Guide to Mental Health Benefits

Effective date: June 29, 2020

Effective June 29, 2020, Express Scripts Canada is providing claims processing services for the mental health benefit. Providers are encouraged to enrol and send their claims directly to Express Scripts Canada so that clients do not pay fees at the point of service. Please refer to the mental health page on the Express Scripts Canada website for the mental health regional fee grids.

Table of contents

1.0 Introduction

1.1 Purpose of the guide

This guide outlines the terms and conditions, criteria, guidelines and policies for the NIHB program's mental health counselling benefit, including:

  • client eligibility
  • benefit coverage
  • prior approval process
  • claims submission process

Administrative information for providers on how to submit prior approval requests and make claims can be found in the Mental Health Claims Submission Kit, available at the Express Scripts Canada website.

For more information, clients and providers may contact the NIHB regional office.

1.2 NIHB program overview

Indigenous Services Canada's Non-Insured Health Benefits program is a national program that provides eligible First Nations and Inuit clients with coverage for a range of medically necessary health benefits when these benefits are not otherwise covered through private or provincial or territorial health insurance plans or social programs.

NIHB program benefits include prescription drugs and over-the-counter medications, dental and vision care, medical supplies and equipment, mental health counselling, and transportation to access medically required health services that are not available on the reserve or in the community of residence.

1.3 NIHB mental health counselling benefit

The mental health counselling benefit operates as part of a continuum of mental wellness programs provided by Indigenous Services Canada, which are linked to mental wellness services that are provided by communities, and provinces and territories. An overview of other Indigenous Services Canada's mental health programming can be found in section 6.2 of this guide.

The NIHB program's mental health counselling benefit is intended to provide coverage for professional mental health counselling to complement other mental wellness services that may be available to clients or in communities. Providers should make themselves aware of the current mental wellness services available in the community, and locally from the province or territory and consider linking the client to such services.

The provision of this benefit is part of Indigenous Services Canada's commitment to work towards the development of a coordinated and comprehensive approach to mental health and addiction programming. Mental health counselling coverage is offered in a way that:

  • recognizes NIHB mental health counselling benefit as a component of a mental wellness continuum that includes other Indigenous Services Canada, community-based and provincial or territorial mental health programming and services
  • supports culturally competent mental health counselling

Providers should be aware that mental health counselling for some clients may be managed or provided by their community. Where this is the case, the regional office will redirect the client or provider to the community.

Some clients receive health benefits coverage through other arrangements, such as a self-government agreement or via a First Nations or Inuit health authority. In such cases, this guide may not apply as these organizations establish their own policies regarding health benefits coverage.

2.0 Provider enrolment and payments

Processing of payments, including provider claims and client reimbursements for the NIHB program mental health benefit are done through Express Scripts Canada.

Effective June 29, 2020, mental health counselling providers must be enroled with Express Scripts Canada in order to bill the NIHB program for services provided to eligible First Nations and Inuit clients. Please note that providers who are not enroled with Express Scripts Canada will no longer be able to submit claims for the NIHB program.

Providers are encouraged to enrol, and to send their claims directly to Express Scripts Canada for payment so that clients do not pay fees at the point of service. For many clients, balance billing and charging up front for services are barriers to accessing services.

Claims for payment, including provider claims and clients reimbursements, must be received by Express Scripts Canada within one year from the date of service to be eligible for payment. In order for the claim to be paid out, the service or item must be an eligible benefit and the client must have been eligible as of the date of service.

2.1 Provider eligibility requirements

To be enroled, providers must be registered in good standing with a legislated professional regulatory body and eligible for independent practice in the province or territory in which the service is being provided. Depending on the governing legislation, this may include the following:

  • registered psychologists
  • registered social workers with clinical counselling orientation
  • registered psychiatric nurses
  • registered psychotherapists
  • other regulated mental health providers permitted to practice by legislation

The provider must remain in good standing at all times to continue to be enroled. The program will regularly confirm provider status with the regulatory body.

Providers may be approved to provide services outside of the province or territory in which they are registered with their legislated regulatory body if:

  • their legislated regulatory body has the capacity of performing its functions in the province or territory where the services being requested is taking place
  • there are no similar legislated regulatory bodies in the province territory where the service is being provided

In exceptional circumstances, other providers belonging to a non-legislated entity that functions as a self-regulatory body may be enroled. In such cases, a counsellor who is certified by a non-legislated self-regulatory body may be enroled, where there are no other legislated providers enroled with the NIHB program in the vicinity and access to services is therefore limited.

2.2 Provider enrolment process

Enrolment process

Providers wishing to deliver services reimbursed by NIHB must complete a Mental Health Counselling Billing Agreement found in the Mental Health Counseling Professional Provider Enrolment Package and submit it Express Scripts Canada. A complete list of documents required for enrolment is available at the Express Scripts Canada website.

Providers must disclose any work that they do with other mental health programs or organizations that provide services to members of First Nations or Inuit communities.

2.3 Provider roles and responsibilities

Before initiating counselling, providers must confirm that the client and any services they propose to provide to the client are eligible for coverage, as ineligible services will not be reimbursed. By submitting a payment request to Express Scripts Canada, a provider indicates understanding and acceptance of the terms and conditions for receiving payment for services.

Providers must:

  • be aware of the current continuum of mental wellness services available to clients in their community, and locally from the province or territory
  • confirm that the client is eligible for NIHB
  • obtain prior approval before initiating counselling (other than the first 2 hours)
  • ensure that the client understands the coverage that is available
  • complete a client assessment and discuss the recommended number of counselling hours with the client
  • complete a treatment plan to be kept on the client's file
  • as part of the treatment plan, the provider is encouraged to consider linking the client to community-based mental health services or other culturally appropriate services, where available
  • keep all client records (including date, location, and start/end time)
  • ensure that they do not knowingly submit a claim for payment for services that are funded by or will be paid by another plan or program
  • comply with professional regulatory body requirements for security, police record checks, and client file management

As part of their ongoing professional development, providers are encouraged to continue to enhance their knowledge of First Nations and Inuit cultures. This can include opportunities provided by their professional associations, through First Nations or Inuit communities or organizations, or other related training.

The Mental health counselling services information form in the Mental Health Counseling Professional Provider Enrolment Package found on the Express Scripts Canada website provides an opportunity for providers to indicate their areas of expertise or specialization and their experience in supporting First Nations and Inuit (cultural competence). Providers are encouraged to update their records regarding areas of expertise or specialization. Clients may contact the programs to request the names and contact information of providers with particular areas of expertise or specialization.

Mental health counselling providers must follow applicable privacy legislation, regulations and professional regulatory body requirements applicable to maintaining their records. Client files are in the control of the provider and not Indigenous Services Canada.

Group counselling

All group counselling hours will be counted towards the client's benefit coverage.

Group counselling is used at the discretion of the provider, whose role it is to plan treatment with the client, such as where a client might benefit from sharing common experiences or interactions with individuals facing similar concerns. The following examples are for illustration only:

  • adjustment to a major life event or transition (for example, medical diagnosis of serious illness or death of a loved one)
  • management of an issue which requires psycho-social support to regain or retain equilibrium (for example, caregiver stress)
  • other issues, for example, anger management

When offering group counselling, providers should provide it using a group size and manner that is in compliance with standards established by their regulatory body.

Providers are to make a claim for each eligible individual client at the group rate indicated on the client's Prior Approval Form (that is, there is no payment provided for running the group as a whole) that can be found at the Express Scripts Canada website as well as the fee grids. Such coverage is not intended to subsidize other new or existing group counselling programs.

Family counselling

Counselling offered to an individual, which includes the participation of family members, is billed as part of the claim for the eligible client at the usual individual hourly rate.

Coverage for telehealth in mental health counselling

Coverage may be available for mental health services provided through telehealth (for example, the use of video-conferencing or telephone to deliver mental health services). Please note that instant messaging and email are not eligible for reimbursement.

Coverage for telehealth is only provided if the client agrees to its use. The provider must return to face-to-face counselling at any time the client wishes to do so.

In using telehealth, providers are responsible to ensure that its use:

  • meets the standards and code of ethics of their respective legislated regulatory bodies and provincial or territorial regulations in the provision of mental health services through telehealth, including client privacy and confidentiality
  • follows the Model Standards for Telepsychology Service Delivery adopted by the Association of Canadian Psychology Regulatory Organizations in provinces or territories where a provider's regulatory body does not have guidelines for the provision of telehealth

Providers must:

  • ensure their ongoing competence with service delivery technologies for mental health, and mitigate any potential negative impacts of the technology on the client
  • determine the suitability of telehealth services for delivering mental health services for the client. This determination should be based on the provider's professional judgment that takes into consideration such factors as client safety and the accomplishment of therapeutic goals

And:

  • the technology (for example, video conferencing or telephone) and location (for example, nursing station, community health centre, or other) used to provide counselling services will be determined by the provider based on the client's case, and in accordance with the provider's regulation related to the delivery of telehealth services
  • the provider must have a process in place to confirm the client's attendance through telephone log, attendance sheet or email confirmation, depending on the modality
  • the fees for telehealth are the same as for face-to-face counselling (the cost of the equipment, line, etc. are the responsibility of the provider).

Initial client assessments should generally be undertaken in-person. In exceptional circumstances, coverage for assessment via telehealth may be approved.

Please also refer to the terms and conditions as outlined in the Mental Health Counselling Billing Agreement found in the Mental Health Counseling Professional Provider Enrolment Package on the Express Scripts Canada website.

2.4 Claims verification program

Verification activities are conducted as part of the NIHB program's need to comply with accountability requirements for the use of public funds and to ensure provider compliance with the terms and conditions of the program as outlined in this provider guide, the Claims Submission Kit, Mental health counselling professional provider enrolment package and other relevant documents. The program reserves the right to withhold any future payments to providers pending receipt of monies determined to be paid in error.

2.5 Privacy statement

Indigenous Services Canada's NIHB program has the responsibility to protect personal information under its control in accordance with the Privacy Act and its related Treasury Board policy and directives, and is responsible for ensuring that the personal information collected is limited to that which is necessary to administer the program.

For more information, please contact Indigenous Services Canada's Access to Information and Privacy (ATIP) Coordinator at 819-997-8277 or aadnc.atiprequest-aiprpdemande.aandc@canada.ca. You also have the right to file a complaint with the Privacy Commissioner of Canada if you think your personal information has been handled improperly.

3.0 Mental health counselling

3.1 Client eligibility

To be eligible for NIHB program benefits, a client must be a Canadian resident and have one of the following statuses:

  • a First Nations person who is registered under the Indian Act (commonly referred to as a "status Indian")

OR

  • an Inuk, recognized by one of the following Inuit Land Claim organizations — Nunavut Tunngavik Incorporated, Inuvialuit Regional Corporation, Makivik Corporation. For an Inuk residing outside of their land claim settlement area, a letter of recognition from one of the Inuit land claim organizations and a birth certificate are required

OR

  • an infant, less than 18 months of age, whose parent is an eligible client

AND

  • currently registered or eligible for registration, under a provincial or territorial health insurance plan
  • not otherwise covered under a separate agreement with federal, provincial or territorial governments

Client identification is noted in section 3.4.

3.2 Client roles and responsibilities

Clients must first access any alternate health coverage that is available to them. They should also contact their local community organizations (health centre, friendship centre, or primary health care provider) and/or the NIHB regional office to determine if community mental health programs are available.

Clients should be aware that only services delivered by an eligible provider (see section 2.1) are eligible for reimbursement. Eligible providers can enrol for direct billing to the program.

Clients can contact the NIHB regional office to obtain a list of enroled providers. Some providers have also indicated their areas of expertise/specialization and their experience with First Nations and Inuit (cultural competence). Note that this information is self-reported by the provider. Clients can request a list of enroled providers closest to them with this experience.

Clients are not limited to enroled providers only: if a client would like to work with an eligible counsellor (see section 2.1) who is not yet enroled, the counsellor should apply for enrolment before counselling begins (if they do not do so, they will not be able to direct bill).

Clients are responsible to keep their information up-to-date in order to avoid delays in accessing NIHB benefits. In case of a name change or changes to any other personal information:

  • First Nations clients should contact their local Band Office or Indigenous Services Canada Registration Services Unit at 1-800-567-9604 to update their status cards
  • Inuit clients should contact their Land Claim Organization to update their personal information. Inuit living outside the Northwest Territories or Nunavut should also contact by sending an email to HC.FNIHB_NIHB_SVSHICPS_DGSPNI_SSNA.SC@canada.ca

If clients have concerns regarding the counselling they receive, or the professional conduct of a counsellor, clients are encouraged to contact the provider's regulatory body. Please note that mental health counsellors are independently regulated health professionals and not employees of Indigenous Services Canada.

3.3 Coverage and frequency guidelines

Every 12 months, coverage is available for up to 22 hours of counselling performed by an enroled provider on a fee-for-service basis (for example, individual, family, or group counselling), consisting of:

  • initial assessment (maximum of 2 hours). Does not require prior approval, in order to facilitate timely access to services
  • up to 20 hours of counselling, not including the initial assessment. Prior approval is required (see section 3.4)

Additional hours in the same 12-month period may be provided on an exception basis.

Providers must verify a client's eligibility (see section 3.4). Only services to eligible clients can be reimbursed.

Services submitted for coverage must not be eligible for payment by another provincial/territorial, federal, or private plan or program, except in the case of coordination of benefits (see Section 3.5).

Exceptions

Requests for counselling beyond the noted frequency or additional requests within any 12-month period may be considered on an exception basis.

Exclusions

Coverage for certain services will NOT be provided under any circumstances and is not subject to the appeal process. These include:

  • accommodations and treatment fees for facility-based addiction treatment (publicly funded addictions treatment is available to eligible clients through the Indigenous Services Canada's Mental Wellness program or through programs funded by provincial or territorial governments. Contact the NIHB Regional office for more information on accessing these programs)
  • services that are paid by the Indian Residential Schools Resolution Health Support Program. Claims are to be made either to the NIHB program or the Indian Residential Schools Resolution Health Support Program, but not both. See the Indigenous Services Canada website for more information on Indian Residential Schools Resolution Health Support Program
  • services that are funded by another program or agency (such as counselling provided to incarcerated clients), psychiatric and family physician services insured through the provincial or territorial health plan
  • services for the purpose of a third party (for example, school application, employment assessment, to support a legal action, child custody)
  • any service by a non-eligible provider, regardless of its purpose (see section 2.1 for eligible providers)
  • services for a purpose other than mental health counselling (for example, psychoeducational testing assessments, educational and vocational counselling, life skills training, life coaching/mentoring, early intervention/enrichment programs, sex therapy)
  • telehealth through instant messaging or emails

3.4 Prior approval process

With the exception of the first 2 hours of counselling, prior approval is required for all services, and on an exception basis, claims may be post-approved. The Prior Approval Form establishes the total number of hours approved and how these services will be delivered (individual, group, telehealth). Prior approval is intended to confirm:

  • the client is eligible for coverage
  • the provider is enroled or eligible for enrolment
  • the coverage that is available

The Prior Approval Form is available at the Express Scripts Canada website.

Consideration of services beyond the annual frequency may be considered on an exception basis, as will reimbursement for services that have already been delivered but where prior approval was not sought in advance. All such claims must include a fully completed Prior Approval Form.

Prior approval requests will be assessed within 5 business days of being submitted. The provider will be advised of the outcome of the prior approval process.

Client identification

To facilitate verification, providers should provide all the following client identification information:

  • surname (under which the client is registered)
  • given names (under which the client is registered)
  • date of birth
  • client Identification number

Identification numbers for registered First Nations clients

One of the following identifiers is required for registered First Nations clients:

  • Indian Act Registration number (may be known as "status or treaty card" or official letter marked "Certificate of Indian Status") (if the client's full number is not known the program's NIHB regional office can assist using the client's name, date of birth and community), or
  • in certain specific situations, instead of a registration number, some First Nations clients may have a number issued by NIHB (B number)

Identification numbers for recognized Inuit clients

One of the following identifiers is required for recognized Inuit clients:

  • Government of Northwest Territories (NWT) health care plan number
  • Government of Nunavut (NU) health care plan number
  • NIHB client identification number (N number)
  • NIHB program letter (on Government of Canada letterhead) identifying the client and accompanied by picture identification

In cases where there is a discrepancy between the information/documents used to verify a client's eligibility for the NIHB program and the name presented by the client, the provider is asked to request, in addition to the status card or Inuit eligibility documents, another recognized form of provincial or federal photo identification (providers should keep a record that this was done).

3.5 Claim submission

Coordination of benefits

Clients are required to access any public (federal, provincial, or territorial) or private health care plan for which they are eligible prior to accessing the NIHB program. If the client has other coverage, the claim must be submitted to the other payer first before submitting to Express Scripts Canada.

Where a client has other coverage, an explanation of benefits or other written confirmation from the other carrier will be required before a NIHB claim can be processed. If this other health benefits coverage is no longer in effect, clients should inform the NIHB Regional Office.

Provider reimbursement

Please note that claims will be paid when all the following criteria are met:

  • the claim is for an eligible client
  • claim has been submitted to any alternate health plans (public or private) to which a client is eligible prior to being submitted to the NIHB program
  • claim has not been submitted for any portion of the service that has already been paid by any other program, or for which the provider has received alternate payment via salary or contract
  • prior approval requirements are met
  • fees charged are as approved on the Prior Approval Form found on Express Scripts Canada website
  • a fully completed and signed Prior Approval Form has been submitted to Express Scripts Canada

There will be no reimbursement for missed appointments and payment may be withheld if attendance cannot be confirmed.

Providers are encouraged to make regular submissions for claims rather than waiting for the end. Claim forms submitted more than 1 year from the service provision date will not be accepted and cannot be processed for payment.

Fees are inclusive of all associated administrative work. There is no separate reimbursement for the writing of any reports associated with the client file.

Client signature guidelines

Prior Approval Forms signed by or on behalf of a client are required to process claim payment.

Note that these administrative forms are not the means by which a client gives consent to his or her provider for treatment and it is not the program's role to collect consent for treatment. They indicate only that the client understands their NIHB coverage and received the service that is being claimed. The following client signatures will be accepted for this purpose:

  • the signature of the client aged 18 or older, unless arrangements for alternative consent have otherwise been established for the client (for example, power of attorney for personal care, guardianship order)
  • for clients between the ages of 14–18, where the provider is of the opinion that the client:
    • has the capacity to understand what he/she is signing: the client may sign
    • does not have the capacity to understand what he/she is signing: a parent or legal guardian may sign
  • clients under the age of 14 should have a parent or legal guardian sign the forms. In exceptional circumstances, when a client under 14 years of age is unaccompanied by a parent or legal guardian, or the provider is of the opinion that the client has the capacity to understand what they are signing, a signature from the child may be accepted

Client reimbursement

While providers are encouraged to submit claims directly to Express Scripts Canada so that clients do not need to pay at the point of service, in some cases, clients may pay directly and seek reimbursement.

Requests for client reimbursement for mental health counselling benefits must be submitted within year of the date of service. See instructions and links to the NIHB Client Reimbursement Form found on the Express Scripts Canada website.

The client must meet all the program's eligibility criteria, including that the service was eligible and was provided by a provider eligible to be enroled (see section 2.2).

All requests for reimbursement must include a completed NIHB Client Reimbursement Form, as well as original receipts.

4.0 Appeal process

Persons eligible for the NIHB program have the right to appeal the denial of a benefit with the exception of items and services that are identified as exclusions. More information about the appeal process is available on NIHB's webpage Appealing a decision under the NIHB program or through the appropriate NIHB regional office.

5.0 Medical transportation

Medical transportation benefit coverage may be provided to the nearest appropriate provider or support may be available so that a provider can travel into a community to provide services when it is deemed more cost-effective. All travel must be pre-approved. For more information, please refer to the NIHB's Medical Transportation Policy Framework.

While clients are expected to access the closest appropriate provider, exceptions may be considered to provide coverage for travel to access a provider with a specific area of expertise, including where the provider may have specific cultural competence experience or training.

6.0 Mental health counselling benefits resources

6.1 Contact information

Contact the Non-Insured Health Benefits program for full contact information.

6.2 Mental health programming

Many municipalities or other local governments, and provincial or territorial governments offer mental health programming, for example, through non-profit organizations such as the Canadian Mental Health Association or local Aboriginal friendship centres.

Through its Mental Wellness programming, Indigenous Services Canada administers contribution agreements and transfers direct departmental spending to support culturally appropriate community-based programs, services, initiatives and strategies related to the mental wellness of First Nations and Inuit clients. The range of services includes prevention, early intervention, treatment, and aftercare. Key services supporting program delivery include: substance abuse prevention and treatment (part of the Canada Drugs and Substances Strategy), mental health promotion, and suicide prevention. The Mental Wellness program objective is to address the greater risks and lower health outcomes associated with the mental wellness of First Nations and Inuit individuals, families and communities.

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