health programs fall under the Ministry of Health and Long-Term Care (MOHLTC) and these programs are to also help the people of Ontario to improve and maintain their health.

IMPORTANT CLIENT INFORMATION

When you call or see a health care service provider, you need to make sure you are eligible for benefit coverage for the health program, service, or product you need. You do not want to end up with out-of-pocket expenses for something that was provided to you by one of the NIHB service providers.

Please ask the service provider if:

1. He/she bills directly to the NIHB Program; and/or

2. If the service is an eligible benefit within the NIHB Program.

If you have any concerns or questions about your eligibility for a medical item, supply, service, and/or travel provided under the NIHB Program, please call: 1. Your local community health worker who works with the NIHB Program; 2. NIHB Client Information Line at 1-800-640-0642; this number is for questions

for all benefit areas except dental benefits;

3. For all dental benefit questions, please call the NIHB Dental Client Information Line at 1-888-283-8885; and

4. NIHB Service Provider Line at 1-800-881-3921; this number is for service provider information. If your community sends in prior approval requests for medical transportation on behalf of a client you may call this line for information on the approval request. This NIHB Service Provider Line includes information for vision care, medical supplies and equipment, and short-term crisis

intervention mental health counselling.

To view NIHB benefit information online, you can visit the Health Canada website at www.hc-sc.gc.ca

ELIGIBLE RECIPIENTS

In order to be eligible for any of the NIHB Program Benefits, you must be recognized by Health Canada as an eligible recipient.

Health Canada describes an eligible recipient as someone who is:  A registered status-Indian according to the Indian Act; and

 An infant less than one year of age, whose parent is an eligible recipient. To register your child for his Indian Status contact Aboriginal Affairs and Northern Development Canada (AANDC) at: 1-800-567-9604

QUESTIONS AND ANSWERS

1. How long does the appeal process take?

Answer: There are three levels of appeal. This means you can appeal a denied benefit three times. Each individual level of appeal can take up to three months. This three month timeline starts on the date the appeal is sent in and ends the date an approval or denial letter is mailed back to the client. Within the NIHB Program, the length of time an appeal process lasts depends on such variables as when the appeal was received, case load, and meetings dates for the appeal review panel.

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2. How long does it take for a client to receive a reimbursement? Answer: Client reimbursement request should only take between six and eight weeks. This six to eight week timeline starts the date the reimbursement was sent in to the date the reimbursement request is mailed back to the client. This timeline is also dependent upon all the required information being included and completed. For more information on client reimbursement request and how to obtain a Client Reimbursement Request Form, contact Health Canada at 1-800-640-0642.

3. How long does it take to get an approval completed for short-term crisis intervention mental health counselling?

Answer: Prior approvals for short-term crisis intervention mental health counselling benefit can take up tofour business days. Your service provider will fax the prior approval request to FNIHB. It is then reviewed by the NIHB consultant. The decision will then be faxed back to the service provider within four business days. This timeline also depends on the service provider providing all the information needed.

4. What services are included in “Benefits Outside of Canada”? Answer: Benefits outside of Canada include coverage of the cost of private insurance premiums and medical transportation. FNIHB NIHB Program will cover the cost of private insurance premiums for approved students, migrant workers and their legal dependents. Medical transportation costs are also covered for eligible clients when medically referred and approved by Ontario Health Insurance Plan (OHIP). For more information on benefits outside of Canada, please refer to the “NIHB Guide” on COO’s website at

www.chiefs-of-ontario.org or contact Health Canada at 1-800-640-0642.

5. Is chiropractic care covered under the NIHB Program?

Answer: First Nations and Inuit Health Branch–Ontario Region (FNIHB-OR) may cover the cost of chiropractic care up to$150.00 per fiscal year. (April 1 to March 31). NIHB co-pays a small portion of the fees. $13.00 for the assessment and $11.75 per treatment and remaining balance is paid by the client. For more information on chiropractic care, please refer to the “NIHB Guide” on COO’s website at

www.chiefs-of-ontario.org or contact Health Canada at 1-800-640-0642.

6. How do I obtain NIHB benefits?

Answer: To obtain NIHB benefits, you will be required to provide (1) your personal information to determine eligibility. To access dental and vision benefits, you may ask for services from a provider of your choice who is registered with the NIHB Program. For access to drug and medical supplies and equipment benefits, you need to obtain a prescription from an authorized and recognized medical professional. To access medical transportation and short-term crisis intervention mental health counselling benefits, you need to obtain a referral from a medical professional. For counselling, you may self-refer. Finally, if the items and services are not listed as “Open Benefits”, prior approval or post-determination will be required. For more information on how to obtain the benefits, please refer to the “NIHB Guide” on COO’s website at www.chiefs-of-ontario.org

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DENTAL

The NIHB Program may cover some or all of your dental services at the rates established on the First Nations Inuit Health Branch, Ontario Region (FNIHB-OR) payment schedule. The payment schedule might not cover the total cost of this service.

PLEASE NOTE

Who is eligible in providing Dental benefits?

NEEDS PROFESSIONAL

 Able to practise under their province; and

 Recognized and registered with the NIHB Program.

 Dentists;

 Dental specialists (endodontist, periodontist, prosthodontist, orthodontist);

 Denturists; and

 Registered dental hygienists. PLEASE NOTE

PLEASE NOTE

What services are covered and not covered under Dental benefits?

All covered items do not need approval ahead of time. Items not covered need to meet specific criteria and prior approval before work is done.

COVERED NOT COVERED

 Exams;

 X-rays;

 Cleanings;

 Root canals (adult back teeth);  Dentures (complete or partial); There are age restrictions for using anaesthetic. For simple extractions, sedation is covered for children under 12 years of age. For those 12 years of age and older sedation is not covered unless there is medical justification for the sedation or if more than two teeth are being surgically extracted.

Hospital procedures that your dental provider is recommending will be submitted to OHIP. The request will be assessed and/or approved by an OHIP adjudicator. If approved, all or some of the costs for the medically necessary procedure will be covered.

Dental providers who are registered with the NIHB Program should not ask for any payment up-front. You should ask them before they begin any service and/or treatment if they are registered with the NIHB Program and whether they direct bill to the NIHB Program. You need to know if they expect you to pay some or all of the cost yourself before they do any work. You need to find out if you can get reimbursed for any payments you make.

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 Preventive services (fluorides, sealants);

 Fillings;

 Root canals (adult front teeth);

 Denture repairs;

 Extractions (simple); and

 Emergency procedures (e.g. exam, x-ray, control for bleeding, trauma to mouth, surgical treatment/extractions, general anaesthesia, and relief for infection and pain as determined by your dental professional).

 Crowns (caps);  Extractions (surgical);  Orthodontics (braces);  Periodontal appliances; and  Anaesthetic.

PLEASE NOTE

EXCEPTIONS OR SPECIAL CASES  Exceptions will be made on a case-by-case basis.

ORTHODONTICS

There are a limited range of orthodontic benefits.

What services are covered and not covered under Orthodontic benefits?

 Orthodontic treatment to ensure dental health.

 Facial esthetics (e.g. significant crowding);

 Psychological purposes (e.g. self-esteem);

 Non-handicapping malocclusion (e.g. a bite that is not ideal, but still functional;  Temporomandibular disorders (e.g. jaw

joint problems);

 Skeletal discrepancies (e.g. jaws that are out of alignment due to the size of the jaw, not the teeth; most of these skeletal discrepancies are surgically corrected); and

 Cosmetic purposes.

DRUGS

Some or all of their drug benefits may be covered when prescribed by a licensed practitioner.

The lists mentioned above do not list every dental service that can be done. Your dental professional will have a complete list. It provides details about what can be covered or what is not covered under the NIHB dental services. You may contact the Client Dental Information Line at 1-888-283-8885.

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Who can prescribe eligible Drug benefits?

 Must be licensed and authorized to prescribe under their scope of practice under their province; and  Recognized and registered with the

NIHB Program.

 Medical doctor;  Medical specialist;  Nurse practitioner;  Dentist; and  Optometrist. PLEASE NOTE

PLEASE NOTE

What services are covered and not covered under Drug benefits?

Please note the covered items are not an all inclusive list. All items not covered are identified as “Exclusions”; therefore not included on the Drug Benefit List (DBL) and cannot be appealed.

 Prescription drugs (requires prescription and listed in the DBL;

 Over the counter drugs (OTC) and health products (requires prescription and listed in the DBL;

 Open benefits (does not have established criteria and does not requireprior approval);

 Limited use benefits (does not require prior approval for [1] multivitamins for children between the

ages of 0 and 6 and [2] prenatal vitamins for women between the

ages of 12 and 50; requires prior approval for benefits with [1] specific criteria which includes the

prescriber’s completion of the Limited

 Household products (e.g. regular soap and shampoos);

 Cosmetics;

 Hair growth stimulants;  Megavitamins;  Anti-obesity drugs;

 Alternative therapies (e.g. herbal medication and glucosamine);  Drugs with investigational/experimental

status;

 Fertility agents and impotence drugs;  Selected over-the-counter products (e.g.

children’s cough medication);  Vaccines for travel;

 Cough preparations containing codeine; and

The process for the prior approval of “Exception” is as follows:  The pharmacist contacts NIHB for approval;

 NIHB determines whether the request is an exception;

 NIHB forwards the Exception Drug Request Form for prescriber’s completion;

 Once completed, the Exception Drug Request Form is returned to the NIHB for processing; and

 If your drug is denied the decision may be appealed, please see page 14 for Appeals Process.

You are required to provide government issued identification (e.g. an Ontario driver’s license, health card, etc. ) to obtain a prescription for monitored drugs. You also need to provide your identification to the dispenser.

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Use Drugs Request Form and [2] quantity and frequency limitations;

 Non-benefit (not considered “Open Benefit” nor “Exclusion” and may be considered under the appeal process;

 Chronic renal failure benefits (requiresprior approval once to be an “Open Benefit”.

 Supplements [e.g. calcium products] necessary on a long-term basis and not included in the DBL are eligible; and

 Palliative care formulary (requires prior approval to be an “Open Benefit” every six months. Supplements that are not included in the DBL are eligible).

 Certain narcotics.

EXCEPTIONS OR SPECIAL CASES  When drugs are not an “Open Benefit” on the DBL;  When it is a “Limited Use” drug;

 When a prescriber has indicated “No Substitution” on your prescription;  When quantity and frequency limits exceed maximum allowable;  When an individual experiences an adverse reaction; and  When a generic drug (substitution) is available.

MEDICAL SUPPLIES AND EQUIPMENT

Some or all of the medical supplies and equipment may be provided when prescribed by a licensed practitioner. These include hearing aids, incontinence supplies, ostomy supplies, prosthetics, and other devices for assisted living.

PLEASE NOTE

Who can prescribe Medical Supplies and Equipment benefits?

 Must be licensed and authorized to prescribe under their scope of practice under their province; and

 Licensed physicians;  Medical specialist; and

 Licensed practitioner (e.g. nurse practitioner, audiologist).

 Prosthetics and Orthotics specialists What services are covered and not covered under Medical Supplies and Equipment benefits?

 Audiology equipment (e.g. hearing aids, such as behind the ear, custom made for ear and CROS/BiCROSS fittings);

 Bathing and toileting aids;

 Cushions and protectors;

 Assistive listening devices (excluding eligible hearing aid benefits);  Assistive speech devises (e.g. speech

enhancers);  Cochlear implants; Frequency and quantity limitations apply.

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 Environmental aids (e.g. dressings);

 Lifting and transfer aids;

 Miscellaneous supplies;

 Mobility aids (e.g. walkers, wheelchairs);

 Orthotics and custom footwear;

 Ostomy supplies and devises;

 Oxygen supplies and equipment;

 Pressure garments and orthotics;

 Prosthetics (e.g. breast, eye, limb);

 Respiratory supplies and equipment;

 Urinary supplies and devices (e.g. catheter, incontinence); and

 Wound dressings.

 Compression stockings (e.g. for short-term use, edema, post-operative);  Cosmetic items;

 Custom made mask for ventilation;  Education items;

 Electric/myo-electric limb prosthetics;  Exercise equipment/items;

 Experimental equipment;

 Foot wear products (e.g. from laser, optical scanning, computerized gait or pressure analysis systems);

 Grab bars (permanently fixed);  Hospital beds;

 Implants;

 Incentive spirometer;

 Oxygen which does not meet NIHB medical criteria (i.e. pain relief from migraines);

 Prosthetics (e.g. temporary for a surgical procedure);

 Respiratory equipment (e.g. in-patients in an institution);

 Scooters;

 Sport equipment/items; and  Work equipment/items. EXCEPTIONS OR SPECIAL CASES

 When supplies and equipment items are not on the Medical Supplies and Equipment Benefit List. These items may be covered on a case-by-case basis. They will require written medical justification and prior approval by the NIHB Program.

 Some of these items may be covered under Home & Community Care. Ask your Community Health Nurse for more information.

PLEASE NOTE

Medical Equipment guidelines for rental and warranty:

 May be leased or rented on a temporary basis (until long-term need is determined);

 Equipment may be replaced if needed;

 When equipment is rented, the agreement must include maintenance and repair costs;

 Some medical supplies and equipment may have an annual quantity limit and must be billed for no more than a three month time period. This includes all items (prior and no-prior approval items); and

 Warranties will be requested at time of approval. MEDICAL TRANSPORTATION

You may be eligible for assistance with the payment of transportation to the nearest appropriate health professional or health facility to access eligible medically necessary health services that cannot be obtained on the reserve or in the

Some medical equipment can be leased or rented. Coverage will be considered on a case-by-case basis. See following information.

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community of residence. This may include assistance with meals and

accommodation when these expenses are incurred while in transit for approved transportation to access medially necessary health services. Except in emergency situations, access to medical transportation benefits requires prior approval.

Access to medical transportation benefits may vary. Contact your community health worker for information on how to access medical transportation benefits.

If you live off-reserve or in a rural area, contact a local health worker to help you access medical transportation benefits. Your local urban Aboriginal health access centre can provide this information. You can call the NIHB Client Information Line at 1-800-640-0642 for information on how to access medical transportation benefits.

Who provides access to Medical Transportation benefits? PROVIDER

 First Nations and Inuit Health Branch regional offices;  First Nations health centres; and

 First Nations health authorities.

What services are covered and not covered under Medical Transportation benefits?

 Ground travel (private vehicle, commercial taxi, fee for service driver and vehicle, band vehicle, bus, train, snowmobile taxi, or ground ambulance);

 Water (motorized boat, boat taxi, or ferry);

 Air travel (scheduled and chartered flights, helicopter, air ambulance, or medevac);

 Coordinated travel;

 Emergency transportation;

 Access to traditional healers;

 Meals and accommodations;

 Client escorts (see “Please Note” box below for more information);

 Addictions treatments;

 Other medically necessary health services;

 Outside of Canada; and

 Reimbursement of travel expenses.

 Compassionate travel (e.g. approval for an escort for emotional support);  Appointments for individuals who are in

the care of federal, provincial or territorial institutions; persons who are incarcerated (staying in a detention facility, jail, or prison);

 Court-ordered treatment/assessment or as a condition of parole coordinated by the justice system;

 Medical appointments when travelling outside of Canada (unless approved by OHIP);

 Travel for clients residing in an off-reserve location where the appropriate health services are available locally;  Travel for third party requested medical

examinations (e.g. when requested by an employer);

 Return trip home in cases of an illness while away from home other than approved travel to access medically required health services;

 To pick up new or repeat prescriptions or vision care products;

 Payment of professional fee(s) for preparation of doctor’s note/document to support provision of benefits; and  Transportation to adult day care,

respite care, and/or interval/safe houses.

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EXCEPTIONS OR SPECIAL CASES  Emergency situations;

 Diagnostic tests for educational purposes;  Speech assessment and therapy;

 Medical supplies and equipment benefits where fittings are required and not available in the First Nations community or in the community of residence;  Methadone clinics;

 Preventative screening programs; and

 Other requests for travel are reviewed on a case-by-case basis with appropriate justification.

PLEASE NOTE

If you cannot attend your appointment, please let the FNIHBB NIHB office know. Contact your local First Nations health centre, nursing station, or the First Nations administration office for assistance.

If you do not contact FNIHBB NIHB office early as possible, you may be penalized for a “No Show.”

Section 6.2 (appointments) of the Medical Transportation Policy Framework states: “When a client does not attend a scheduled appointment and medical

transportation benefits have been provided, the client may have to assume the cost of the return trip or of the next trip to access medically necessary health services unless proper justification is provided to explain why the client was unable to attend or to notify the appropriate public carrier of the cancellation.”

Please choose a non-medical escort carefully.

The escort must be sure he/she has the time to travel with you. Only one escort may be approved. He/she must be able to help you in one of the following ways. When choosing an escort, he/she should be:

 A family member who has your consent to sign documents and/or has knowledge of your health history;

 A reliable community member. Someone who can physically take care of you and drive you to your appointments; and

 Someone who can translate for you (if applicable).

If you must leave your community longer than three months for medical

treatment, you may not be eligible for further medical transportation benefits. After three months, you may have to apply for assistance through other Ontario programs (e.g. Ontario Works, Social Housing Programs).

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Once you complete the medical appointment, have the medical provider complete a written confirmation form. He/she must confirm that you attended your appointment.

Please make sure that you:

 Use the Medical Transportation Form provided by your community as your written confirmation (if applicable);

 Hand in your written confirmation to your health centre, nursing station, or First Nations administration office (if applicable);

 Contact your health centre, nursing station, or the First Nations administration office for assistance if you need help; and

 Make sure this written confirmation or form is sent to FNIHB NIHB.

VISION CARE

Some or all vision care services may be covered when they are provided by a licensed practitioner.

PLEASE NOTE

When am I eligible for Vision Care Benefits?

 If you are under 18 years of age, you can get service every 12 months. It must be at leastone year from date of the last appointment;

 If you are over 18 years of age, you can get service every 24 months. It must be at least two years from date of the last appointment;

 Every 12 months if you have a medical condition that may affect your vision (e.g. diabetes). Additional follow-up exams may be required by your doctor;  If there is a change or correction in your vision. The doctor examining your

eyes will tell you if these changes have occurred; and  Changes include:

o A negative or positive of 0.50 diopter over the sphere cylinder

o A change in the axis greater than 15 degrees for cylinder power up to 2.00 diopters, or greater than10 degrees for a cylinder power greater than 2.00 diopters

o A change of at least 1.00 prism diopter vertically or at least 2.00 prism diopters horizontally.

PLEASE NOTE

Under the Vision Care Policy Framework the above noted changes must be met to be eligible for new eye glasses.

Vision care providers must be asked before they begin any services if they are registered with the NIHB Program and if they direct bill to the NIHB Program. It is important to know this information ahead of time. You need to know if they expect you to pay some or all of the cost yourself before they do any work. Find out if you can get reimbursed for any payment you make.

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Who is eligible to provide Vision Care benefits?

 Licensed optometrist;  Ophthalmologist ; and  Optician.

PLEASE NOTE

What services are covered and not covered under Vision Care Benefits?

 General eye and vision exams (NIHB will cover $43.80 towards the cost of an eye exam);

 Specific/partial eye exams;

 Follow-up exams partial and single procedure eye exams;

 Eyeglasses (this includes the lenses and $50.00 towards the cost of frames);

 Replacement eyeglasses/lenses (will not be replaced if lost or broken by misuse); and

 Eyeglass repairs.

 Progressive or trifocal lenses;  Photocromatic/photocromic lenses;  Implants;

 Refractive laser surgery;  Investigational or experimental

treatments;

 Vision exams required for

employment, sports activities, drivers tests, or third party requests (e.g. medical report);

 Vision training;

 Replacement or repairs as a result of misuse;

 Additional case for glasses/contact lenses;

 Contact lens solution products;  Cleaning kits;

 Sunglasses with no prescription;  Safety frames, sport lenses, or

professional use eyewear;  Eyeglasses or contact lenses for

esthetic purposes; and  Travel costs to pick up new

eyeglasses.

EXCEPTIONS OR SPECIAL CASES  Monocular;

 Replacement eyeglasses;

 Contact lenses (only when the doctor confirms after examination that you cannot wear eye glasses);

 Replacement of contact lenses;  Trial of bifocals;

 Tints and coatings for lenses; and

 Frames (flex frames, second set of frames, oversized frames).

Be sure to discuss the costs of your new eyeglasses (lenses/frames) with the service provider before he/she completes the order. There may be additional costs you have to pay above the NIHB coverage.

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SHORT-TERM CRISIS INTERVENTION MENTAL HEALTH COUNSELLING Some or all of mental health counselling may be covered when services are provided by an approved registered provider.

Who is eligible in providing Short-Term Crisis Intervention Mental Health Counselling benefits?

 Psychologist;

 Mental health therapist;  Clinical social worker; and  Traditional healer.

What is covered and not covered under Short-Term Crisis Intervention Mental Health Counselling benefits?

 Community services (approved [1] when cost effective for the mental health professional to travel into the community [includes fees and associated travel costs] and [2] in response to a community crisis);

 Individual and family counselling (covers [1] traumatic experience [crisis]; [2] an at-risk situation; and [3] when no other source of funds are available); and

 A maximum of 15 hours of counselling (approved and includes [1] assessment and [2] extensions if required [maybe provided at the service provider’s request]. Treatment sessions must be used within asix month period unless an extension [up to eight weeks] is requested by the service provider [additional report is not required]).

 Psychiatrist services;  Psychoanalysis;

 Situations such as (1) mandated by children’s aid society for parents; (2) children in care; (3) infants with delayed development; (4) court ordered; and (5) persons who are incarcerated [staying in a detention facility, jail, or prison];  Therapies such as (1) group; (2)

experimental; (3) “expressive arts”; (4) hypnotherapy; (5) sex; (6) self-esteem; and (7) personal growth;

 Counselling such as (1) alcohol, drug, or solvent abuse; (2) marriage [unless deemed necessary due to crisis]; (3) long-term; (4) non-crisis; (5) motor vehicle cases; and (6) educational and vocational;

 Assessments such as (1) Fetal Alcohol Spectrum Disorder; (2) learning disabilities; (3) child custody and access; (4) paperwork; and (5) services used for legal actions;

 When similar services are provided directly from another program or agency; and

 Life skills training such as (1) parenting and (2) communication.

How do I obtain a reimbursement?

 Clients are not eligible for reimbursements for this benefit.

For more information on short-term crisis intervention mental health counselling benefits for both Sioux Lookout Zone and Moose Factory Zone, please refer to the “NIHB Guide” on COO’s website at www.chiefs-of-ontario.org

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APPEALS

APPEALS FOR DENTAL, MEDICAL SUPPLIES AND EQUIPMENT, MEDICAL TRANSPORTATION, VISION CARE, SHORT-TERM CRISIS INTERVENTION MENTAL HEALTH COUNSELLING, AND BENEFITS OUTSIDE OF CANADA What if I do not agree with the decision made on my NIHB Benefit?

If you do not agree with a decision made through the NIHB Program, you have the right to appeal the decision. A First Nations person or his/her parent or guardian may initiate an appeal in writing. You may also have someone act on your behalf such as a community health worker. He/she can help initiate and/or assist in the appeal process. If you do not agree with the decision made at Level 1, you may choose to have your appeal reviewed at Level 2. If you do not agree with the decision made at Level 2, you may choose to have your appeal reviewed at Level 3. Please mark on the envelope “APPEALS-CONFIDENTIAL” on every level of appeal.

LEVEL 1 APPEAL LEVEL 2 APPEAL LEVEL 3 APPEAL Regional Manager

Non-Insured Health Benefits First Nations and Inuit Health Branch

Health Canada Ontario Region Postal Locator 6103A 1547 Merivale Road, 3rd Floor

Nepean, ON K1A 0L3

Regional Executive Non-Insured Health Benefits First Nations and Inuit Health Branch

Health Canada Ontario Region Postal Locator 6103A 1547 Merivale Road, 3rd Floor Nepean, ON K1A 0L3

NIHB Director General First Nations and Inuit Health Branch, Health Canada

Non-Insured Health Benefits Directorate Postal Locator 1914 A 200 Eglantine Driveway, 14th Floor

Tunney’s Pasture Ottawa, ON K1A OK9 What information do I need to provide in order to make an appeal?

 A signed and dated letter of appeal from you, the client, including your name, Indian status registration number, date of birth, address, and telephone number;

 Explain the reason why you are appealing the benefit. Include the reason NIHB denied the benefit initially;

 You need to explain why the initial request was made;

 Include supporting documentation for your request from a licensed health service provider, medical doctor, health worker, etc.;

 Include diagnosis and prognosis and diagnostic test results (if applicable);

 For appealing dental benefits requests, attach whatever form applies to your request: Standard Dental Claim Form, ACDQ Dental Claim and Treatment Form, NIHB Dent-29 Form, or computer generated form (for dental benefit only and provided by your dental provider); and

 Attach the denial letter that was sent to you by NIHB (if applicable). PLEASE NOTE:

At each level of appeal, supporting medical documentation is needed. You have to keep sending new information to support your appeal. Keep copies of everything you send in for your records.

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APPEALS FOR DRUG BENEFITS

If you do not agree with a decision made through the NIHB Program, you have the right to appeal the decision. A First Nations person or his/her parent or guardian may initiate an appeal in writing. You may have someone act on your behalf such as a community health worker. He/she can help initiate and/or assist in the appeal process. If you do not agree with the decision made at Level 1, you may choose to have your appeal reviewed at Level 2. If you do not agree with the decision made at Level 2, you may choose to have your appeal reviewed at Level 3.

Please mark on the envelope “APPEALS-CONFIDENTIAL” on every level of appeal.

LEVEL 1 APPEAL LEVEL 2 APPEAL LEVEL 3 APPEAL Director

Benefits Review Services Division

First Nations and Inuit Health Branch

Health Canada

Non-Insured Health Benefits Directorate

Postal Locator1902 D 200 Eglantine Drivewa 2nd Floor

Tunney’s Pasture Ottawa, ON K1A 0K9

Director

Benefit Management Division First Nations and Inuit Health Branch

Health Canada

Postal Locator 1902 A 200 Eglantine Driveway 2nd Floor

Director General Non-Insured Health Benefits

First Nations and Inuit Health Branch Health Canada Non-Insured Health Benefits Directorate Postal Locator 1914 A 200 Eglantine Driveway 2nd Floor

Tunney’s Pasture Ottawa, ON K1A 0K9 What information do I need to make an appeal?

 Describe the health condition for which benefit is being requested;

 Attach supporting documentation from other health care providers. They can be from a medical doctor, specialist, nurse, health worker, etc.;

 Diagnosis and prognosis and previous treatments completed;

 Diagnostics test results (if applicable); and

 Proposed treatment plan (if applicable).

APPEALS FOR ORTHODONTIC BENEFITS

If you disagree with a decision made through the NIHB Program you have the right to appeal this decision. A First Nations person or his/her parent or guardian may initiate an appeal in writing. You may have someone act on your behalf such as a community health worker. He/she can help initiate and/or assist in the appeal process. If you do not agree with the decision made at Level 1, you may choose to have your appeal reviewed at Level 2. If you do not agree with the decision made at Level 2, you may choose to have your appeal reviewed at Level 3.

Please mark on the envelope “APPEALS-CONFIDENTIAL” on every level of appeal.

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LEVEL 1 APPEAL LEVEL 2 APPEAL LEVEL 3 APPEAL Orthodontic Review Centre

Director, Benefits Review Services Division

First Nations and Inuit Health Branch

Health Canada

Postal Locator 1902 C 200 Eglantine Driveway 2nd_Floor

Orthodontic Review Centre Director, Benefits

Management Division First Nations and Inuit Health Branch

Health Canada

Postal Locator 1902 C 200 Eglantine Driveway 2nd_Floor

Orthodontic Review Centre NIHB Director General First Nations and Inuit Health Branch

Health Canada

Postal Locator 1902 C 200 Eglantine Driveway 2nd Floor

What do I need to send in an appeal?

 Orthodontic models (soaped and trimmed, either mounted or unmounted);

 Cephalometric (radiographs and tracing);

 Photographs (3 intra oral and 3 extra oral);

 Panoramic radiograph (or full mouth survey); and

 Treatment plan (including estimated duration of treatment phases and costs). PLEASE NOTE

CLIENT REIMBURSMENT

How do I obtain a client reimbursement?

You may be eligible to have some or all of your costs reimbursed. This can happen if you meet the eligibility criteria and have received a prior approval. Prior approval may not be necessary when in an emergency situation.

PLEASE NOTE

Under short-term crisis intervention mental health counselling benefits, the service provider must bill NIHB directly and receive payment from the NIHB Program. Therefore reimbursements do not apply under this benefit.

An appeal must occur before the child’s 18th birthday. An appeal will not be considered after the child reaches 18 years of age.

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PLEASE NOTE

For reimbursement requests, you will need to send in the following information:

 Your name, date of birth, Indian status registration number, mailing address, and telephone number;

 Completed Health Canada Client Reimbursement Request Form. You can find one on the Health Canada website at http://www.hc-sc.gc.ca/fniah-spnia/nihb-ssna/benefit-prestation/form_reimburse-rembourse-eng.php

 Print a copy of the PDF form located on the Health Canada website.

 A copy of the prescription (if applicable);

 Original receipt showing the cost breakdown;

 Original receipt showing purchase of a private health insurance plan with a letter from a recognized institution confirming you attended a medical appointment;

 When appealing for benefits outside of Canada, you need to include a letter from your employer confirming that you are employed;

 Explanation of Benefits Statement from Third Party Insurance (if applicable);

 To appeal for dental benefits provided by dental provider, you need to include one of these forms: Standard Dental Claim Form, ACDQ Dental Claim and Treatment Form, NIHB Dent-29 Form, or computer generated form;

 The date you obtained service must be on or after your eligibility criteria date; and

 You can only ask for a reimbursement within one year of the date you obtained the service or incurred the cost.

Client reimbursement requests should be mailed to:

Health Canada First Nations and Inuit Health Branch Ontario Region

Non-Insured Health Benefits 1547 Merivale Road, 3rd Floor

Postal Locator 6103A Nepean, ON K1A 0L3

ONTARIO HEALTH PROGRAMS BENEFITS

There are other Ontario health programs that First Nations people can access and they are as follows.

Ontario Health Insurance Plan (OHIP): Ministry of Health and Long Term Care (MOHLTC) covers the cost for a wide range of health care through OHIP. Health care services include insured hospital care and primary health care such as physician and other health professional services.

To learn more about the OHIP Program, please contact:

 OHIP Information Line for Sioux Lookout Zone: 1-800-465-5067  OHIP Information Line for James Bay Coast: 1-800-461-4006

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You may also find more information on the MOHLTC website at

http://www.health.gov.on.ca/en/public/programs/ohip/ or by calling the OHIP Information Line at 1-866-523-3161 (toll free).

Ontario Drug Benefit Program: MOHLTC provides drug benefits through the Ontario Drug Benefit (ODB) Program. This program is for Ontario residents who have reached 65 years of age. The Ministry will notify the person by mail two months prior to their 65th birthday that he/she is eligible for the ODB Program. Once a person has turned 65 years of age the ODB Program will take effect the first day of the month following their 65th birthday. ODB co-payment and deductible fees will be covered for First Nations people by the NIHB Program.

You may also find more information on the MOHLTC website listed above or by calling the ODB Information Line at 1-866-532-3161.

For more detailed information on both OHIP and ODB Programs, please refer to the “NIHB Guide” on COO’s website at http://www.chiefs-of-ontario.org/

Ontario Works: This program is delivered through the Ministry of Community and Social Services (MCSS). Ontario Works (OW) provides financial and employment assistance. To be eligible, you need to be living in Ontario. You are in need of financial aid for food and housing expenses. You are willing to participate in activities that will help you find employment.

To learn more about the OW Program, please contact:

 Your First Nations OW Administrator (Social Services Administrator); or  Your local regional office.

You may also find more information on the MCSS website at www.mcss.gov.on.ca or by calling 1-888-789-4199 or 1-416-325-5666.

Ontario Disability Support Program: The Ontario Disability Support Program (ODSP) is accessed through MCSS. ODSP provides income supports and employment supports. People living with disabilities can get some financial assistance. This is to help them with living expenses (e.g. food, housing). The ODSP also offers employment support for those who are looking for employment.

To learn more about ODSP, please contact:

 Your First Nations OW administrator (social service administrator); or  Your local regional office.

You may also find more information on the MCSS website at www.mcss.gov.on.ca or by calling 1-888-789-4199 or 1-416-325-5666.

Trillium Drug Program: This program is through MOHLTC and it provides help with drug costs to Ontario residents who have high prescription drug costs in relation to the net household income.

To learn more about the Trillium Drug Program, please contact:  Your local pharmacy; or

 Your physician; or

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Northern Health Travel Grant Program: The Northern Travel Grants Program is through the MOHLTC. The grants may help pay some of the travel related costs for Northern Ontario residents who must travel at least 100 kilometres one way to access a medical specialist or designated health care facility services that are not locally available. The Northern Health Travel Grant Program may also provide an accommodation allowance of $100.00 per eligible trip to patients who must travel at least 200 kilometers one way to access the closest specialist or designated health care facility. To learn more about the Northern Health Travel Grants Program, please contact your local community health worker.

www.health.gov.on.ca/en/public/publications/ohip/northern.aspx or by telephone at 1 800 461-4006 (for service in English) or call ServiceOntario Infoline at 1-866-532-3161, TTY 1-800-387-5559, in Toronto 1-416-327-4282.

ONTARIO ASSISTIVE DEVICES PROGRAM

The Ontario MOHLTC may provide limited coverage to pay for a range of

equipment and supplies. This help is for Ontario residents with a long-term physical disability and a valid OHIP card. Apply through the Assistive Devices Program (ADP).

Who is eligible for ADP?

 Ontario residents who have a long-term disability (no age restrictions) and a valid Ontario health card.

How does the ADP Program work with the NIHB Program?

The two programs both have eligibility criteria and guidelines that need to be followed. Once these criteria and guidelines are met, the two programs will both be used to best meet your needs. Your ADP/NIHB approved and registered health care professional/service provider will have the complete list of criteria and guidelines. The provider will coordinate benefits between the two programs (ADP and NIHB) to ensure that you have maximum coverage. For ADP coordinated items, the NIHB Program will cover the 25 percent fee of eligible and approved NIHB items.

What is covered and not covered under ADP?

 Communication devices;

 Diabetes equipment and supplies;

 Enteral feeding supplies;

 Hearing aids;

 Home oxygen;

 Insulin pumps and supplies;

 Orthotic devices;

 Ostomy supplies;

 Pressure modification devices;

 Prosthetic devices (breast, eye, limb);

 Respiratory supplies and equipment;

 Visual aids; and

 Wheelchairs, positioning, and ambulation aids.

 Equipment available under Workplace Safety & Insurance Board; and

 Equipment available under Group “A” Veterans (pensioned conditions)

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How do I enrol in ADP?

To enrol for ADP, you need:

 An assessment by your medical doctor and/or a team of health professionals;  After your examination the doctor will describe and confirm your physical

disability on the ADP Form;

 Your doctor will then refer you to a health care professional that is registered with ADP;

 The health care professional will assess your needs to see if you meet the ADP funding criteria;

 After criteria are met, the health care professional will complete the ADP Form for you. Then you take the form to a supplier to get your equipment; and  In some cases, prior approval is required by ADP.

PLEASE NOTE

You may find more information on the MOHLTC website at

http://www.health.gov.on.ca/english/public/program/adp/adp_mn.html or call the ADP Information Line at 1-800-268-6021, TTY 1-800-387-5559; in Toronto 1-416-327-8804.

GLOSSARY OF TERMS

Eligible Means someone who meets the criteria for services being offered. Guidelines and limitations have been set that describe who is entitled to receive services, which services they can access, and how much help they can get. If you are deemed eligible for

something, you may get approved for the service you are seeking. If it is decided you are not eligible, you will not get approval for your request.

Eligibility Requirements

Meansthere is criteria that must be met in order to access the health benefits you are interested in. You can talk to staff delivering the program to find out if you meet the eligibility requirements. They may ask for your name, date of birth, Indian status registration number, full address, and telephone number.

ADP pays up to 75 percent of the costs of items such as:  Orthopaedic braces

 Wheelchairs  Breathing aids;

ADP pays a grant each year directly to the person to help pay for supplies such as:  Needles

 Syringes (for insulin dependent seniors)  Ostomy supplies; and

ADP contributes a fixed amount for items such as:  Artificial limbs

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Escort Is an adult who travels with a client to a medical appointment. This person may be a medical or non-medical escort. A non-medical escort is a doctor, nurse, or any other qualified health worker. A non-medical escort is a person of choice who is first approved by a health professional.

Exceptions Means a medical item, supply, service, and/or travel cost that is not covered by NIHB benefits or

procedures. It may be approved on a case-by case basis.

Exclusions Is a medical item, supply, service, and/or travel cost that is simply never covered. You cannot ask for approval through the NIHB appeal process. Explanation of

Benefits Form

Is a form that comes with a third party insurance company payment. It explains what is covered. It tells you the amount covered by your private insurance company.

Frequency and Quantity Limitations

Means you are only allowed a limited supply of a medical item, supply, and/or services under the benefit area (e.g. drug, medical supplies and equipment benefits) within a certain time. You must get approval before you obtain the item needed. Health Coordination

Unit

Comprised of one health director from participating provincial and territorial organizations in Ontario, and one from the Independent First Nations in Ontario. Licensed

Practitioner

Means health staff such as a medical doctor, medical specialist, nurse practitioner, and home and

community care nurse with a license to practice in Ontario.

Limited Use Means drugs that have quantity or frequency limitations.

NIHB Benefits (Website Addresses)

Refer you to internet links. You can enter these addresses into a computer to do a web search for NIHB Benefit Program information. Health Canada has a website about First Nation and Inuit Health. NIHB Recognized

Prescriber

Means a licensed practitioner recognized as having the authority to write prescriptions within his/her scope of practice in Ontario.

Ontario Chiefs Committee on Health

Comprised of one chief and/or political leadership from participating provincial and territorial organizations in Ontario, and one from the Independent First Nations in Ontario.

Open Benefit Means a medical item, supply, and/or service you can access right away. You do not need to get approval for it ahead of time.

Policy Framework Means theguide under the NIHB Program that explains what is covered in each benefit area. It tells you what to ask for or what to expect from your health service provider. The guide points out the

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items and services that can be paid for you if you are an eligible registered First Nation member.

Predetermination Means dental services that must be approved before any treatment begins. The NIHB regional office has to say whether it is allowed or not.

Prior Approval Means a medical item, supply, service, and/or travel cost that needs to be approved by NIHB if you want NIHB to cover the cost. Before you can receive the item or service, the NIHB office has to give permission saying it will cover the cost.

Reimbursements Means that some or all of the medical costs you paid might be eligible for repayment to you by the NIHB Program. The item or service has to be on the NIHB list of benefits that are covered. You need to send them the requested information and receipts within one year from the date of service.

Third Party Insurance Means other types of health coverage besides NIHB or the Ontario health benefits. This might be through a public or private health care plan.

CONTACT INFORMATION

If you need more information or require more COO NIHB booklets, please contact:

Chiefs of Ontario

Administrative Office 111 Peter Street, Suite 804 Toronto, ON M5V 2H1 Toll Free: 1-877-517-6527 Fax: 1-416-597-8365 www.chiefs-of-ontario.org

Chiefs of Ontario

Political Office

Fort William First Nation 109 Mission Rd

Thunder Bay, ON, P7J 1K7 Tel: 1-807-626-9339 Fax: 1-807-626-9404

NIHB Regional Office

Non-Insured Health Benefits Health Canada

First Nations and Inuit Health Branch 1547 Merivale Road, 3rd Floor Postal Locator 6103A

Nepean, ON K1A 0L3 Toll Free: 1-800-640-0642

Assembly of First Nations (AFN) Headquarters

AFN Health Secretariat 900-473 Albert Street Ottawa, ON K1R 5B4 Toll Free: 1-866-869-6789