(2014) Dental Benefit Policy Framework: Non-Insured Health Benefits Program
The purpose of this document is to explain the overarching policies that guide the administration of the dental benefit under the Non-Insured Health Benefits (NIHB) Program of Health Canada's First Nations and Inuit Health Branch (FNIHB).
This policy framework is intended to provide stakeholders, providers and clients with a broad overview of the parameters of the NIHB Program policies as they relate specifically to the dental benefit area.
- 1.0 The Non-Insured Health Benefits Program
- 2.0 Dental Benefit
- 3.0 Dental Benefit Publications
1. The Non-Insured Health Benefits Program
The Canada Health Act requires that provinces and territories provide coverage for "insured services" (medically necessary hospital and physician services) to all eligible residents including First Nations and Inuit. Individuals may have access to other health-related goods and services through other publicly-funded programs or through private insurance plans.
The Non-Insured Health Benefits (NIHB) Program is a national program that provides coverage to registered First Nations and recognized Inuit for a limited range of medically necessary health-related goods and services not otherwise provided through private insurance plans, provincial/territorial health or social programs.
1.2. Program Objectives and Principles
The objectives of the NIHB Program are to provide benefits to registered First Nations and recognized Inuit in a manner that:
- is suitable to their unique health needs;
- helps eligible First Nations and Inuit to reach an overall health status that is comparable to other Canadians;
- is cost-effective; and
- will maintain and improve health and prevent disease and assist in detecting and managing illnesses, injuries, or disabilities.
The NIHB Program operates according to a number of guiding principles:
- All registered First Nations and recognized Inuit who are normally residents of Canada, and not otherwise covered under a separate agreement with federal, provincial or territorial governments, are eligible for Non-Insured Health Benefits, regardless of location in Canada or income level.
- Benefits are based on the judgment of recognized medical professionals, consistent with the best practices of health services delivery and evidence-based standards of care.
- There is national consistency of mandatory benefits, equitable access and portability of benefits and services.
- The Program is to be managed in a sustainable and cost-effective manner.
- Management processes will involve transparency and joint review structures whenever agreed to with First Nations and Inuit organizations.
- In cases where a benefit is covered under another health care plan, the NIHB Program will act to coordinate payment in order to help ensure that the other plan meets its obligations and the client is not denied service.
The NIHB Program Dental Benefit operates under the following general principles:
- The NIHB Dental Benefits Guide applies to the coverage of dental benefits by the NIHB Dental Predetermination Centre (DPC) or by First Nations or Inuit Health Authorities or organizations (including territorial governments) who, under contribution agreements, have assumed responsibility for the administration and coverage of dental benefits to eligible clients.
- Dental benefits are covered in accordance with the mandate of the NIHB Program. NIHB clients do not pay deductibles or co-payments. The NIHB Program encourages dental providers to bill the Program directly and not to balance-bill clients so that clients do not face charges at the point of service.
- The NIHB Program provides benefits based on policies established to provide eligible clients with access to benefits not otherwise available under federal, provincial, territorial or private health insurance plans.
- The NIHB Program covers most dental procedures that treat dental disease or the consequences of dental disease.
- Coverage of dental services is determined on an individual basis taking into consideration criteria such as the client's oral health status.
- Some dental services are not covered under the NIHB Program (e.g. extensive rehabilitation and cosmetic treatment). These services are defined as exclusions and cannot be considered for appeal.
- Consistent with the NIHB Program policies for all benefits, the Program does not cover any dental procedures related to non-eligible dental services, nor does it cover dental procedures related to a dental service reviewed by the Program where it did not meet the established policies, guidelines and criteria.
- Dental benefits must be provided by a NIHB recognized dental provider (i.e. a dentist, dental specialist or denturist) who is licensed, authorized, and in good standing with the regulatory body of the province/territory in which they practice. They may provide eligible clients with medically necessary NIHB eligible dental services, provided that the services are rendered within NIHB Program policies, guidelines and criteria, frequency limitations and predetermination requirements.
- When claiming for services, it is the dental provider's responsibility to:
- verify the eligibility of the client;
- ensure that no limitations will be exceeded; and
- ensure compliance with NIHB coverage criteria, guidelines and policies.
1.3. Client Eligibility
To be eligible for NIHB Program benefits from Health Canada, a person must be a Canadian resident and have the following status:
- is a registered Indian according to the Indian Act; or
- an Inuk recognized by one of the following Inuit Land Claim organizations — Nunavut Tunngavik Incorporated, Inuvialuit Regional Corporation or 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 age one, whose parent is an eligible client; and
- is currently registered or eligible for registration, under a provincial or territorial health insurance plan; and
- is not otherwise covered under a separate agreement (e.g. a self-government agreement such as the Nisga'a and Nunatsiavut agreements) with federal, provincial or territorial governments.
1.4. Coordination of Benefits
Clients are required to access any public or private health or provincial/territorial programs for which they are eligible prior to accessing the NIHB Program.
When an NIHB-eligible client is also covered by another public or private health care plan, claims must be submitted to the client's other health care/benefits plan first. The NIHB Program will then coordinate payment with the other payer on eligible benefits.
1.5. Client Reimbursement
Service providers are encouraged to bill the NIHB Program directly so that clients do not face charges at the point of service when receiving health care services.
When a client does pay directly for services, he or she may seek reimbursement from the NIHB Program within one year from the date of service. In order to be reimbursed, the service must be an eligible benefit under the Program and all NIHB policies and requirements for coverage must be met.
In order for clients to be considered for reimbursement for eligible dental benefits, their request must include:
- Original receipt(s) for proof of payment;
- NIHB Client Reimbursement Request Form completed and signed; and
- ONE of the following:
- Association des Chirurgiens Dentistes du Québec (ACDQ) Dental Claim and Treatment Plan Form;
- Standard Dental Claim Form; or
- Canadian Association of Orthodontics Information Form;
- Original receipt(s) for proof of payment; and
- NIHB Dental Claim Form (Dent-29) completed and signed.
If applicable, a detailed statement or Explanation of Benefits (EOB) from all other health plan(s)/program(s) must be provided.
Credit card/debit (Interac) slips are not acceptable forms of proof of payment. Original receipts are not required when they have been submitted first to the other health plan(s)/ program(s), and the detailed statement or EOB from them is attached along with a copy of the original receipt.
Claims submitted for clients who no longer have coverage with a third party must be supported with a letter from a client or the provider on behalf of the client, confirming that primary coverage does not exist.
Additional information on the NIHB Program client reimbursement process can be obtained from the NIHB Dental Predetermination Centre (DPC), or found on the Health Canada website at NIHB Client Reimbursement Question and Answer.
The Client Reimbursement Request Form and the NIHB Dental Claim Form are available on the Health Canada website at Health Provider Information.
1.6. Appeal Process
Clients eligible for the NIHB Program have the right to appeal the denial of a benefit with the exception of items that are identified as exclusions. Appeals must be initiated and submitted in writing by the client, their parent, or a legal guardian.
There are three levels of appeal available to NIHB clients. At each stage of the appeal process, supporting information/documentation from the health care provider(s) must also be provided to justify the grounds on which the appeal is based.
At each level of appeal, the information will be reviewed by a different dental professional that will provide recommendations to the Program. For each level of appeal, the client will be provided in a timely manner with a written explanation of the decision taken.
1.7. Provider Audit Program
Audit 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, the NIHB Dental Benefit Policy Framework and the NIHB Dental Benefits Guide, as well as with other relevant documents.
The objectives of the NIHB Provider Audit Program are to:
- prevent and detect inappropriate billing practices;
- detect billing irregularities;
- validate active licensure of registered providers;
- ensure that services paid for were received by eligible NIHB Program clients; and
- ensure that providers have retained appropriate documentation to support submitted claims.
Audit activities are administrative in nature and based on accepted industry practices. All claims, supported or not with a predetermination number, that do not meet the billing requirements of the NIHB Program are subject to audit recovery.
For additional information on the Provider Audit Program for the NIHB dental benefit, please consult the NIHB Dental Claims Submission Kit.
Health Canada's Non-Insured Health Benefits Program is committed to protecting clients' privacy and safeguarding the personal information in its possession. When a benefit request is received, the NIHB Program collects, uses, discloses and retains an individual's personal information according to the applicable federal privacy legislation. The information collected is limited to only that information required for the NIHB Program to administer and verify benefit eligibility.
As a program of the federal government, the NIHB Program must comply with the Privacy Act, the Canadian Charter of Rights and Freedoms, the Access to Information Act, the Treasury Board of Canada Privacy and Data Protection Policies, the Government Security Policy, and Health Canada's Security Policy.
2. Dental Benefit
The objective of the NIHB Program dental benefit is to provide eligible clients with access to oral health services in a fair, equitable and cost-effective manner that will:
- address oral health needs and contribute to improving the oral health status of eligible First Nations and Inuit clients; and
- provide coverage for a range of dental services based on professional judgment and the client's oral health status/condition, consistent with current best practices of health services delivery, and evidence-based services and standards of care.
2.2. Dental Benefit Coverage
2.2.1. General Description
The NIHB Program dental benefit covers a range of services under the following categories which are described in more detail in section 2.2.4:
- diagnostic services;
- preventive services;
- restorative services;
- endodontic services;
- periodontal services;
- prosthodontic services;
- oral and maxillofacial surgery services;
- orthodontic services; and
- adjunctive services.
Predetermination is required for certain dental services prior to the start of treatment. Predetermination requests for coverage are reviewed against established NIHB Program policies, guidelines and criteria. This process enables both the dental provider and the client to understand the coverage commitments.
The following dental services covered under the NIHB Program require predetermination:
- Schedule A services exceeding frequency; and
- Schedule B services.
2.2.3. NIHB Regional Dental Benefit Grid
The NIHB Regional Dental Benefit Grid lists what services are covered under the NIHB Program dental benefit by placing benefits into two schedules:
- Schedule A: outlines dental services that may be completed and billed directly for payment provided that they are within NIHB Program requirements (e.g., frequency limitations, age restrictions).
- Schedule B: outlines dental services that require predetermination. In addition, some of these services have frequency limitations.
The NIHB Regional Dental Benefit Grid lists are located on the Express Scripts Canada Website (password required).
Dental providers must adhere to the terms and conditions of the NIHB Program dental benefit, in order to be eligible for payment of services rendered. Terms and conditions for coverage are contained in the NIHB Dental Claims Submission Kit, and the NIHB Dental Benefits Guide.
2.2.4. Dental Service Categories
For each category, the NIHB Dental Benefits Guide should be referenced to determine the policies, guidelines and criteria that apply for each service.
The services listed in each category below are not comprehensive and are given for explanation purposes only. Examples include, but are not limited to:
- Diagnostic services, including examinations and radiographs.
- Preventive services, including polishing, scaling and sealants.
- Restorative services, including composite (tooth coloured) and amalgam (silver) restorations, and crowns. Some services, such as crowns, require predetermination.
- Endodontic services, including root canal treatments. Root canal treatments on some teeth may require predetermination. It is expected that prior to proceeding with treatment, the provider will ensure that all the teeth requiring root canal treatment will meet the NIHB endodontic policy, guidelines and criteria.
Primary incisor teeth are not eligible for pulpotomy and pulpectomy services.
- Periodontal services, including scaling and root planing beyond routine preventive services covered under the Preventive Services category. When established frequency limitations are reached, these services require predetermination.
- Prosthodontic services (removable dentures), including removable partial and complete dentures and certain related procedures. Partial and complete dentures require predetermination. Predetermination is not required for replacement of standard complete dentures provided that the existing complete denture is at least eight years old.
Partial and complete dentures supported by implants along with all implant-related procedures are considered exclusions under the Program and are not appealable.
- Oral and maxillofacial surgery services, including extractions. Simple extractions on primary or permanent teeth do not require predetermination. Other oral surgical services, such as surgical extractions, do require predetermination.
- Orthodontic services, including removable and fixed appliances.
The NIHB Program covers a limited range of orthodontic services when a client presents with a severe and functionally handicapping malocclusion. All orthodontic services require predetermination.
- Adjunctive services, including general anaesthesia, sedation and facility services. All adjunctive services require predetermination.
These are dental procedures that are outside the NIHB Program scope of benefits or procedures that require special consideration. Requests must be supported with a rationale and other supporting documentation as per the NIHB Program's policies. Predetermination is mandatory.
These are dental procedures that are outside the mandate of the NIHB Program and will not be considered for coverage nor considered for appeal, such as but not limited to: fixed prosthodontics, implants and all implant related procedures, veneers, cosmetic services, ridge augmentation, and appliances to treat bruxism and sleep apnea.
2.3. Dental Providers
NIHB eligible dental benefits must be provided by an NIHB recognized dental provider.
A dental provider, such as dentist, dental specialist and denturists, must be licensed, authorized to provide dental services within their scope of practice in their province/territory, and be in good standing with the regulatory body in the province/territory in which they practice.
2.4. Accessing Dental Benefits
Dental benefits are available to eligible registered First Nations and recognized Inuit when all of the following criteria are met:
- the requested service is an eligible service listed on the NIHB Regional Dental Benefit Grid (Schedules A and B), respecting established NIHB Program policies, guidelines and criteria;
- the dental service is provided according to established professional standards and applicable provincial/territorial laws; and
- any public or private health or provincial/territorial program/plan for which the client is eligible has been exhausted prior to accessing the NIHB Program.
NIHB eligible clients are expected to contact their dental provider and are encouraged to:
- inform the dental provider whether they have coverage under any other public or private health or provincial/territorial program/plan;
- inform the dental provider that they are eligible to receive benefits under the NIHB Program; and
- self-identify by providing their eight to ten digit identification number (treaty/status, 'N' or 'B' number), Band name and family number or other health care number.
2.5. Dental Benefit Review Process
Dental services covered under the NIHB Program dental benefit are reviewed on an ongoing basis through consultation with dental provider associations, and First Nations and Inuit organizations. As adjustments are made to the Program, dental providers and clients are notified through NIHB dental newsletters. In addition, dental providers are informed through other means such as faxes or NIHB communications to dental associations. Updates are made as well to the NIHB Dental Benefits Guide and the NIHB Regional Dental Benefit Grids.
3. Dental Benefit Publications
The NIHB Program maintains a list of dental publications including the NIHB Dental Benefits Guide and dental newsletters. To access these dental publications, please consult the Health Canada website at FNIHB Reports and Publications and the Express Scripts Canada website (password required).