9.0 Self-care benefits list

On this page

9.1 General information

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 reversals of claims.

NIHB recognized prescribers/recommenders include:

  • MD — Physician
  • NP — Nurse Practitioner
  • OT — Occupational Therapist
  • PT — Physiotherapist
  • RD — Registered Dietitian
  • RM — Registered Midwife
  • RN — Registered Nurse
  • PSY — Psychologist

NIHB recognized providers include:

  • GEN — Enrolled general medical supplies and equipment 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 NIHB Self-care Prior Approval Form, found on the Express Scripts Canada website, must be completed in full and submitted to the 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

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

To be eligible for replacement the item must meet ONE of the following conditions:

  • be outside the recommended replacement guideline
  • not working, outside of warranty and the cost of repair exceeds the cost of a new item
  • the item no longer meets the client's needs due to a change in medical condition

All requests for replacement require a new prescription. If an item is required before the recommended replacement guidelines, documentation supporting the need for early replacement must be provided.

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

Item code

The item code is an 8-digit code that identifies the benefit being requested and is submitted to Express Scripts Canada for billing purposes.

Prior approval

A program coverage confirmation is issued by a FNIHB regional office to a provider to ensure that the client is eligible for specific medical supplies and equipment benefits. The approval is issued primarily for items identified as requiring prior approval before being billed to the program.

Recommended replacement guidelines

The recommended replacement guidelines set a maximum number of each item a client may receive over a given period of time (frequency). Coverage of additional items may be considered on a case-by-case basis. For requests exceeding the recommended replacement guidelines, a prior approval is required.

Maximum price

The NIHB program has established a maximum price for specific items. Maximum price information may be found on the price files located on the Express Script Canada website.

9.2 Bathing and toileting aids

9.2.1 Bathing

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400295 Bath chair MD, NP, OT, PT, RN GEN No 1 every 5 years
99400474 Bath chair lift, battery powered MD, NP, OT, PT GEN Yes 1 every 5 years
99400935 Bath chair lift, bariatric battery powered, purchase MD, NP, OT, PT GEN Yes 1 every 5 years
99400937 Bath chair lift, battery GEN Yes 1 per year
99400936 Bath chair lift, battery powered, rental MD, NP, OT, PT GEN Yes
99400303 Commode shower chair MD, NP, OT, PT, RN GEN Yes 1 every 5 years
99400649 Grab bar tub (non-permanent) MD, NP, OT, PT, RN GEN No 1 every 3 years
99400301 Mat non-slip tub MD, NP, OT, PT, RN GEN No 1 every 2 years
99400304 Tub transfer bench MD, NP, OT, PT, RN GEN No 1 every 5 years
99400305 Tub transfer board MD, NP, OT, PT, RN GEN Yes 1 every 5 years

9.2.2 Toileting

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400294 Bedpan MD, NP, OT, RN GEN No 1 every 3 years
99400296 Commode, standard, purchase MD, NP, OT, PT, RN GEN No 1 every 5 years
99400890 Commode, wheeled, purchase MD, NP, OT, PT, RN GEN No 1 every 5 years
99400298 Raised toilet seat, standard MD, NP, OT, PT, RN GEN No 1 every 3 years
99400299 Raised toilet seat, standard with arm MD, NP, OT, PT, RN GEN No 1 every 3 years
99400302 Safety frame for toilet MD, NP, OT, PT, RN GEN No 1 every 5 years
99400306 Urinal MD, NP, OT, PT, RN GEN No 1 every 3 years
99400297 Commode, rental MD, NP, OT, PT, RN GEN Yes
99400878 Toilet tissue aid MD, NP, OT, PT, RN GEN Yes 1 every 5 years

9.3 Cushion and protective aid

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400308 Elbow protector MD, NP, OT, PT, RN GEN No 1 every 5 year
99400310 Heel protector, 1 pair MD, NP, OT, PT, RN GEN No 1 per year
99400309 Leg lifter MD, NP, OT, PT, RN GEN No 1 every 5 years
99400315 Positioning wedge MD, NP, OT, PT, RN GEN Yes 1 every 3 years
99400316 Quad knee separator MD, NP, OT, PT, RN GEN No 1 every 3 years

 

99400311 Ring cushion MD, NP, OT, PT, RM, RN GEN No 1 every 3 years

9.4 Dressing aid

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400277 Button hook MD, NP, OT, PT, RN GEN No 1 every 5 years
99400278 Dressing hook MD, NP, OT, PT, RN GEN No 1 every 5 years
99400279 Long handle shoe horn MD, NP, OT, PT, RN GEN No 1 every 5 years
99400280 Reacher MD, NP, OT, PT, RN GEN No 1 every 5 years
99400281 Sock/stocking aid MD, NP, OT, PT, RN GEN No 1 every 5 years

9.5 Feeding

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 when a mother or infant presents medico-physical complications hindering the normal physiological process of breastfeeding. Prior authorization and medical documentation is required to support the request

Information to provide includes:

  • the medical justification supporting the need for the electric breast pump
  • the gestational age
  • 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 Script Canada website, that can be printed and taken to the prescriber for ease of application.

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400317 Breast pump, manual MD, NP, RM, RN GEN No one per birth event
99400658 Breast pump, electric, rental MD, NP, RM, RN GEN Yes
99401153 Breast pump, electric, purchase MD, NP, RM, RN GEN Yes 1 every 3 years
99400932 Nipple shield MD, NP, RM, RN GEN No 6 shields every 3 months Maximum coverage of 6 months

9.5.2 Feeding aids

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99401279 Adaptive Cup MD, NP, OT, PT, RN GEN No 1 per year
99400287 Built-up handle or universal cuff MD, NP, OT, RN GEN No 1 every 5 years
99400288 Food guard MD, NP, OT, RN GEN No 1 every 5 years
99400289 Mat, non-slip MD, NP, OT, RN GEN No 1 every 5 years
99401133 Overbed table, purchase MD, NP, OT, PT, RN GEN Yes
99401145 Overbed table, rental MD, NP, OT, PT, RN GEN Yes
99400290 Specialized utensil fork or spork MD, NP, OT, PT, RN GEN No 1 every 5 years
99400292 Specialized utensil, spoon MD, NP, OT, PT, RN GEN No 1 every 5 years
99400291 Specialized utensil, knife MD, NP, OT, PT, RN GEN No 1 every 5 years

9.5.3 Enteral feeding

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400286 Enteral feeding, nasogastric tube MD, NP, RN, RD GEN No 24 per year
99400655 Enteral feeding, gastronomy catheter/tube MD, NP, RN, RD GEN No 12 per year
99400656 Enteral feeding, supplies extension, sets MD, NP, RN, RD GEN No 12 per year
99400657 Enteral feeding, supplies adaptor plugs MD, NP, RN, RD GEN No 12 per year
99400767 Enteral feeding, button MD, NP, RN, RD GEN Yes 3 per year
99401124 Backpack for feeding pump MD, NP, RN, RD, OT GEN Yes 1 per year
99400285 Feeding pump, bag MD, NP, RN, RD GEN No 1 per day higher frequencies will be considered on a case-by-case basis for premature or immunocompromised children and for transplant patients
99400284 Feeding pump pole (iv pole) MD, NP, RN, RD, OT GEN Yes 1 per lifetime
99400283 Feeding pump, purchase MD, NP, RN, RD GEN Yes 1 every 5 years medical documentation that establishes the client's inability to receive feeding through gravity
99400282 Feeding pump, rental MD, NP, RN, RD GEN Yes
99400530 Feeding syringe, 3cc, disposable MD, NP, RN, RD GEN No 1 per day higher frequencies will be considered on a case-by-case basis for premature or immunocompromised children and for transplant patients
99400535 Feeding syringe, 5cc, disposable MD, NP, RN, RD GEN No 1 per day
99400539 Feeding syringe,10 cc, disposable MD, NP, RN, RD GEN No 1 per day
99400548 Feeding syringe, 20cc, disposable MD, NP, RN, RD GEN No 1 per day
99401246 Feeding syringe, other, disposable MD, NP, RN, RD GEN No 1 per day
99400653 Gravity feeding, bag MD, NP, RN, RD GEN No 1 per day higher frequencies will be considered on a case-by-case basis for premature or immunocompromised children and for transplant patients
99400651 Gravity feeding, delivery set with bag MD, NP, RN, RD GEN No 1 per day
99400652 Gravity feeding, delivery set without bag MD, NP, RN, RD GEN No 1 per day
99400654 Gravity feeding, rigid container MD, NP, RN, RD GEN No 24 per year

9.6 Gender identity

Providers must keep the following information in the client's file:

9.6.1 Upper body

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400921 Bra inserts, pair MD, NP, PSY GEN No 1 every 2 years
99400922 Brassiere for bra insert MD, NP, PSY GEN No 3 per year
99400920 Compression — chest binder MD, NP, PSY GEN No 2 per year

9.6.2 Lower body

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400923 Compression — gaff or shorts MD, NP, PSY GEN No 2 per year
99400927 Female urination aid (stand-to-pee device) MD, NP, PSY GEN No 1 per year
99400924 Packer (phallus) MD, NP, PSY GEN No 1 per year
99400926 Packer securement (strap / harness / brief) MD, NP, PSY GEN No 1 per year
99400925 Packer with stand-to-pee MD, NP, PSY GEN No 1 per year
99400928 Vaginal dilator, kit (4) MD, NP, PSY GEN No 1 every 5 years
99400929 Vaginal dilator, single MD, NP, PSY GEN No 1 every 5 years

9.7 Lifting and transfer

9.7.1 Grab bar

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400322 Grab bar for bed, purchase MD, NP, OT, PT, RN GEN No 1 every 10 years
99400323 Grab bar for bed, rental MD, NP, OT, PT, RN GEN Yes

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

Required Information

Prior approval is required. Assessment from occupational therapist or physiotherapist must include:

  • the need for the item
  • the client's anthropometric measurements including height and weight
  • the client's medical, physical status and functional level (for example, mobility)
  • other relevant information
  • justification is required for specialized sling requests
  • device manufacturer, model, and weight capacity
  • completed manufacturer's order sheet
  • installation quote including type and locations where portable track is being considered
Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400953 Ceiling lift, accessories MD, NP, OT, PT GEN Yes 1 every 2 years
99400949 Ceiling lift and portable track MD, NP, OT, PT GEN Yes 1 every 7 years
99400952 Ceiling lift battery, replacement GEN Yes 1 every 2 years
99400950 Ceiling lift, replacement MD, NP, OT, PT GEN Yes 1 every 7 years
99400951 Ceiling lift, sling, replacement MD, NP, OT, PT GEN Yes 2 every 2 years
99400324 Hydraulic lift, powered MD, NP, OT, PT GEN Yes 1 every 7 years justification as to why a standard hydraulic lift will not meet the client's need
99400817 Hydraulic lift, powered, recycled MD, NP, OT, PT GEN Yes 1 every 7 years
99400325 Hydraulic lift, standard MD, NP, OT, PT GEN Yes 1 every 7 years
99400816 Hydraulic lift, standard, recycled MD, NP, OT, PT GEN Yes 1 every 7 years
99400326 Hydraulic lift, sling/hammock replacement MD, NP, OT, PT, RN GEN Yes 2 every 2 years

9.7.3 Pole

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400321 Floor to ceiling pole MD, NP, OT, PT GEN No 1 per lifetime

9.7.4 Trapeze

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400329 Trapeze bar and floor stand, purchase MD, NP, OT, PT GEN Yes 1 per lifetime
99401134 Trapeze bar and floor stand, bariatric, purchase MD, NP, OT, PT GEN Yes 1 per lifetime
99400330 Trapeze, rental MD, NP, OT, PT GEN Yes

9.7.5 Transfer

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400327 Transfer belt MD, NP, OT, PT, RN GEN No 1 per year
99400328 Transfer board MD, NP, OT, PT, RN GEN No 1 every 10 years

9.8 Uncategorized medical supplies

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400765 Electronic blood pressure monitor with arm cuff MD, NP, RM GEN No 1 every 5 years
99400877 Inspection mirror MD, NP, OT, PT, RN GEN Yes 1 per lifetime
99400471 Medic alert bracelet, standard MD, NP, RN GEN Yes 1 per lifetime
99401270 Thermometer, oral, digital MD, NP, RN GEN No 1 every 5 years Recommendations by pharmacists will be considered during pandemic

9.9 Servicing

9.9.1 Repairs

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400938 Repair, bath chair lift GEN Yes
99400307 Repair, bathing & toileting aid GEN Yes
99400954 Repair, ceiling lift motor GEN Yes
99400293 Repair, feeding aid GEN Yes
99400331 Repair, lifting/transfer aids GEN Yes

9.9.2 Delivery

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400930 Delivery, gender identity GEN No
99401266 Delivery, self-care GEN Yes
Date modified: