9.0 Self-care equipment and supplies benefits list

9.1.1 Benefit policies

General information common to all medical supplies and equipment (MS&E) can be found in the general policies.

9.1.2 Prescriber and provider requirements

Prescriptions or recommendations for coverage must be initiated by the health professionals identified as prescribers or recommenders of the specific item as listed in the tables. Items that are prescribed by prescribers/recommenders not recognized by NIHB will lead to denials or reversal of claims.

The following is a list of NIHB recognized prescriber/recommender abbreviations found in this segment of the benefits list. Please refer to the prescriber section of the item tables below to identify the eligible prescriber/recommender of a specific item:

• LPN/RPN – Licensed Practical Nurse/Registered Practical Nurse when within their scope of practice in their province/territory
• MD — Physician
• NP — Nurse Practitioner
• OT — Occupational Therapist
• PSY — Psychologist
• PT — Physiotherapist
• RD — Registered Dietitian
• RM — Registered Midwife
• RN — Registered Nurse
• SLP — Speech-Language Pathologist

The following is a list of NIHB recognized provider abbreviations found in this segment of the benefits list. Please refer to the provider section of the item tables below to identify the eligible provider of a specific item:

• GEN — Enrolled general MS&E or pharmacy provider

9.1.3 Prior approval requirements

General prior approval requirements can be found in the general policies.

To initiate the prior approval process, the Self-care Prior Approval Form, found on the Express Scripts Canada NIHB provider and client website, must be completed in full and submitted to your NIHB regional office along with the following supporting documentation:

• the prescription or recommendation or referral form signed by an NIHB recognized prescriber for the requested benefit
• detailed assessment as required
• relevant information the provider, physician, nurse practitioner, occupational therapist, psychologist or physiotherapist may have to support the request
• an explanation of benefits from any third-party coverage available to the client (for example: provincial plan, workers' compensation board, private insurance, education plan, etc.)

9.1.4 Exclusions

In addition to the general exclusion policy listed in the general policies, the following items are excluded from the self-care benefit and are not considered for coverage or appeal under the NIHB program:

• environmental protection devices and supplies (for example: air cleaners, filters, UV protection garments and lotions, etc.)
• permanently fixed equipment
• equipment with a rated capacity that would be unable to bear the client's weight
• lift chairs
• child's regular feeding bottle and teat

9.1.5 Warranties

Providers must honour the manufacturer's warranty.

9.1.6 Repairs

Repairs that are not covered under the warranty are eligible for coverage when supported by proper documentation.

The following rules apply:

• prior approval is required for repairs
• request must include detailed cost breakdown of parts, labour time and rates
• repairs must have a minimum warranty of 90 days

A description of all repairs with dates, detailed cost breakdown of parts, labour time and rates must be kept on file for each client.

Note: The NIHB program will not cover the labour cost for repairs that are covered under the warranty.

9.1.7 Replacement requirements

Recommended replacement guidelines indicate the quantity and frequency at which a benefit item will be eligible for coverage. Recommended replacement guidelines are based on a client's customary medical needs and the typical device's lifespan.

Replacement is subject to the same process as the original purchase.

All requests for replacement require a new prescription.

For more general information please see section 1.12 Recommended replacement guidelines.

9.1.8 Services included in the price

The following services must be included in the cost of the item to be considered for coverage:

• product and parts ordering and delivery from manufacturer to provider (including delivery costs, exchange rate)
• dispensing of the benefit, which includes any required adjustments or fittings

9.1.9 Terminology

9.2.1 Bathing

9.2.2 Toileting

9.3.1 Positioning Wedge

A triangular foam wedge (generally with a 7, 10, or 12-inch height), covered in fabric, to be used on the bed to:

• elevate the upper body for those with respiratory issues or aspiration risk that require the head of bed elevation, or with pain that impacts their ability to sleep in a supine position
• support the body in a side-lying position to offload pressure for those with a risk of skin breakdown

Must be large enough to support the client's entire upper body.

OR

A foam rectangle with one sloped end, covered in fabric, to be used on the bed to:

• elevate the legs for those with lower extremity edema or with pain that impacts their ability to sleep in a supine position

Must be large enough to support the client's legs.

Standard residential bed pillows, cervical pillows and other shaped pillows are not eligible for coverage.

9.5.1 Breastfeeding aids

The infant's date of birth must be indicated on the prescription/written recommendation.

Electric breast pump purchase or rental is considered for coverage only once the child is born and when a parent or infant presents medico-physical complications hindering the normal physiological process of chestfeeding. Prior authorization and medical documentation are required to support the request.

Information to provide includes:

• the medical justification supporting the need for the electric breast pump
• the date of birth
• the infant's weight
• the length of time the electric breast pump is needed

NIHB has created an Electric Breast Pump Recommendation Form, found on the Express Scripts Canada NIHB provider and client website, that can be printed and taken to the prescriber for ease of application.

9.5.2 Feeding aids

9.5.3 Enteral feeding

9.6.1 Upper body

9.6.2 Lower body

9.7.1 Grab bar

9.7.2 Lift

The program only covers portable tracking systems. Ceiling lift where permanent tracking is already installed or covered by another program may be eligible for coverage.

Eligibility criteria:

• the client has a chronic, long-term disability resulting in an inability to safely transfer from one position to another, which requires assistive technology to lift and transfer the client between their bed and their wheelchair and/or the bathroom. (note: NIHB will only approve lifts for transfers between these surfaces)
• the client's weight is within the weight capacity of the device
• the client has no other lift in place that will meet their needs
• the client has been assessed in their home environment by an occupational therapist or physiotherapist
• if the client is funded for a floor lift and their medical condition changes significantly, a request for a ceiling lift may be considered

9.7.3 Pole

9.7.4 Trapeze

9.7.5 Transfer

9.9.1 Repairs

9.9.2 Delivery