9.0 Self-care 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 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

9.2.1 Bathing

9.2.2 Toileting

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.

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