health benefits - first nations health authority purpose of the program is to provide health...

Health BenefitsInformation Package

Contents

Introduction 3Benefits 5Dental 5MedicalSupplies&Equipment(MS&E) 7MedicalTransportation 10MentalHealth-CrisisIntervention(Shortterm) 13MSP–BCMedicalServicePlan(CareCard) 15Pharmacy 18VisionCare 21General 24AppealsProcess 24ClientReimbursement 28LeavingBritishColumbia 29CommonQuestions&Answers:FNHAHealthBenefits 32ContactList 36MailingAddress 36WebsiteAddress 36PhoneNumbersandEmail 36HealthBenefitsTollFreeNumberTreeMap 37

2 | FirstNationsHealthAuthority| HEALTHTHROUGHWELLNESS

FNHA Health Benefits Program

Introduction

TheFirstNationsHealthAuthority(FNHA)HealthBenefitsprogramprovidesaspecificnumberofhealthrelatedgoodsandservicestomeetmedicalordentalneedsnotcoveredbyprovincial,territorial,orotherthirdpartyhealthinsuranceforBCFirstNations.

The FNHA Health Benefits program currently includes:• Dental•MedicalSupplies&Equipment(MS&E)•MedicalTransportation•MentalHealth-CrisisIntervention(ShortTerm)

The purpose of the program is to provide Health Benefits to BC First Nations peoples in a manner that:•Isappropriatetotheiruniquehealthneeds•ContributestotheachievementofanoverallhealthstatusforBCFirstNationscomparabletothatoftheCanadianpopulationasawhole

•Issustainablefromafiscalandbenefitsmanagementperspective•FacilitatesFirstNationscontrolatatimeoftheirchoosing•ShiftsthefocusofhealthservicedeliveryforFirstNationsresidinginBCtowellnessandprevention

The principles of the FNHA Health Benefits program are as follows:•Benefitswillbeprovidedbasedonprofessional,medicalordentaljudgment,consistentwiththebestpracticesofhealthservicesdeliveryandevidence-basedstandardsofcare.

•Theprogramwillbemanagedinacost-effectivemanner.•Managementprocesswillinvolvetransparencyandjointreviewstructures.•Incaseswhereabenefitiscoveredunderanotherplan,theFNHAHealthBenefitsprogramwillactastheprimaryfacilitatorincoordinatingpaymentinordertoensurethattheotherplanmeetsitsobligationsandthatclientsarenotdeniedservice.

What is buy-back?Buy-backisanarrangementbetweentheFNHAandHealthCanadawheretheFNHA“buys-back”theadminis-trationofclaimsprocessingandbenefitsreviewservicesfromHealthCanada.ItwilltakesometimefortheFNHAtobuildtheappropriatesystemstoprocessthetensofthousandsofdailyclaims.Thebuy-backarrangementwillensurecontinuityofserviceastheFNHAbuildsthesesystems.

How long will the FNHA buy-back services?TheFNHAcurrentlyhasabuy-backagreementforatermof2yearsinplace.Thisagreementmaybeextendedforanadditional2years.

What are affected by the buy-back agreement?AnysystemupdatesfromHealthCanadawouldaffecttheDental,MedicalSuppliesandEquipment,andPharmacybenefitareas.

HEALTHTHROUGHWELLNESS| FirstNationsHealthAuthority | 3

•MSP-BCMedicalServicePlan(CareCard)•Pharmacy•VisionCare

TheFirstNationsHealthAuthorityHealthBenefitsprogramdesign,delivery,andtransformationisdrivenandguidedbytheFNHAVision,Values,andDirectives.

Our Vision

Healthy,Self-determiningandVibrantBCFirstNationsChildren,FamiliesandCommunities.

Our Values

RespectDisciplineRelationshipsCultureExcellenceFairness

Our Directives

•Community-Driven,Nation-Based•IncreaseFirstNationsDecision-MakingandControl•ImproveServices•FosterMeaningfulCollaborationandPartnership•DevelopHumanandEconomicCapacity•BeWithoutPrejudicetoFirstNationsInterests•FunctionataHighOperationalStandard

Eligibility

TheFNHAHealthBenefitsprogramoffershealth-relatedgoodsandservicestoanyFirstNationsperson(orchildunder1yearofageofaFirstNationspersonwhomeetsallofthesecriteria)who:•hasaCanadianstatusnumber;•isaresidentofBritishColumbia(asdefinedbyBC’sMedicalServicePlan)andhavingactiveMedicalServicePlancoverage;and

•isnotcoveredunderanyotherbenefitsprovidedbytheFederalGovernmentorFirstNationsorganizationthroughself-governmentorlandclaimsagreements.


Benefits

Dental

Coveragefordentalservicesisdeterminedonanindividualbasis,takingintoconsiderationthecurrentoralhealthstatus,recipienthistory,accumulatedscientificresearch,andavailabilityoftreatment.

What is covered?

•Diagnosticservices(e.g.examinationsorx-rays);•Preventiveservices(e.g.cleanings);•Restorativeservices(e.g.fillings);•Endodonticservices(e.g.rootcanals);•Periodontalservices(e.g.deepcleanings);•Prosthodonticservices(e.g.removabledentures);•Oralsurgeryservices(e.g.removalofteeth);•Orthodonticservices(e.g.braces);and•Adjunctiveservices(e.g.generalanaestheticsorsedation)

Who can provide dental benefits?

Dentalservicesmustbeprovidedbyalicenseddentalprofessionalsuchasadentist,dentalspecialist, ordenturist.

How do eligible clients access dental benefits?

Eligibleclientsmustmakeanappointmentwithadentalproviderwhowillcompleteanexamination,establishatreatmentplan,anddiscusstheservicesrequiredwiththeindividual.ThisbenefitisdeliveredbyNIHBfortheFNHAthroughtheshorttermbuy-backagreement.

Therearetwoschedulesfordentalservices:Schedule A:includesservicesthatdonotneedpriorapprovalSchedule B:includesservicesthatdorequirepriorapproval

ThedentalprovidershouldadvisetheclientwhatiscoveredbytheFNHAHealthBenefitsprogramand whichservicesrequirepriorapproval.Iftheproviderisnotaware,therecipientshouldcontactFNHAHealthBenefitsoffice1.800.317.7878andspeaktothedentalbenefitstaff;orhavethedentalprovidercontacttheclaimcentreat1.888.511.4666todeterminewhatiscovered.



DentalProcess

EligibleFNHAclientmakesanappointmentwithDentist.

Clientisexamined.

Dentistwillestablishatreatmentplan.

Dentistwillidentify:A:Theservicesthatdonotneedpre-determination;andB:Theservicesthatwillneedpre-determination.

Thedentalproviderforwardstherequestforservicesthatneedpre-determination.Pre-determinationrequestswithsupportingdocumentationmustbemailedtoFNHA.

TheFNHAHealthBenefitsprogramreviewstherequestanddetermineseligibilitybasedonprogramguidelines.

Ifnecessary,theFNHAHealthBenefitsprogramreferstherequesttotheDentalConsultantfora professionalopinionondentalrequirements.

Registereddentalproviderswillreceivealetterconfirmingbenefitsviafaxormail.

Clientreceivesdentalservicesandsignsformconfirmingreceiptofservice.

Providercompletesclaimformandforwardstoclaimscentreforpayment.

Medical Supplies & Equipment (MS&E)

Specific Medical Supplies and Equipment are available to eligible BC First Nations for personal use when all of the following criteria are met:

•TheitemisontheFNHAHealthBenefitsprogramMedicalSupplies&EquipmentList.•PriorApproval,ifrequired,isgrantedbytheFNHAHealthBenefitsprogram.•Theitemisnotavailabletoclientsthroughotherfederal,provincial,orotherthirdpartyplan.•Thebenefitisprescribedbyaneligibleprescriber.•TheitemisprovidedbyaFNHArecognizedpharmacyormedicalsupply&equipmentprovider.

Medical Supplies & Equipment provided through the FNHA Health Benefits program include the following:

•Audiology(HearingAidsandSupplies)•BathingandToiletingAids•CushionsandProtectors•EnvironmentalAids(DressingandFeeding)•LiftingandTransferAids•LowVisionAids•MiscellaneousSuppliesandEquipment•MobilityAids(WalkingAids,Wheelchairs)•OrthoticsandCustomFootwear•OstomySuppliesandDevices•OxygenSuppliesandEquipment•PressureGarmentsandPressureOrthotics(CompressionDeviceandScarManagement)•ProstheticBenefits(Breast,Eye,Limbs)•RespiratorySuppliesandEquipment•UrinarySuppliesandDevices(CatheterSuppliesandDevices,IncontinenceSupplies)•WoundDressingSupplies

ThisbenefitisdeliveredbyNIHBfortheFNHAthroughtheshorttermbuy-backagreement.Foracompletelistofthebenefits,consulttheNIHBwebsiteatwww.hc-sc.gc.ca/fniah-spnia/nihb-ssna/index-eng.phpwhichprovidesadescriptionofthebenefititem,thebenefitcode,requirementsforpriorapproval,andexpectedreplacementguidelines.


Certain medical supplies and all medical equipment require prior approval.Approval procedures are provided on page 9.

The following are exclusions under the program:

•Assistivelisteningdevices(excludingeligiblehearingaids)•Assistivespeechdevices(i.e.,keyboardspeechsystems,speechenhancers)•Cochlearimplants•Custom-mademaskforventilation•Electric/myoelectriclimbprosthetics•Exercisedevices•Experimentalequipment•Footproductsmanufacturedonlyfromlaseroropticalscanningorcomputerizedgaitandpressureanalysis systems

•Grabbarspermanentlyfixed•Hospitalbedsandmattresses•Implants•Itemsforcosmeticpurposes•Itemsusedexclusivelyforsports,workoreducation•Incentivespirometer•Orthopaedicfootwear“offtheshelf”•Partofasurgicalprocedure•ProvidingoxygenforindicationswhichdonotmeetthemedicalcriteriaoftheNIHBProgram (e.g.anginaandpainrelieffrommigraines)

•Respiratoryequipmentforin-patientsofaninstitution•Scooters•Short-termcompressionstockings/garments (i.e.post-operative:surgicalstripping,sclerotherapy,andedemaconditions)

•Temporaryprostheticsrequiredaspartofasurgicalprocedure



MedicalSupplies&EquipmentAccessProcess

EligibleFNHAclientreceivesprescriptionfromauthorizedprescriber.

Clientisassessedformedicalsupplies&equipmentneedsbyhealthprofessional.

HealthprofessionalpreparesassessmentresultsandrecommendsMS&E.

ClienttakesassessmenttorecognizedMS&Eproviderandselectsproducts.

MS&Eprovidercompletesandforwardstherequest,assessment,andprescriptiontotheFNHAHealthBenefitsprogramforPriorApproval.

TheFNHAHealthBenefitsprogramreviewsrequestanddetermineseligibilitybasedonprogramguidelines.

Ifnecessary,theFNHAHealthBenefitsprogramrefersrequesttoMedicalConsultantforprofessionalopiniononmedicalrequirements.

TheFNHAHealthBenefitsprogramfaxesletterconfirmingbenefitsapprovedtoMS&Eprovider.

ClientreceivesMS&Eandsignsformconfirmingreceiptofproduct.

Providercompletesclaimformandforwardstoclaimspayerforpayment.

Medical Transportation

Eligibility

InordertoqualifyformedicaltransportationbenefitsundertheFNHAHealthBenefitsprogram,theindividualmusthaveaCanadianStatusnumber.MedicaltransportationbenefitsarenotprovidedbytheFNHAHealthBenefitsprogramiftheFNHAclientiseligibleforbenefitsunderanyotherpubliclyfundedhealthorsocialprogram,suchastheInsuranceCorporationofBC(ICBC)ortheWorkersCompensationBoard(WCB),thenthealternatecoveragemustbeusedfirst.

InfantsunderoneyearofageareeligibleformedicaltransportationbenefitsifoneoftheirparentsisaFNHAclientwithaCanadianStatusnumber.Afteroneyearofagethechildrenmustthemselves,haveaCanadianStatusnumbertoqualifyformedicaltransportationbenefits.

Eligible Benefits

MedicaltransportationbenefitsmaybeprovidedforclientstoaccessmedicallynecessaryhealthservicesthatarecoveredundertheBCMedicalServicesPlan(MSP)and/ortheFNHAHealthBenefitsprogram.PleaserefertotheMedicalTransportationFrameworkforfurtherinformationoneligiblebenefits.TheFrameworkcanbefoundonthewebsite:www.hc-sc.gc.ca/fniah-spnia/pubs/nihb-ssna/_medtransp/2005_med-transp-frame-cadre/index-eng.php

Appropriate Documentation

Inordertodetermineeligibilityformedicaltransportationbenefits,theFNHAclientinquestionmustprovidethefollowingdocumentation:•AreferralfromaGeneralPractitionerorfamilyphysician•Confirmationofappointmentfromthehealthprovider/healthfacility

Aftertheappropriatemedicaltravelarrangementshavebeenmadeandtheclienthasattendedtheirappoint-ment,theclientmustprovideconfirmationofattendancefromthehealthprovider/healthfacility.

Travel expenses will not be reimbursed without written confirmation of attendance.

Travel Arrangements

Medicaltransportationbenefitsareprovidedtoassistclientsinaccessingmedicallyrequiredhealthservicesatthenearestappropriatehealthprofessionalorhealthfacility.Themosteconomicalandefficientmeansoftransportationistobeused,takingintoaccounttheurgencyofthesituationandthemedicalconditionbeingaddressed.


PLEASEREFERTOTHEMEDICALTRANSPORTATIONFRAMEWORKFORMOREDETAILEDINFORMATION.

Medical Transportation Responsibilities for BC First Nations:

AFNHAclientaccessingmedicaltransportationthroughtheFNHAHealthBenefitsprogram,eitherthroughthecommunityortheregionaloffice,isresponsiblefor:

•Givingsufficientnotice,ideally5-10days(ormoreasperthecommunity’spolicy)priortoleavingthecommu-nity.Thiswillavoidlastminuteconfusionorhavingtocancelappointmentsbecausearrangementscouldnotbemadeintime.

•AdheringtotheMedicalTransportationFrameworkandregional/communitypoliciesonMedicalTransportation.•Obtainingallofthenecessarypaperworkfortheirtrippriortoleavingthecommunity (i.e.referralfromGPorconfirmationofappointmentwithspecialist).

•Gettingpriorapprovalforallnon-emergencytrips.Theonlyexceptionisinthecaseofamedicalemergency.•Attendingtheirmedicalappointmentasscheduled.•GettingasignedConfirmationofAttendance(COA)signedbytheDoctor/Nursestatingtheyhaveattendedtheirmedicalappointment.ThesignedCOAmustbereturnedtotheTransportationCoordinatorafterthemedicalappointment.

•Protectingalloftheoriginalvouchers/warrants/receiptsissuedtothemfortheirmedicaltrip. Vouchers/warrants/receiptswillnotbereissuediflostorstolen.

•Givingnotificationwhencancellinganappointmentpriortothedateoftheappointment;including24hours’noticetocancelanyhotelarrangements.

•Retainingandforwardingallrequiredreceipts.•Notdamagingpropertyorabusingaccommodationarrangements,suchascausingexcessivenoise.•Notbecomingverballyabusiveorthreateningtothepatienttransportationclerkorcoordinator.



MedicalTransportationAccessProcess

EligibleFNHAclientreceivesappointmentforaspecialtyphysicianlocatedoutsideoftheclient’s residentcommunity.

FNHAclientcontactstheircommunitytoseeiftheyarecoveredbyacontributionagreement.

Ifcoveredundercontributionagreement,benefitsareprovidedthroughthecommunity.

Ifnotcoveredunderacontributionagreement,clientcontactsFNHAHealthBenefits.

Theclientorcommunityhealthrepresentativeforwardstherequestwiththecompletedform,confir-mationofappointment,relevantreferraldocument,andanyothersupportingmedicaldocumentstoFNHAHealthBenefits,5-10dayspriortoleavingthecommunity.

TheFNHAHealthBenefitsprogramreviewsrequestanddetermineseligibilitybasedonforwardedinformationandonprogramguidelines.

TheFNHAHealthBenefitsmaketravelarrangementsusingthemosteconomicalandefficientmeansoftransportation,takingintoaccounttheurgencyofthesituationandthemedicalconditionbeingaddressed.

TheFNHAHealthBenefitsforwardsthetravelarrangementstotheclient.

TheclientusesthetravelarrangementsandvouchersaspreparedbyFNHAHealthBenefits, andfollowsthevoucher’sinstructionsasrequired,includingsigningthetravelvouchers.

Theclientgoestotheappointmentasscheduled,andasksthephysician’sofficetosign/stampanddatetheconfirmationofattendancefortheappointment.

Theclientreturnstotheirhomecommunityasarranged.

TheclientorthecommunityhealthrepresentativeforwardstheconfirmationofattendancefortheappointmenttotheFNHAHealthBenefitstocompletethefileforthetrip.

TheprovidersofthetravelarrangementsforwardinvoicestoFNHAforpaymentoftheservices rendered,aspriorapproved.

Mental Health - Crisis Intervention (Short-term)

MentalHealth–Clientswholiveon-reserveshouldcontacttheirbandofficeformentalhealthservices. Forclientswholiveawayoff-reserve,pleasecontactFNHAHealthBenefitsat 1.800.317.7878regardingcrisisInterventionbenefits.


The following program is also available for clients through FNHA Health Services

Mental Health Support Programs for Indian Residential Schools:

ServicesfundedbyHealthCanadainsupportofthosewhohavesufferedabusesinIndianResidentialSchoolsmayincludementalhealthcounseling,transportationtoattendcounselingortobeassistedbyanElderorHealer,andtheservicesofaResolutionHealthSupportWorker.

Indian Residential School Survivors Society Support Line

1.866.925.4419(Open24-hoursaday,7daysaweek)

Indian and Residential School Mental Health Support Program

Toll-Free:1.877.477.0775Facsimile:1.604.666.6458


MentalHealth-CrisisInterventionAccessProcess

FNHAclientcontactstheircommunitytoseeiftheyarecoveredbyacontributionagreement.

Ifcoveredundercontributionagreement,benefitsareprovidedthroughthecommunity.

Ifnotcoveredunderacontributionagreement,clientmaycontactFNHAHealthBenefitsforalistofregisteredproviders.

ClientcontactsFNHAregisteredprovidertomakeanappointmentforassessment.

TheproviderrequestspriorapprovalfromtheFNHAHealthBenefitsprogramfortheinitialassessment.

Theproviderdoestheinitialassessmenttodeterminethattheclientisatriskorincrisis.

Ifclientisatriskorincrisis,theproviderdevelopsatreatmentplan.

TheproviderforwardstreatmentplantoFNHAforapproval.

Providerisinformedofnumberofsessionsapprovedtocompletethetreatmentplan.

Providerandclientcompletethetreatmentplan.

Providercompletesandclientsignstheinvoiceform,andforwardstoFNHAforpayment.

MSP – BC Medical Service Plan (Care Card)

TheprovincialMinistryofHealthadministerstheBCMedicalServicesPlan,whichensuresthatalleligibleBCresidentshaveaccesstomedicallyessentialcare.AllresidentsinBCmustapplyforaBCMedicalServicesHealthCardtoreceivehealthserviceswithinBC.

InBC,theFNHAmanagestheMSPprogramforclientsresidinginBC.Formsareavailablefromlocalcommunitybandofficesand/ortheFNHAHealthBenefitsprogramoffice.Oncetheapplicationisreceived,verified,andapproved,thecostofthepremiumispaiddirectlybytheFNHAHealthBenefitsprogram.

Itiseachclient’sresponsibilitytoensuretheyareenrolledwiththeFNHAHealthBenefitsprogramfortheirmedicalhealthcarecardinorderfortheirpremiumstobepaid.

Who should apply for enrolment?

•ClientsanddependentswhoarenewtoBC•ClientsanddependentsreturningtoBC(after3ormoremonthsaway)•Clientswhohaveturned19yearsofageandhavenotyetcompletedaform•Clientswhohadtheirpremiumspaidbyanemployerorothersource(i.e.MinistryofIncomeAssistance)andarenolongeronthatplan.

All applications must have copies of your birth certificate or passport and status card, both sides.

When should you use a Change Form Application?

•Individualhaslosttheirownortheirdependent’sCareCard•IndividualneedstocorrecttheinformationshownontheirCareCard,suchaschangeofaddress, namechange,ortoaddanewdependent

All change form applications require the necessary supporting documentation, such as a copy of the marriage certificate, birth certificate, etc.

MSP Enrolment or Change Form Applications should be mailed or faxed to the following:

MailFirstNationsHealthAuthorityHealthBenefitsProgramSuite540-757WestHastingsStreetVancouver,BCV6C1A

Fax1.888.299.9222


MSP Application Checklist

qApplicationisclearlyprinted,signed,anddatedbyapplicant(andeligiblespousewhereapplicable).

qApersonsigningonbehalfofsomeoneelsemustprovidelegaldocumentationgrantingPowerofAttorneyorclearlyindicatesigningasawitnessforaclientincapableofsigning.

q Thefollowingmandatoryinformationisprovided: •Bandnameandnumber •Registeredfirstname •Registeredsurname •Dateofbirth •Residentialaddress(iflivingoff-reserveyoumusthaveastreetaddressandnotaP.O.Boxnumber)

qAcopyofdependent’sbirthcertificate(ifeligibleandapplicable)isprovided.

qForclientswhoarepreviousresidentsofBCorforcontinuedenrolmentatageof19,indicateprevious BCHealthCareNumber(ifknown).

qEnsureallboxesaremarkedoffandallinformationiscompleted.

qCopiesofsupportingdocumentationareprovided(i.e.birthcertificateandstatuscard, both sides).

qIffaxingtheapplication,BOTHsidesarefaxed.


PLEASE NOTE THAT APPLICATIONS MAY BE DELAYED AND/OR RETURNED IF THE ABOVE INFORMATION IS NOT PROVIDED.

NOTE: BC MEDICAL PREMIUMS THAT HAVE ALREADY BEEN PAID BY CLIENTS AND NOT THROUGH THE FNHA HEALTH BENEFITS PROGRAM ARE NON-REFUNDABLE.

MSPandPROVIDERBILLING

ThefollowinginformationwastakenfromtheMedicalServicesPlanwebpageandismeanttoprovidebasicinformationonly.FordetailedinformationonMSP,pleasevisittheirwebpageat:www.health.gov.bc.ca/msp

De-insurance of Provincially Insured Services

•Fromtimetotime,provincesmayde-insureahealthbenefit.TheFNHAHealthBenefitsprogramwillnot automaticallyassumeresponsibilityforthecostofanyde-insuredbenefit.Whende-insuranceoccurs, adeterminationwillbemadebytheFNHAHealthBenefitsprogramastowhetherthebenefitwillbeincludedintheprogram.

Extra billing

•“ExtraBilling”iswhenapractitionerbillsaclientoverandabovetheamountpaidorpayablebytheMedicalServicesPlanofBCforaninsuredservice.TheFNHAwillnotacceptresponsibilityforpayingextrabillingchargesnorreimburseclientswhohavepaidextrabillingcharges.Ifclientsreceivebillsfromadoctororhospitalwhichmaybean“extrabilling”charge,thedoctororhospitalshouldbeaskedtoprovideanexplanationoftheexpenseinwriting.

Costs Exceeding Fee Schedules

•IfaclientwishestopurchaseagoodorservicethatismoreexpensivethanthebenefitprovidedbytheFNHAHealthBenefitsprogram,theclientisresponsibleforcostsoverandabovethenegotiatedfeeschedulecosts.

Inter-Regional Health

•Fromtimetotimeaclientmayaccessservicesinanotherprovince,asthelocationistheclosestappropriate medicalservice.TheFNHAHealthBenefitsprogramwillpaythecostofapprovedFNHAHealthBenefitsprogramservicesforpatientswhonormallyreceivehealthservicesinanotherregionbecauseofthecloseproximityofhealthservices.TheserequestsaresubjectedtoreviewbytheHealthBenefitsprogram.


Pharmacy

TheFNHAHealthBenefitsprogramprovideseligibleclientsspecifieddrugs,includingcertainprescriptiondrugs,over-the-counter(OTC)drugs,proprietarymedicines,andextemporaneousproducts.

ThisbenefitisdeliveredbyNIHBfortheFNHAthroughtheshort-termbuybackagreement.AlldrugsapprovedforcoveragebytheFNHAHealthBenefitsprogramarelistedontheNIHBDrugBenefitList.Thelistispublishedonceperyearwithupdateseverythreemonths.ThecompleteDrugBenefitListandprogrampoliciescanbefoundontheNIHBwebsiteat:www.hc-sc.gc.ca/fniah-spnia/nihb-ssna/index-eng.php

DrugsthatarenotontheDrugBenefitListmaybeapprovedforcoverageonacase-by-casebasiswhenanexceptionalneedisdemonstrated.TheserequestsmustgothroughtheDrugExceptionCenterandare forwardedbythepharmacy.

The following drug products are exclusions under the program:

•Householdproducts(e.g.soapandshampoos)•Anti-obesitydrugs•Cosmetics•Alternativetherapies(e.g.glucosamineandeveningprimroseoil)•Megavitamins•Drugswithinvestigational/experimentalstatus•Vaccinationsfortravel•Hair-growthstimulants•Fertilityagentsandimpotencedrugs•Selectover-the-counterproducts•Coughpreparationscontainingcodeine

Basic Information on Generic Drugs:

Theconceptofageneric drugversusabrand name drugisoftenaconfusingmatterforconsumers.

Thepurposeofthebelowinformationistohelpclientsunderstandwhatagenericdrugis,andwhyagenericdrugmaysuddenlybecomeavailableatpharmacieswhenpreviouslyitwasnot.


The following is for informational purposes only and does not cover the whole spectrum of generic drugs:

Definitions

Brand name drug

Adrugthathasatradenameandisprotectedbyapatent.Itcanbeproducedandsoldonlybythecompanyholdingthepatent.

Generic drug

Whenthepatentprotectionforabrandnamedrugexpiresgenericversionsofthedrugcanbesold.Itoftenhasanameindicativeofitschemicalcontents.

Genericdrugscanonlybeproducedandsoldwhenapatentonabrandnameexpiresorwhenapatentneverexisted.Theyaregenerallylessexpensivethantheequivalentbrandnamedrugbecauseofmuchlowerdevel-opmentandmarketingcosts.

Genericdrugsusuallycostlessthanthebrandnamedrug,butarechemicallyidenticalandmeetthesamestandardsforsafety,purity,andeffectiveness.



DrugAccessProcess

EligibleFNHAclientvisitsphysician.

Physicianwritesprescription.

FNHAclienttakesprescriptiontopharmacy.

Pharmacistenterstheclientandbenefitinformation,andbenefitcostsattheirpointofsalesystemfordrugsthatareopenbenefits.

PharmacisttelephonestheNIHBDrugExceptionCentreandprovidesoperatorwithclientandbenefitinformation,andbenefitcostsfordrugsthatarenotonthelistorarelimitedusedrugs.

ThePhysicianiscontactedbyNIHBtocompleteformoutliningmedicalrequirementsofthedrug.

ThePhysicianreturnstheformtoNIHB.TherequestandsupportinginformationisforwardedtoaMedicalConsultantforaprofessionalopiniononmedicalrequirements.

NIHBDrugExceptionCentrereviewstherequestanddetermineseligibilitybasedonprogramguidelines.

DrugExceptionCentreprovidespharmacywithpriorapprovaldetailsbytelephone.

FNHAclientreceivesmedication.

Pharmacistforwardsclaimtoclaimspayer.

Vision Care

Eye Examination

•TheFNHAHealthBenefitsprogramfundsroutineeyeexamsonceevery24monthsforadultsbetweentheagesof19-64.

•BCMedicalServicesPlan(MPS)fundsroutineeyeexamsonceevery12monthsforchildrenundertheageof19andadults65andolder.

Eyeglasses are available to eligible BC First Nations under the FNHA Health Benefits program when the following conditions are met:

•PriorapprovalhasbeenprovidedbytheFNHAHealthBenefitsprogram,astherequestforinitialorreplace-menteyewearorrepairsmeetsthebenefitscriteria.

•Theitemisnotavailabletotheindividualinquestionunderaprovincial,thirdpartyagencyorhealthplan.•Theprescriptionmeetsthecriteriaforinitialorreplacementeyewearprescribedwithinthelast12monthsbyanOptometristorOphthalmologist.

The FNHA Health Benefits program will assist in the provision of initial eye glasses based on the following criteria:

•Whenthereisarefractiveerrorofatleast0.50diopters(eithereye)•Highindexlenseswillbeapprovedwherethereisarefractiveerrorwithatotalpowerinanymeridianofatleastplusorminus7.00diopters.

The FNHA Health Benefits program will assist in the provision of replacement eye glasses/ lenses based on the following criteria:

For clients age 19 & older:•Whereatleast24monthshaveelapsedsincethelastlensesorframeshavebeenapproved;•Wherethereisachangeinrefractiveerrorofatleast0.50diopters(eithereye);or•Wherethereareotherchangesinlensrequirementswhichmaynotbeassociatedwithchangeinrefractiveerrorsubjecttoapproval.

For clients 18 and younger:•Whereatleast12monthshaveelapsedsincetheeyeglasseshavebeenauthorized;or•Wheretherearechangesinframerequirementsrelatingtomedicalneedorphysiologicalchange(i.e.growthofthechild)thathasbeensubstantiatedbyamedicaldoctor,ophthalmologistoroptometrist.

The FNHA Health Benefits program will assist in the repair of eye glasses provided:•Thetotalcostoftherepairdoesnotexceedthecostforreplacementglasses;and•Therepairwillrendertheglassesinanacceptableandserviceablecondition.* Please note: Replacement frames or pairs of lenses are not considered eyeglass repairs.


The FNHA Health Benefits program pays for standard frames and lenses based on the terms and rates of the FNHA payment schedule. Any extra charges for exams and eyewear are the responsibility of the individual. The FNHA Health Benefits program is not responsible for lost or stolen eyewear.

The following are exclusions under the program (but not limited to):

•Twopairsofglasses,exceptinthesituationslistedunder“bifocallenses”•Visioncaregoodsandservicescoveredbyprovincial/territorialhealthinsuranceplans•Additionalcarryingcasesforglassesorcontactlenses•Bifocalcontactlenses•Cleaningkit•Estheticproducts•Shampoo(e.g.“nomoretears”typeshampoosolution)•Visionexamsrequiredforajob:driver’slicenseortoengageinsportsactivity•Visionexamsattherequestofa3rdparty(e.g.completingareportormedicalcertificate)•Contactlensesforestheticpurposes•Contactlenssolution•Industrialsafetyframesorlensesforsportsorprofessionaluse•Sunglasseswithnoprescription•Progressiveortrifocallenses•Photochromic/photochromaticlenses•Replacementsorrepairsasaresultofmisuse,carelessnessornegligence•Implants(e.g.punctualocclusionprocedure)•Refractivelasersurgery•Treatmentswithinvestigational/experimentalstatus•Visiontraining



VisionCareAccessProcess

EligibleFNHAclientaccesseslicensedprescriberforanexaminationandobtainsaprescription.

Clienttakesprescriptiontolicensedvisioncareprovider,suchasanopticianoranoptometrist.

IftheproviderisregisteredwithFNHA,theycompleteandforwardtherequest,assessment,and prescriptiontoFNHAHealthBenefitsforpriorapproval.

IftheproviderisnotregisteredwithFNHAtheclientmayapplyforreimbursement(uptotheFNHAbenefitamount)butmustprovidepaymentfirst.

TheFNHAHealthBenefitsprogramreviewsrequestanddetermineseligibilitybasedonprogramguidelines.

TheFNHAHealthBenefitsprogramrespondstotheproviderconfirmingbenefits.

Theproviderthenfabricates,fits,anddispensesthevisioncareitemtotheclient.

Providercompletesandtheclientsignstheapproval,whichbecomestheinvoice;theprovider forwardsthesignedinvoicetoFNHAforpayment.

GeneralAppealsProcess

Dental,MedicalSupplies&Equipment,MedicalTransportationBenefits, MentalHealth&Vision

When coverage for a benefit has been denied, the recipient or parent/ guardian of the recipient have the right to appeal the decision.Pleasenotethatexclusionsoftheprogramarenotappealable.

Therecipientorparent/guardianshouldforwardtheirletterofappealandsupportingdocumentationbymail.

Therearethreelevelsofappealavailablewhichonlytherecipientorparent/guardiancaninitiate.Inorder foracasetobereviewedasanappeal,aletterfromtherecipientorparent/guardian,accompaniedby supportinginformationfromtheproviderorprescribermustbeforwardedtotheHealthBenefitsprogram.

This information includes:

•Theconditionforwhichthebenefitisbeingrequested•Thediagnosisandprognosis,includingwhatotheralternativeshavebeentried•Relevantdiagnostictestresults(ex:dentalx-rays)•Justificationfortheproposedtreatmentandanyadditionalsupportinginformation

Ifanappealisdeniedandnewinformationbecomesavailablesupportingtheclaim,theappealcanbeescalatedtothenextappeallevel.Uponreceivingthesubmission,theFNHAHealthBenefitsprogram(orNIHBprogram)willarrangetohavethecasereviewedbyrelevantappeallevelandthedecisionwillbemadebasedonthespecificneedsoftherecipient,accumulatedresearch,theavailabilityofalternatives,andtheFNHAHealthBenefitsprogrampolicyand/orprofessionalreview.Therecipientorparent/guardianwillbeprovidedwithawrittenexplanationofthedecisionmade.

Therecipientorparent/guardianshouldforwardtheirletterofappealandsupportingdocumentationbymail,clearlymarked“APPEALS - CONFIDENTIAL”.

Formoreinformationontheappealprocessorthestatusofyourappeal,pleasecontacttheFNHAHealthBenefitsofficeat1.800.317.7878.


APPEALLevel1Director, Health Benefits Operations FirstNationHealthAuthority#540-757WestHastingsStVancouver,BC-V6C1A1 APPEALLevel2FNHA Health Benefits Appeal Review Committee Attention:VicePresident,HealthBenefits#540-757WestHastingsStVancouver,BC-V6C1A1

APPEALLevel3:CEOFirstNationsHealthAuthority#501–100ParkRoyalSouthWestVancouver,BC-V7T1A2

Appeals Procedure for: Pharmacy

APPEALLevel1:NIHB Drug Exception CentreFirstNationsandInuitHealthBranch,HealthCanadaHealth Canada200EglantineDriveway,2ndfloorTunney’sPasture,PostalLocator1902DOttawa,ON-K1A0K9

APPEALLevel2:Benefit Management and Review Services DivisionNon-InsuredHealthBenefitsFirstNationsandInuitHealthBranchHealth Canada200EglantineDriveway,2ndfloorTunney’sPasture,PostalLocator1902DOttawa,ON-K1A0K9



AppealsProcedurefor:OrthodonticBenefits

ThefollowinginformationwastakenfromtheHealthCanadaNIHBwebpageandisintendedtoprovidebasicinformationonly.Fordetailedandup-to-dateinformationonappealsprocedures,pleasevisitthewebpageat:www.hc-sc.gc.ca/fnih-spni/nihb-ssna/benefit-prestation/appe/index_e.html

ForOrthodonticBenefits,the appeal must be forwarded before the child reaches the age of 18. Noappealswillbeconsideredaftertherecipient’s18thbirthday.

The following supporting information must be provided by the Orthodontist or Dentist, including:

•Theconditionforwhichthebenefitisbeingrequested•Thediagnosisandprognosis,includingwhatotheralternativeshavebeentried•Relevantinformationanddiagnostictestresults,including:•DiagnosticOrthodonticModels-soapedandtrimmed(mountedorunmounted)•Cephalometric-radiograph(s)andtracing•Photographs-3intraoraland3extraoral•PanoramicradiographorFullmouthsurvey•Treatmentplan,estimateddurationofactiveandretentionphasesoftreatmentandcostsforwardedeitheronaFNHAHealthBenefitsprogramOrthodonticSummarySheet,CAOStandardOrthodonticInformationForm,orletterontheOrthodontist’sletterhead

•CompletedFNHAHealthBenefitsprogramDent-29Form•Parent/Guardiansignature(includingBandnameandnumberand/ordateofbirth)•Justificationfortheproposedtreatmentandanyadditionalsupportinginformation.

Therecipientorparent/guardianshouldforwardtheirletterofappealandsupportingdocumentationbymail,clearlymarked“APPEALS - CONFIDENTIAL”.

Uponreceivingthesubmission,theOrthodonticReviewCentrewillarrangetohavethecasereviewedbyanappealscommitteeofdentalprofessionals.Thedecisionwillbemadebasedonthespecificneedsofthe recipient,accumulatedresearch,theavailabilityofalternativesandFNHAHealthBenefitsprogrampolicy.

Atalllevelsoftheappealprocess,youwillbeprovidedwithawrittenexplanationofthedecisiontaken.Ifyouhavenotheardwithinonemonthofforwardingyourappealandwishtoenquireastoitsstatus,pleasecallthetoll-freenumberfortheFNHA Health Benefits program at 1.800.317.7878.


APPEALLevel1:Orthodontic ConsultantNIHBOrthodonticReviewCentreHealth Canada200EglantineDriveway,2ndfloorTunney’sPasture,PostalLocator1902DOttawa,ON-K1A0K9

APPEALLevel2:Director, Benefit ManagementNIHBOrthodonticReviewCentreHealth Canada200EglantineDriveway,2ndfloorTunney’sPasture,PostalLocator1902DOttawa,ON-K1A0K9



Client ReimbursementRecipient Reimbursement:

•ServiceprovidersareencouragedtobilltheFNHAHealthBenefitsprogramdirectlysothatclientsdonotfacechargesatthepointofservicewhenreceivinghealthcaregoodsorservices.

•WhenaFNHAclientdoespaydirectlyforgoodsorservices,heorshemayseekreimbursementfromtheFNHAHealthBenefitsprogramforeligiblebenefits.RequestsforreimbursementmustbereceivedonanFNHAHealthBenefitsprogramClientReimbursementRequestForm,withinoneyearfromthedateonwhichtheserviceswerereceived.

•Allreimbursementrequestsarereviewedbasedonbenefitscriteria.• ClientReimbursementForm(PDF123kb)Canalsobefoundthroughwww.fnha.ca/benefits

All requests for reimbursement of eligible benefits must include:

•Originalreceiptswithcostbreakdown(forexample,forPharmacy:dispensingfees,unitcost,andtheDrugIdentificationNumber(DIN);foreyewear:framesandlenses);

•IdentificationofBenefitCategory(i.e.Dental,MedicalSupplies&Equipment,MedicalTransportation,Pharmacy,Vision,Short-termCrisisIntervention,orMentalHealthCounselling);

•Client’sname,correctmailingaddress,identificationnumber,andhealthcarenumber;•Acopyoftheprescription,ifapplicable;•AcompletedrecipientauthorizationsectionontheFNHAHealthBenefitsprogramClientReimbursementRequestFormincludingrecipient’ssignatureanddate;and

•Primaryinsurer’sExplanationofBenefits,ifcoordinationofbenefitsisapplicable;•IndicatePayeenameandaddressifdifferentfromtheclientortheclientisaminor.

Dental reimbursements must include:

•CompletedStandardDentalClaimformorFNHAHealthBenefitsprogramDent-29formfromprovidersignedbytheclientandprovider;

•Originalreceipts/StatementofAccountverifyingprocedurespaidinfull;•Primaryinsurer’sExplanationofBenefits,ifcoordinationofbenefitsisapplicable.

FOR DETAILED INSTRUCTIONS ON HOW TO COMPLETE THE REIMBURSEMENT REQUEST FORM, REFER TO PAGE 2 OF THE FORM.


Leaving British ColumbiaThefollowinginformationwastakenfromtheMedicalServicesPlanwebpageandismeanttoprovidebasicinformationonly.FordetailedinformationonMSP,pleasevisittheirwebpageat:www.health.gov.bc.ca/msp

Temporary Absence from British Columbia:

•Youmaybeeligibletoreceivecoverageforupto24monthsduringatemporaryabsencefromBC.Approvalislimitedtoonceinfiveyearsforabsencesthatexceedsixmonthsinacalendaryear.

•ResidentswhospendpartofeveryyearoutsideBCmustbephysicallypresentinCanadaatleastsixmonthsinacalendaryearandcontinuetomaintaintheirhomeinBCinordertoretaincoverage.Ifyouareunsurewhetheryouwillqualifyforcoverageduringanabsenceorknowyoureligibilitywillend,contactMSPwithdetails.

•WhenyoustayoutsideBClongerthantheperiodforwhichyouareentitledtocoverage,youwillberequiredtofulfillawaitingperioduponreturntotheprovincebeforecoveragecanberenewed.

•Youshouldbeawarethatyourprovincialcoveragemaynotpayforallthehealthcarecostsyoumayincur outsidetheprovince,andthedifferencecanbesubstantial.Forexample,BCpays$75(Cdn)adayforemer-gencyin-patienthospitalcare,whiletheaveragecostintheU.S.oftenexceeds$1,000(US)aday,andcanbeashighas$10,000(US)adayinintensivecare.Forthisreason,youarestronglyadvisedtopurchaseadditionalhealthinsurancefromaprivateinsurerbeforeyouleavetheprovince,whetheryouaregoingtoanotherpartofCanadaoroutsidethecountry–evenifyouplantobeawayforonlyaday.SeeMedical Care – Outside British ColumbiaontheBCMSPWebpageformoreinformation.

Renewing Your Coverage:

•Whenclientsturnnineteen(19)yearsold,theyneedtobethemainaccountholderontheircoveragesinsteadofasdependentsontheirparents’orguardians’MSPcoverages.TheHealthBenefitsprogramrecommendsthatthoseclientsconfirmthattheirMSPcoveragesareactiveatthattime.

•Ifyouworkedinanotherprovinceforpartoftheyear,oraccessedmedicaland/orambulanceservices outsideofBC,yourMSPrecordsmaybeflaggedforresidencyverification.Ifthereisconfusionregardingyourresidentaddress,MSPmayrequestforproofofresidency,suchasacopyofyourrentalorlease agreementofaBCresidentaddress.

•IfthereisanyinterruptiontoyourMSPcoverage,youmayneedtoreapply.


Studying Outside British Columbia:

•ResidentswholeaveBCtemporarilytoattendschooloruniversitymaybeeligibleforMSPcoverageforthedurationofstudies,providedtheyareinfull-timeattendanceatarecognizededucationalfacilityandareenrolledinaprogramthatleadstoadegreeorcertificaterecognizedinCanada.

•Generally,beneficiarieswhohavebeenstudyingoutsideBCmustreturntotheprovincebytheendofthemonthfollowingthemonthinwhichstudiesarecompleted.AnystudentwhowillnotreturntoBCwithinthattimeframe,andwhohasbeenawayforlessthan24months,shouldcontactMSPtodiscusstheirsituation.

Permanent Move from British Columbia:

• Within Canada–coverageisprovidedforthebalanceofthemonthinwhichyouleavetheprovinceplustwoconsecutivemonths.Ifrequired,coveragemaybeextendedforuptothreeextramonthstocoveryouwhileintransit.Uponarrival,youshouldimmediatelyapplytothehealthplanofthenewprovinceorterritory.

• Outside Canada–coverageisprovidedforthebalanceofthemonthinwhichyouleavetheprovince. YoushouldadviseMSPofyourmoveassoonaspossible.

Cancelling Your Coverage:

•IfyouwillnolongerbearesidentofBC,youmustnotifyMSPofthedateofyourdepartureandyournewaddress;otherwise,premiumbillingmaycontinue(Note:failuretopaypremiumsdoesnotconstitute notificationtocancelyourcoverage).

Medical Care – Outside British Columbia:

•IfyouareeligibleforcoveragewhiletemporarilyabsentfromBC(seeTemporary Absence from British ColumbiaontheBCMSPWebpage),MSPwillhelppayforunexpectedmedicalservicesyoureceiveany-whereintheworld,providedtheservicesaremedicallyrequired,renderedbyalicensedphysician,andnormallyinsuredbyMSP. ReimbursementismadeinCanadianfundsanddoesnotexceedtheamountpayablehadthesameservicesbeenperformedinBC.Anyexcesscostistheresponsibilityofthebeneficiary.

•MSPdoesnotcovertheservicesofhealthcareprovidersotherthanphysicians(e.g.chiropractorsorphysicaltherapists)outsidetheprovince.Similarly,PharmaCaredoesnotprovidecoverageforprescriptiondrugsormedicalsupplieswhenobtainedoutsideBC.

•ItisalsoimportanttobeawarethattheMinistryofHealthdoesnotsubsidizefeeschargedforambulanceserviceobtainedoutsideofBC.IfyourequireambulanceservicewhileinanotherprovinceoroutsideCanada,youwillbechargedthefeesestablishedbytheout-of-provinceambulanceserviceprovider.Feesrangefromseveralhundredtoseveralthousanddollars.Whenpurchasingadditionalout-of-provinceinsurance,youareadvisedtoobtaininsurancethatwillcoveremergencytransportationwhileyouareawayand,ifnecessary,thecostoftransportationbacktoBC.


Out of Province Emergency Medical Care:

•MostphysiciansinotherCanadianprovincesandterritories(exceptQuebec)willbilltheirownprovincialhealthplanforservicesprovidedifyoupresentyourvalidBCCareCard.Theprovincesrecoverthefundingmonthlybetweeneachother.

•WhentravellinginQuebecoroutsideCanada,youwillprobablyberequiredtopayforyourmedicalservicesandseekreimbursementlaterfromMSP(useanOutofCountryClaimForm).

•BCresidentsarestronglyadvisedtopurchaseadditionalhealthinsurancewhentravellingtootherCanadianprovincestocoverthecostofservicesnotincludedinthereciprocalagreementbetweenprovinces.

IT IS STRONGLY ADVISED THAT CLIENTS PURCHASE ADDITIONAL HEALTH INSURANCE WHEN TRAVELLING OUTSIDE OF CANADA.


Common Questions & Answers: FNHA Health BenefitsGeneralQuestions

Q) Do I have to pay upfront for FNHA Health Benefits?

A)Yourbenefitprovider(e.g.yourpharmacistordentist)mustinformyouifyouareexpectedtopaydirectlyforanyservicesoritems.FNHAHealthBenefitsstronglyencouragesproviderstobillFNHAHealthBenefitsdirectly;however,somedonot.

Q) Can I continue to use my current provider (e.g. my pharmacist or dentist) if they do not bill FNHA Health Benefits directly?

A)Yes,thatisyourchoice.However,itisrecommendedthatyoucontacttheFNHAHealthBenefitsoffice(604.666.3331;ortollfree1.800.317.7878)beforepurchasinganyitemorreceivinganyservicetoensurethattherequesteditemorserviceiseligibleforcoverageunderFNHAHealthBenefits.Rememberthatinsuchcases,youmustpayyourproviderfirstandthenforwardtheproperinformationtoFNHAHealthBenefitsinordertobeconsideredforreimbursement.YoushouldalsonotethatyourprovidermaychargemorethantheratecoveredbyFNHAHealthBenefits,whichmeansthatyouwouldnotbereimbursedthefullamountthatyoupaid.

Q) Why should I keep my private insurance if I am eligible for FNHA Health Benefits?

A)ItisimportanttonotethatasaregisteredFNHAclient,youshouldmaintainanyprivate,employer-sponsored,orotherpublichealthcarecoverageyoumayhave,assomeofthebenefitsyoumaycurrentlybereceivingmaynotbeeligiblebenefitsunderFNHAHealthBenefits(e.g.physiotherapyandchiropractictreatment).ForbenefitsthatareavailableunderbothyourprivateplanandFNHAHealthBenefits,yourclaimsmustfirstbeforwardedtoyourcurrentplanorprogrambeforeforwardingthemtoFNHAHealthBenefits.ForFNHAHealthBenefitseligiblebenefits,theremainingamountofyourclaimnotpaidforbyyourprivateplancanthenbeforwardedtoFNHAHealthBenefitsinordertobeconsideredforreimbursement.

Q) Does FNHA Health Benefits provide out-of-country coverage?

A)FNHAHealthBenefitsmaycoverthecostofprivatelyacquiredsupplementalhealthinsurancepremiumsforapprovedclientswhomaybestudentsormigrantworkers.Supplementaryhealthinsurancecoverageforallotheroutsideofcountrytravel(e.g.vacationtravel)isnotabenefitunderFNHAHealthBenefits.WhentravellingoutsideofCanada,itisrecommendedthatyoubuytravelhealthinsuranceincaseofanemergency.


Q) What is the difference between an exception and exclusion?

A)FNHAHealthBenefitsmayprovidecoverageasanexceptionforgoodsandservicesthatarenotincludedintheNIHBbenefitlistsandthatarenotanexclusionoftheProgram.Exceptionrequestswillbeconsideredonacase-by-casebasisuponreceiptofwrittenmedicaljustificationfromtheprovider. ExclusionitemsaregoodsandserviceswhicharenotlistedasbenefitsonFNHAHealthBenefitsbenefitlistsandarenotavailablethroughtheexceptionprocessorsubjecttoappeal.Therefore,excludeditemswillnotbecoveredbyFNHAHealthBenefitsunderanycircumstance.Thesemayinclude,butarenotlimitedto,itemsusedexclusivelyforsports,work,education,cosmeticreasons,areexperimental,orarepartofasurgicalprocedure.

Q) Can I appeal a decision and how would I go about it?

A)WhencoverageforabenefitthroughFNHAHealthBenefitshasbeendenied,therecipientorparent/guardianoftherecipient,hastherighttoappealthedecision.Appealsmustbeforwardedinwritingandcanbeinitiatedbytheclientorlegalguardian.Aninterpreter,advocate,CHR,orsupportliaisonmayassisttheclientincompilingtheappeal,buttheclientmustrequesttheappealbygivinginputintoitandsigningthelettertoinitiatetheappealprocess.Therearethreelevelsofappealavailable.Ateachstage,theappealmustbeaccompaniedbysupportinginformationfromtheproviderorprescribertojustifytheexceptionalneed. Ateachlevelofappeal,theinformationwillbereviewedbyanindependentappealstructurethatwill providerecommendationstotheprogrambasedontheclient’sneeds,availabilityofalternatives,andFNHAHealthBenefits.Atalllevelsoftheappealprocess,theclientwillbeprovidedwithawrittenexplanation ofthedecisionmade.Pleasenotethatexclusionsoftheprogramarenotsubjecttoappeal.

AMBULANCEBILLS

Q) Why have I received a bill for ambulance services?

A)AmbulanceservicesarenotcoveredthroughtheBCMedicalServicesPlan;however,theycanbecoveredthroughFNHAHealthBenefits.Theserviceprovider(BCAmbulance)maynothavebeenprovidedwithyour10digitstatusnumberatthetimeoftheservice.Clientsmustprovidetheirstatusnumbertothe serviceproviderinorderforthemtoinvoiceFNHAHealthBenefits.Calltheproviderorsendbackthebillwithyour10digitstatusnumber,dateofbirthandregisteredstatusname.Oncetheproviderhasthe statusnumberanddateofbirththeinvoicewillbesenttotheFNHAHealthBenefitsofficeforreview. Ambulance Services Billings Department:1.800.665.7199


BCMEDICALSERVICESPLAN(MSP)

Q) I filed my income tax return and the Canada Revenue Agency is indicating that I owe for unpaid MSP premiums.

A)TheMedicalServicesPlanpremiumsarebeingbilleddirectlytotheFNHAclientratherthantoFNHAHealthBenefits.ThismayoccurwhenaFNHAclientisregisteredunderanotherplan(i.e.throughtheiremploy-er)andisnotregisteredthroughFNHAHealthBenefits.Oncetheyleavetheirjob,theemployerhastakenthemofftheirlistandMSPautomaticallybeginsinvoicingtheclient.Itisimportantforclientswhoarere-ceivingMSPbenefitsthroughanotherplantonotifytheFNHAHealthBenefitsoffice.TheFNHAclientneedstocompleteanMSPapplicationformandforwardittotheHealthBenefitsoffice,withtheattachedbillandaphotocopyoftheindividual’sbirthcertificatesotheycanberegisteredontheFNHAHealthBenefitsgroupnumber.IftheFNHAclientishavingdifficultieswiththeirincometaxesbecauseofunpaidpremiumstheymaycontacttheFNHAHealthBenefitsoffice.

Q) Can you tell me what services the CareCard (or its replacement, the BC Services Card) does not cover?

A)SomeexclusionforMSPinclude:surgeryforalterationofappearance(cosmeticsurgery),reversalofsteriliza-tion,in-vitrofertilization,artificialinsemination,geneticscreeningandothergeneticinvestigationsincludingDNAprobes,acupuncture,hypnotherapy,acupressure,andproceduresstillintheexperimentalordevelop-mentalphase.ClientsshouldcontactMSPforacompletelistofwhatiscoveredandwhatisnot.

Q) Do I have to replace my MSP card?

A)HavingFNHAcoveragefortheMSPpremiumsdoesnotchangethePersonalHealthNumber(PHN).However, thenewBCServicesCardarenowbeingissuedwiththegoalofeventuallyreplacingallexistingCareCards by2018.Thenewcardshaveenhancedsecurityfeaturestohelpprotectpersonalinformation.Thenew cardscanbeprocessedbyanICBCdriverlicensingofficeorServiceBCcanbecontactedtollfreeat:1.800.663.7867foranalternateapproach.FormoreinformationabouttheBCServicesCard,pleasevisitwww.gov.bc.ca/bcservicescard

Q) I received an ambulance and hospital bill for medical care incurred in the United States and, unfortunately, I did not buy the supplemental coverage for travel outside of Canada. Can FNHA Health Benefits assist in paying?

A)No,FNHAHealthBenefitswillnotcoversupplementalcoverage.YoumaywanttocontacttheMinistryofHealthServicesout-of-countryclaimsdepartmenttodiscussanyothercoverageyoumayhavethroughtheBCmedicalplan.

Q) Are chiropractic, massage therapy, naturopathy, physical therapy and podiatry services covered through MSP or FNHA Health Benefits?

A)TheseservicesarenotgenerallycoveredthroughMSP.ThereisanexceptionforclientswhosepremiumsarebeingpaidbyFNHA.MSPpaysasetamountpervisitforacombinedannuallimitof10visitseachcalendaryearforthefollowingservices:chiropractic,massagetherapy,naturopathy,physicaltherapy,andnon-surgicalpodiatry.ClientsshouldcontactMSPtodetermineeligibilityandtheamounttheywillcover.


Q) Are there any exceptions for additional physical therapy, chiropractic or massage therapy, and can the user fees be reimbursed by FNHA Health Benefits?

A)No,FNHAHealthBenefitsdoesnotpayfortheseservicesanddoesnotreimburseanyuserfees.

Q) Are removable air casts a benefit?

A)AircastsforthetreatmentofinjuriessuchassprainsorbrokenbonesarenotabenefitunderFNHAHealthBenefits.Treatmentoftheseconditionsisusuallyprovidedbyahospitalasaprovinciallyinsuredservice(i.e.plastercasts).Removableaircastsmaybeconsideredasanexceptionwithappropriatejustification,suchasdiagnosisandtreatmentofDiabeticPlantarNeuropathic/Ischaemicfootulcers.

PHARMACYBENEFITS

Q) I have been prescribed a drug by my physician and the pharmacy has told me that it is not covered through FNHA Health Benefits. Why?

A)FNHAHealthBenefitshasacomprehensiveDrugBenefitListtowhichthepharmacyhasaccess.Inmostcasesthedrugsprescribedareonthelistandthepharmacistcandispensethemimmediately;however,somedrugsprescribedneedpriorapprovalandmustgothroughtheDrugExceptionCentre(DEC).Theseareconsideredexceptions.OncethepharmacistinitiatesanexceptionandithasbeendeniedbytheDrugExceptionCenter,thentheFNHAclientmayappealthedecision.Somedrugsareexcludedfromthedrugbenefitlistandarenotsubjecttotheappealprocess.

DENTALBENEFITS

Q) My dentist is charging me for treatment. Why?

A)FNHAHealthBenefitsDentalprogramhasitsownfeeschedule,whichmaynotcoverallthefeeschargedbytheprovider.AnychargesexceedingFNHAHealthBenefitsfeesarenoteligibleforreimbursement.Pleaseconfirmwithyourproviderwhat,ifany,yourfinancialresponsibilityispriortoreceivingtreatment.

Q) Why does my dental provider have to send in a request before performing some services?

A)Predetermination,orpriorapproval,iscommontomostpublicandprivatedentalplans.ThepredeterminationprocessensuresthatboththedentalproviderandFNHAclientareinformedofthepoliciesandunderstandthecoveragecommitments.ClientsmustmeetalloftheclinicalcriteriaandguidelinesestablishedbyFNHAHealthBenefitsforthedentaltreatmenttobeconsideredforcoverage.

Q) My dentist informed me that treatment was not approved. Why?

A)FNHAHealthBenefitsevaluatesalldentalpredeterminationsagainstitsDentalFrameworkwhichoutlinesthetypesofbenefitsavailabletoclientsandtheircoveragecriteria.Toprovidecoverage,allestablishedpolicies,guidelinesandcriteriamustbemet.


Contact Information

GeneralToll-Free: 1.855.550.5454Email:[email protected]

Operations(ClaimSpecific)Dental MedicalSupplies&EquipmentMedicalTransportationMentalHealthCrisisInterventionMSPCoveragePharmacyVision

Toll-Free:1.800.317.7878Dental Toll-Free: 1.888.321.5003Fax:1.888.299.9222PleasehaveyourStatuscardandCareCardready

In-personInquiries1166AlberniStreet,Room701Vancouver,BCV6E3Z3

MailingAddressFirstNationsHealthAuthorityHealthBenefitsProgram-ClientServices540-757WestHastingsStreetVancouver,BCV6C1A1

Onlinewww.fnha.ca/benefits


Health Benefits Operations Toll-Free Number Tree Map

Health Benefits Toll Free Number: 1-800-317-7878

Press 1:PatientTravel/Vision/MedicalSupplies&EquipmentorPharmacy

Press 2:DentalorDial1-888-321-5003

Press 4 :MedicalServicePlan(MSP)-CareCard

Press 3:MentalHealth(IndianResidentialSchool)

Press 5:BenefitExceptionandAppeals

Press 6:FaxandAddress

Press 1:PatientTravel

Press 1:MentalHealthCrisisInterventionCounselling

Press 2:Vision

Press 2:IndianResidentialSchoolCounselling

Press 3:MedicalSupplies&Equipment

Press 4:Pharmacy


First Nations Health Authority Health BenefitsContact Information

GeneralToll-Free: 1.855.550.5454Email:[email protected]

Operations(ClaimSpecific)Dental MedicalSupplies&EquipmentMedicalTransportationMentalHealthCrisisInterventionMSPCoveragePharmacyVision

Toll-Free:1.800.317.7878Dental Toll-Free: 1.888.321.5003Fax:1.888.299.9222PleasehaveyourStatuscardandCareCardready

In-personInquiries1166AlberniStreet,Room701Vancouver,BCV6E3Z3

MailingAddressFirstNationsHealthAuthorityHealthBenefitsProgram-ClientServices540-757WestHastingsStreetVancouver,BCV6C1A1

Onlinewww.fnha.ca/benefits

health benefits - first nations health authority purpose of the program is to provide health...

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