9.0 Self-care equipment and supplies benefits list
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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.
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:
- prescriptions or recommendations for gender identity items require an indication of diagnosis of gender dysphoria
- prescriptions or recommendations are required for the initial benefit request only
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 |