9.0 Self-care equipment and supplies benefits list

Effective date: September 14, 2022

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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.

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

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 NIHB 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.

Unit price

Unit price information may be found on the price files, located on the Express Scripts Canada NIHB provider and client 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, LPN/RPNFootnote 1 GEN No 1 every 5 years
  • Aluminum frame with 4 height adjustable legs
  • Fits inside tub
  • Includes back and seat, with or without perineal cutout
  • May include arms
  • Must have non-skid rubber tips or suction feet on the legs
  • The client's weight must be within the weight capacity of the device
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, LPN/RPNFootnote 1 GEN Yes 1 every 5 years
99400649 Grab bar tub (non-permanent) MD, NP, OT, PT, RN, LPN/RPNFootnote 1 GEN No 1 every 3 years
  • Assists in transferring in/out of bathtub
  • Clamp-on style constructed with steel tubing
  • Powder/plastic coated or textured grip surface
  • The client's weight must be within the weight capacity of the device
99400301 Mat non-slip tub MD, NP, OT, PT, RN, LPN/RPNFootnote 1 GEN No 1 every 2 years
99400304 Tub transfer bench MD, NP, OT, PT, RN, LPN/RPNFootnote 1 GEN No 1 every 5 years
  • Height adjustable legs: two legs sit on outside of tub, 2 on inside of tub, and seat extends over the bathtub wall
  • Padded or smooth plastic
  • The client's weight must be within the weight capacity of the device
99400305 Tub transfer board MD, NP, OT, PT, RN, LPN/RPNFootnote 1 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
  • Variable height
  • The client's weight must be within the weight capacity of the device
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, LPN/RPNFootnote 1 GEN No 1 every 3 years
99400299 Raised toilet seat, standard with arm MD, NP, OT, PT, RN, LPN/RPNFootnote 1 GEN No 1 every 3 years
  • Armrests attached to raised toilet seat
  • Must have clamps to secure to toilet bowl

OR

  • Molded plastic construction with locking mechanism for safe secure fit to toilet
  • Fits elongated or standard toilet bowl. May have sloped opening for peri-fit
  • The client's weight must be within the weight capacity of the device
99400302 Safety frame for toilet MD, NP, OT, PT, RN, LPN/RPNFootnote 1 GEN No 1 every 5 years
  • Attaches to existing toilet seat bolts. Can be used separately or with a raised toilet seat
  • The client's weight must be within the weight capacity of the device
99400306 Urinal MD, NP, OT, PT, RN, LPN/RPNFootnote 1 GEN No 1 every 3 years
99400297 Commode, rental MD, NP, OT, PT, RN, LPN/RPNFootnote 1 GEN Yes
99400878 Toilet tissue aid MD, NP, OT, PT, RN, LPN/RPNFootnote 1 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, LPN/RPNFootnote 1 GEN No 1 every 5 year
99400310 Heel protector, 1 pair MD, NP, OT, PT, RN, LPN/RPNFootnote 1 GEN No 1 per year
99400309 Leg lifter MD, NP, OT, PT, RN, LPN/RPNFootnote 1 GEN No 1 every 5 years
99400315 Positioning wedge MD, NP, OT, PT, RN, LPN/RPNFootnote 1 GEN Yes 1 every 3 years
99400316 Quad knee separator MD, NP, OT, PT, RN, LPN/RPNFootnote 1 GEN No 1 every 3 years
99400311 Ring cushion MD, NP, OT, PT, RM, RN, LPN/RPNFootnote 1 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, LPN/RPNFootnote 1 GEN No 1 every 5 years
99400278 Dressing hook MD, NP, OT, PT, RN, LPN/RPNFootnote 1 GEN No 1 every 5 years
99400279 Long handle shoe horn MD, NP, OT, PT, RN, LPN/RPNFootnote 1 GEN No 1 every 5 years
99400280 Reacher MD, NP, OT, PT, RN, LPN/RPNFootnote 1 GEN No 1 every 5 years
99400281 Sock/stocking aid MD, NP, OT, PT, RN, LPN/RPNFootnote 1 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 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 gestational age
  • 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.

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400317 Breast pump, manual MD, NP, RM, RN, LPN/RPN GEN No one per birth event
99400658 Breast pump, electric, rental MD, NP, RM, RN GEN Yes
  • Rented for one month at a time
  • In areas where the rental is not available or the purchase is more cost-effective, consider the coverage of a standard electric breast pump
  • All supplies necessary to operate the hospital-grade electric breast pump are included in the monthly rental fee
99401153 Breast pump, electric, purchase MD, NP, RM, RN GEN Yes 1 every 3 years
99400932 Nipple shield MD, NP, RM, RN, LPN/RPN GEN No 6 shields every 3 months Maximum coverage of 6 months

9.5.2 Feeding aids

9.5.2.1 Specialized feeding bottles and teats

The child (0-18 years old) presents with complex feeding challenges where a regular feeding bottle and teat do not meet their needs.

Information required:

  • completed and signed prior approval form
  • device make, model, cost, and quantity of item requested
  • prescription
  • completed clinical feeding and swallowing assessment*, which includes:
    • diagnosis
      • please note that general information such as feeding difficulty is not sufficient information to support review
    • physical concerns (for example, cleft lip, cleft palate, high-arched palate, syndromic sequences, etc.)
    • oral motor skills (for example, poor lip seal, reduced tongue movement, reduced gag reflex, etc.)
    • feeding or swallowing concerns (for example, choking, coughing, reduced suck, etc.)
    • current diet, including safe and unsafe consistencies
    • recommendation for specialized feeding bottles and teat
    • other relevant information to support review
  • replacement teat will be considered when the client meets the criteria for the specialized feeding kit and the replacement teat are required for one of the following reasons:
    • damaged teat (for example, cracked, leaking, torn, etc.)
    • different teat size is required (for example, size included in the kit is not appropriate for the child's developmental age and/or functional feeding skills, or the child has outgrown the teat size)

*A Specialized Feeding Bottles and Teats Assessment Form is available on the Express Scripts Canada NIHB provider and client website. When completed and signed by an NIHB recognized prescriber, this form can also be used as the prescription/recommendation for specialized feeding bottles and teats. Please note: if another feeding and swallowing assessment report is submitted, the clinician must include the required assessment information.

Specialized feeding kits and replacement teat purchase will be considered for coverage only once the child is born.

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99401279 Adaptive Cup MD, NP, OT, PT, RN, LPN/RPNFootnote 1 GEN No 1 per year
99400287 Built-up handle or universal cuff MD, NP, OT, PT, RN, LPN/RPNFootnote 1 GEN No 1 every 5 years
99400288 Food guard MD, NP, OT, PT, RN, LPN/RPNFootnote 1 GEN No 1 every 5 years
99400289 Mat, non-slip MD, NP, OT, PT, RN, LPN/RPNFootnote 1 GEN No 1 every 5 years
99401133 Overbed table, purchase MD, NP, OT, PT, RN, LPN/RPNFootnote 1 GEN Yes
99401145 Overbed table, rental MD, NP, OT, PT, RN, LPN/RPNFootnote 1 GEN Yes
99400290 Specialized utensil fork or spork MD, NP, OT, PT, RN, LPN/RPNFootnote 1 GEN No 1 every 5 years
99400292 Specialized utensil, spoon MD, NP, OT, PT, RN, LPN/RPNFootnote 1 GEN No 1 every 5 years
99400291 Specialized utensil, knife MD, NP, OT, PT, RN, LPN/RPNFootnote 1 GEN No 1 every 5 years
99401367 Kit, Specialized feeding bottle and teat MD, NP, RM, SLP, RN, OT GEN Yes 8 bottles and 8 teats every 6 month
  • Includes: bottle(s), teat(s), valve(s), etc.
  • For complex feeding challenges where the child cannot use a regular feeding bottle and teat to obtain adequate nutrition.
  • Maximum of 8 bottles and 8 teats regardless of packaging quantities
99401368 Teat, Replacement for specialized feeding kit MD, NP, RM, SLP, RN, OT GEN Yes 4 teats every 3 months
  • For damaged teats or if a different teat size is required
  • Teat replacement should be considered when it is more cost-effective than kit replacement

9.5.3 Enteral feeding

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400476 Adhesive remover MD, NP, RN, RD GEN No 6 boxes per year For the long-term use of adhesives (for example: ostomy supplies, dressings, tape)
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 Also included: jejunal tube or a MIC-KEY jejunal tube
99400656 Enteral feeding, supplies extension, sets MD, NP, RN, RD GEN No 12 per year

Device that connects to the main feeding system. Could Include extension sets such as a bolus or a Y extension set, for feeding bag system

Higher frequencies will be considered on a case-by-case basis when medical justification is provided

99400657 Enteral feeding, supplies adaptor plugs MD, NP, RN, RD GEN No 12 per year Adapter which provides a connection between feeding sets and tubes, or extension sets
99400767 Enteral feeding, button (tube) MD, NP, RN, RD GEN Yes 3 per year Low profile G-tube (button) which lays on top of the abdominal wall, kept in place by a water filled balloon, and is used for providing nutrition and medication
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

Includes feeding bag with tubing (spike set). It can include a dual bag set such as a feed and flush bag combination

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, LPN/RPN 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, (LPN/RPN - renewals only) 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, (LPN/RPN - renewals only) GEN No 1 per day
99400539 Feeding syringe,10 cc, disposable MD, NP, RN, RD, (LPN/RPN - renewals only) GEN No 1 per day
99400548 Feeding syringe, 20cc, disposable MD, NP, RN, RD, (LPN/RPN - renewals only) GEN No 1 per day
99401246 Feeding syringe, other, disposable MD, NP, RN, RD, (LPN/RPN - renewals only) GEN No 1 per day
99400653 Gravity feeding, bag MD, NP, RN, RD, (LPN/RPN - renewals only) GEN No 1 per day

Gravity feeding bag without tubing

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, (LPN/RPN - renewals only) GEN No 1 per day

Combination of feeding bag with tubing

Higher frequencies will be considered on a case-by-case basis for premature or immunocompromised children and for transplant patients

99400652 Gravity feeding, delivery set without bag MD, NP, RN, RD, (LPN/RPN - renewals only) GEN No 1 per day

Tubing from a gravity feeding set, without the bag

Higher frequencies will be considered on a case-by-case basis for premature or immunocompromised children and for transplant patients

99400654 Gravity feeding, rigid container MD, NP, RN, RD, (LPN/RPN - renewals only) GEN No 24 per year
99400411 Protective skin wipes/spray MD, NP, RN, RD GEN No 4 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, LPN/RPNFootnote 1 GEN No 1 every 10 years
  • Includes swivel, pivot or static grab bar
  • Non-permanent
  • The client's weight must be within the weight capacity of the device
99400323 Grab bar for bed, rental MD, NP, OT, PT, RN, LPN/RPNFootnote 1 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

9.7.2.1 Information required

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, LPN/RPNFootnote 1 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
  • Floor to ceiling transfer pole without accessories
  • The client's weight must be within the weight capacity of the device

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, LPN/RPNFootnote 1 GEN No 1 per year
99400328 Transfer board MD, NP, OT, PT, RN, LPN/RPNFootnote 1 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, LPN/RPNFootnote 1 GEN Yes 1 per lifetime
99400471 MedicAlert subscription MD, NP, RN, LPN/RPNFootnote 1 GEN Yes 1 every 5 years
99401270 Thermometer, oral, digital MD, NP, RN, LPN/RPNFootnote 1 GEN No 1 every 5 years

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
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