First Nation of Nacho Nyak Dun. Medical Policy

Transcription

1 Social Programs Department Approved by Chief and Council: Motion # April 2 nd 2012 Effective Date: May 1 st 2012 Last Updated: April 20 th 2012

2 ii P a g e Motion # April 2 nd 2012

3 iii P a g e Motion # April 2 nd 2012

4 Table of Contents 1 Introduction Vision of First Nation of Nacho Nyak Dun FNNND Health and Social Mission Statement Purpose of the Statement of Authority How to use this Policy Retroactivity Definitions Background on Non-Insured Health Benefits (NIHB) What is NIHB? NIHB Benefit Criteria Who is an Eligible Recipient for NIHB supports? NIHB Regional Navigator NIHB Reimbursement Process NIHB Medical Transportation Benefits NIHB Medical Supplies and Equipment Policies NIHB Eye and Vision Care Policies NIHB Dental Benefits Policy NIHB Pharmacy / Drug Benefits Policies NIHB Crisis Counselling Policies Background on Yukon Government Insured Health and Hearing Services What is Insured Health and Hearing Services? Who is an Eligible Recipient? YG Medical Travel Policy YG Medical Escort Policy YG Children s Drug andoptical Program Policy YG Children s Dental Program Policy YG Seniors(Pharmacare and Extended Health) Policy YG Chronic Disease Program Policy (Prescription Drug Benefits) YG Alcohol and Drug Services Policy YG Mental Health Services Policy Whitehorse General Hospital First Nations Health Programs Yukon Hospital Services and Health Care Policies FNNND Medical Policies Medical Travel FNNND Non-Medical Escort Policy FNNND Driver Policy Family Member Medical Travel Policy Patient Medivac Travel Policy FNNNDMedical Equipment and Supplies Policy FNNNDEye and Vision Care Policy FNNND Dental Support Policy FNNND Drug Policy iv P a g e Motion # April 2 nd 2012

5 4.10 Medical Emergency Support Policy Long-Term Support Policy Palliative Care Worker Policy Appeals Processes NIHB Appeals Process FNNND Appeals Process Appendices Medical Travel Form Appendix 1 Medical Transportation Rates Medical Client, Escort and Driver Guidelines NIHB Links Yukon Government Links Further detail regarding NIHB travel per diems NIHB Reimbursement Form v P a g e Motion # April 2 nd 2012

6 1 Introduction 1.1 Vision of First Nation of Nacho Nyak Dun Our vision is a stable, self-sustaining community that provides choices in education, employment and economic opportunity for our citizens as well as preserves our history, traditions, values, language and the future of our citizens as a distinct people. 1.2 FNNND Health and Social Mission Statement The Social Programs Department provides financial benefits and services to individuals and families who are in need. Needs is determined by the application of a needs test and other eligibility requirements. The purpose of the program is to enable individuals and families to maintain health, safety, dignity and family unity. The services are offered in a respectful way with a view toward self-sufficiency whenever possible. 1.3 Purpose of the This policy is intended to provide FNNND with the parameters and procedures for providing additional supports to its citizens who are unable to access medically necessary supplies, equipment and services through existing private or public health insurance coverage. This policy operates under the fundamental principles described below: 1. Self-Sufficiency: Individuals have the responsibility to support themselves and their dependants when it is possible to do so. 2. Applicant s Right to Benefits and Services: Individuals have the right to benefits and services for which they qualify under existing regulations, such as Non-Insured Health Benefits (NIHB). Benefits and services provided by the FNNND are not entitlements; they are provided to citizens based on need and are subject to budgetary allocations. 3. Respect for the Applicant: An applicant for social services must be respected as a person having worth, dignity and the right to self-determination. 4. Privacy and Confidentiality: Applicants have the right to privacy and confidentiality concerning personal, health and family affairs. 5. Applicant s Right to Consultation and Appeal: Applicants for health benefits and social services have the right and responsibility to be involved in the process of establishing eligibility for benefits and services, and have the right to appeal any decision concerning their application Responsibilities of the Applicant 1. Responsible for applying for health benefits by either completing the appropriate form or contacting the FNNND Social Programs Department, depending on circumstances; and 2. Required to show that, within the limits of their abilities and circumstances, all other avenues of health benefits, such as Non-Insured Health Benefits (NIHB) or Yukon Government (YG) or private health insurance have been explored and proof of this can be provided to the Social Programs Department if requested. 1 P a g e Motion # April 2 nd 2012

7 3. Individuals seeking medical support though this policy are responsible for providing Social Programs staff with all necessary documentation. This policy promotes personal accountability. As citizens of FNNND, all individuals are personally accountable for complying with any and all policies and procedures, whether those of FNNND, YG or NIHB Responsibilities of the FNNND With this policy the First Nation of Nacho Nyak Dun wants to better support citizens in situations related to their health care and emergency medical needs. Social Programs Department staff will work with citizens to access other government services as well as fill in applications, forms, etc., in order to recover health-related expenses paid from the First Nation government. It is important to note that the FNNND has no legal obligation to provide any support, services or funding to its citizens related to medical, dental, or vision-related services, equipment or supplies. Any funding provided to citizens through this policy should be considered a privilege. The supports provided under this policy are subject to available funds; FNNND has the right to decline any application based on the lack of available funds. FNNND also has the right to refuse support to any individual that it determines is abusing the policies in this document. All applicants have the right to appeal any decisions made through this policy, by following the appeals process as described in Section Statement of Authority The Social Programs Manager shall be the Manual author and be responsible for all and any revisions, corrections and updates to this document as approved by council. The Social Programs Manager shall ensure compliance with this policy, with the support of all Directors and Managers at FNNND. Council shall have final and ultimate authority with respect to any questions or clarifications arising from the implementation of this policy, provided that the appropriate appeals process has taken place. 1.5 How to use this Policy The FNNND medical policy manual has been drafted in such a way that it can easily be amended when desirable. This policy is to be used to define the guidelines and criterions for all medical related expenses or services to the citizens of FNNND. Citizens must use existing medical program/service coverage in particular any private health insurance, Yukon Government Health Care, and Health Canada Non-Insured Health Benefits before seeking support from the FNNND. The FNNND may require proof that attempts have been made to access these other sources before they approve any supplemental assistance. For greater clarity, the FNNND will not provide any of the benefits under their policy to people who are not citizens of FNNND. 2 P a g e Motion # April 2 nd 2012

8 1.6 Retroactivity No benefits of this policy, once approved, will be applied retroactively. 1.7 Definitions Advance the amount of money paid to the citizen which is equal to the amount to be reimbursed from the appropriate government agency. Benefits Refers to services and supplies included for coverage, assuming that a citizen meets the eligibility requirements. Beneficiary FNNND citizens who are non-status Indians (as per the non-status Indian definition below). Compassionate Travel Travel by citizens for the purpose of being with a family member during a medical emergency. This is not the same as a medical escort or driver. Confidential Information Refers to any information which is acquired by Social Programs Department staff or others involved in the implementation of one or more of the medical policies included in this document, which is not intended for public consumption. Only authorized individuals will have access to citizen s personal health and social service information. All medical information is considered confidential and will not be discussed with anyone other than the patient or authorized individuals. Driver A person whose role is to transport a citizen to an appointment. Economic Family - Economic family refers to a group of two or more persons who live in the same dwelling and are related to each other by blood, marriage, common-law or adoption. A couple may be of opposite or same sex. Foster children are included. By definition, all persons who are members of a census family are also members of an economic family. Examples of the broader concept of economic family include the following: two co-resident census families who are related to one another are considered one economic family; co-resident siblings who are not members of a census family are considered as one economic family; and, nieces or nephews living with aunts or uncles are considered one economic family (Statistics Canada Definition) Eligibility Describes the criteria for citizens to qualify for medical service and supply coverage. Exceptions Refers to services and supplies that are provided but only in exceptional circumstances. Exclusions Refers to services and supplies that are not covered by a particular policy. First Nation of Nacho Nyak Dun citizen a person whose name is on the FNNND Citizenship List. Generic Drug a drug product that is comparable to brand/reference listed drug product in dosage form, strength, route of administration, quality and performance characteristics, and intended use. Although they may not be associated with a particular company, generic drugs are subject to the regulations of the governments of countries where they are dispensed. 3 P a g e Motion # April 2 nd 2012

9 Honorarium A payment given to someone for services for which fees are not legally required. Immediate family Defined as one s spouse (including common-law), son, daughter, foster child, mother, father, sister, grandmother, brother, grandfather, parent-in-law, sister or brother-in-law, grandchild, or parent surrogate by tradition (as per the FNNND Personnel Policy). Insured Health and Hearing Services Refers to the delivery of health care benefits as set out in the YG Health Care Insurance Plan, the Hospital Insurance Services Plan, and the Travel for Medical Treatment Act. Low-income Category Economic family whose gross income is below the threshold based on the Low income cut-offs from Statistics Canada. The most up to date information available will be used. 1 person 15,583 2 persons 19,400 3 persons 23,849 4 persons 28,957 5 persons 32,842 6 persons 37,041 7 or more persons 41,240 (Statistics Canada 2010) Medical Emergency an injury or illness that is acute and poses an immediate risk to a person's life or long term health; it is an unexpected, sudden and traumatic event. Medical Escort A medically-trained individual, such as a nurse, required to escort a patient to an appointment. Medically Necessary - Refers to services or supplies that are required to properly treat a specific medical condition. Services or supplies that are not considered medically necessary by insurance or recognized health practitioner may be denied. Non-medical Escort A non-medically trained individual required to escort a patient to an appointment. Non-Insured Health Benefits (NIHB) Program NIHB is Health Canada's national, medically necessary health benefit program that provides coverage for benefit claims for a specified range of drugs, dental care, vision care, medical supplies and equipment, short-term crisis intervention mental health counselling and medical transportation for eligible First Nations people and Inuit. Non-Status Indian An individual who is not registered under the Indian Act. Patient A person receiving medical services, equipment, or supplies. 4 P a g e Motion # April 2 nd 2012

10 Policy Refers to a standard or a rule that guides decision-making. Private Health Insurance Supplemental health insurance that an individual can purchase or gain through employment, that covers items such as dental and vision care, cosmetic surgery and some forms of elective surgery which are not considered essential care and are generally not covered through public health insurance. Scope Defines the policy (i.e., explains what the policy is about), and provides the boundaries for the policy. Status Indian An individual recognized by the federal government as being registered under the Indian Act is referred to as a Registered Indian (commonly referred to as a Status Indian). Travel-related Expenses Refers to the following expenses: airfare, ground transportation, accommodation, meals and incidentals. 5 P a g e Motion # April 2 nd 2012

11 2 Background on Non-Insured Health Benefits (NIHB) 2.1 What is NIHB? Provinces and territories are responsible for delivering health care services, guided by the provisions of the Canada Health Act. Health care services include insured hospital care and primary health care, such as physicians and other health professional services. Like any other resident, First Nations people and Inuit access these insured services through provincial and territorial governments. There are, however, a number of health-related goods and services that are not insured by provinces and territories or other private insurance plans. To support First Nations and Inuit people in reaching an overall health status that is comparable with other Canadians, Health Canada's Non-Insured Health Benefits (NIHB) Program provides coverage for a limited range of these goods and services when they are not insured elsewhere. The NIHB Program is Health Canada's national, medically necessary health benefit program that provides coverage for benefit claims for a specified range of drugs, dental care, vision care, medical supplies and equipment, short-term crisis intervention mental health counselling and medical transportation for eligible First Nations people and Inuit. 2.2 NIHB Benefit Criteria A benefit will be considered for coverage when: 1. It is not available through any other federal, provincial, territorial, or private health or social program; 2. The item or service is on a NIHB Program benefit list or NIHB schedule; 3. It is intended for use in a home or other ambulatory care settings; 4. Prior approval or predetermination is obtained (if required); 5. The item is prescribed by a physician, dental care provider, or other health professional licensed to prescribe; and 6. The item is provided by a recognized provider. 2.3 Who is an Eligible Recipient for NIHB supports? An eligible recipient is someone who is entitled to receive benefits such as vision care, prescription drugs or other benefits or services from the NIHB Program. An eligible recipient must be identified as a resident of Canada and one of the following: 1. A registered Indian according to the Indian Act; 2. An Inuk recognized by one of the Inuit Land Claim organizations; or 3. An infant less than one year of age, whose parent is an eligible recipient. When recipients are eligible for benefits under a private health care plan, or public health or social program, claims must be submitted to these plans and programs first before submitting them to the NIHB Program. 6 P a g e Motion # April 2 nd 2012

12 2.4 NIHB Regional Navigator A regional navigator supports and provides assistance to eligible First Nations and Inuit clients with access to NIHB. The role of a navigator is to support First Nation and Inuit clients and communities in gaining an increased understanding of existing health services, jurisdictions and the NIHB Program. The Navigator works to exchange, gather and collate information on health access issues, and identifies ways of improving health services for First Nation and Inuit clients Northern Region Yukon Office Non-Insured Health Benefits First Nations and Inuit Health Health Canada 300 Main Street, Suite 100 Whitehorse, Yukon Y1A 2B5 Telephone: General NIHB Inquiries Toll free: or Fax: (867) Community Analyst for Mayo Toll-free Northern Region Non-Insured Health Benefits First Nations and Inuit Health Health Canada Qualicum Building 2936 Baseline Road Tower A, 4 th Floor Ottawa, Ontario K1A OK9 Toll free: Dental Predetermination Extension 1 Medical Supplies and Equipment Extension 2 Fax (toll free): P a g e Motion # April 2 nd 2012

13 2.5 NIHB Reimbursement Process Appointment booked by client or by doctor referral Application filled out by family doctor, nursing station or drop-in clinic If rejected If accepted Corrections made or option for appeal If rejected Health Professional and/or client notified reason given by NIHB Travel booked by NIHB or nursing station client notified Patient hands in Appointment Confirmation with signatures (must be originals) * Also hand in any meal or accommodation receipts for reimbursement. Client Reimbursement 8 P a g e Motion # April 2 nd 2012

14 2.6 NIHB Medical Transportation Benefits (From Your Health Benefits: A guide for First Nations to Access Non-Insured Health Benefits, 2011) What is covered? Assistance with the payment of transportation to the nearest appropriate health professional or health facility for clients to access eligible medically necessary health services that cannot be obtained on the reserve or in the community of residence. This may include assistance with meals and accommodation when these expenses are incurred while in transit for approved transportation to access medically necessary health services. Except in emergency situations, access to medical transportation benefits requires prior approval. Modes of Transportation Ground travel: private vehicle, commercial taxi, fee-for-service driver and vehicle, Band vehicle, bus, train, snowmobile taxi or ground ambulance. Water travel: motorized boat, boat taxi or ferry. Air travel: scheduled and chartered flights, helicopter, air ambulance or Medevac where not provincially insured. The most efficient and economical mode of transportation, consistent with the urgency of the situation and the medical condition of the client, is to be utilized at all times. Clients who choose to use another method will be responsible for the cost difference. When scheduled and/or coordinated medical transportation benefits are provided, clients who choose to use another mode of transportation will be responsible for the full cost. Coordinated Travel 1. Schedule same-day appointments for clients travelling to the same location. 2. When a client requires more than one medical appointment, schedule all appointments for the same day or trip. 3. When more than one client is travelling in the same vehicle, the rate reimbursed will be for one (1) trip only. Emergency Transportation 1. Ambulance services when required and not provincially insured (Ground or Air Ambulance/Medevac). 2. There are regional differences in eligibility depending on provincial and territorial legislation. 3. Salaries for doctors or nurses accompanying clients on the ambulance are not covered. 4. Licensed ambulance operators will be reimbursed according to terms, conditions and rules of regional guidelines and/or processes. 9 P a g e Motion # April 2 nd 2012

15 Access to Traditional Healers 1. Destination within the client's province/territory of residence or if healer is outside the client's province/territory travel reimbursement will be to the border only. 2. The prior approval process considers: a. whether the healer is recognized by the local Band, Tribal Council or health professional; b. the location of the healer; and c. a note from a health professional confirming a medical condition. 3. When more than one (1) client requires the service of a traditional healer it may be more economical for a traditional healer to travel to the community. Costs related to honoraria, ceremonial expenses or medicines remain the sole responsibility of the client(s). Meals and Accommodations 1. May provide assistance with meals and accommodations when travelling to access medically necessary health services. 2. Amount of coverage will depend on preset regional rates. Regional rates are available through your Health Canada regional office. 3. The most efficient and economical means of accommodation will be chosen taking into consideration the client's health condition, location of accommodation, and travel requirements. 4. Accommodation arrangements will be made by a Health Canada regional or zone office or a First Nations health authority. Clients may be responsible for the full costs if prior approval is not obtained, and, if post-approved, they will be responsible for the cost difference if they choose to make their own arrangements. 5. Time away from home is a consideration in determining the meals that will be covered. 6. Accommodation in a private home may be reimbursed at the regional rate. 7. Hotel Accommodations: Room and taxes only will be covered. Other expenses are at the cost of the client. 8. When a client needs to be close to medical treatment for an extended period, assistance with the cost of meals, accommodation, and in-city transportation to access the medically necessary care/treatment may be covered for up to a three-month transition period only. Escorts (General) Medical Escorts: Medical escorts, either a physician or registered nurse, may be approved in cases which involve a client with a health condition where monitoring and/or stabilization are required during travel and such services are not covered by the provincial/territorial health or social program, other publicly funded program or private insurance. Non-Medical Escorts: The provision of a non-medical escort may be approved, following a doctor s or community health professional s request, only when there is a legal or medical requirement such as: 1. Where the client has a physical/mental disability of a nature that he or she is unable to travel unassisted; 2. Where the client is medically incapacitated; 10 P a g e Motion # April 2 nd 2012

16 3. Where the client has been declared "mentally incompetent" by a court of competent jurisdiction and assistance to access medically required health services, legal consent or help with activities of daily living is required; 4. When there is a need for legal consent by a parent or guardian; 5. To accompany a minor (as determined by provincial/territorial legislation) who is accessing medically required health services; 6. When a language barrier exists to access medically required health services and these services are not available at the referred location; or 7. To receive instructions on specific and essential home medical/nursing procedures that cannot be given to the client only. Criteria for Escorts: 1. May include transportation, accommodations and meals for medical and non-medical escorts. 2. Prior approval is required, and the length of time is determined by the client's medical condition or legal requirements. 3. The client has a physical/mental disability, or has legally been declared "mentally incompetent" and is, therefore, unable to travel unassisted. 4. The client is medically incapacitated. 5. There is a need for legal consent by a parent or guardian. 6. To accompany a minor who is accessing required health services. 7. When a language barrier exists and/or interpreter services are unavailable. 8. To receive instructions on specific and essential home medical/nursing procedures that cannot be given to the client only. Unless there is a medical or legal requirement for an escort to stay longer, or it is more practical financially to have the escort stay longer, the escort shall return to the community by the earliest and most economical reasonable means. Note: When an escort has been authorized, the following criteria should be considered in selecting the escort: 1. A family member who is required to sign consent forms or provide a client history; 2. A reliable member of the community; 3. Physically capable of taking care of themselves and the client and not requiring assistance or an escort themselves; 4. Proficient in translating from local language to English/French; 5. Able to share personal space to support the client; 6. Interested in the well-being of the client; and 7. Able to serve as driver when the client is unable to transport him/herself to or from appointments. The use of an escort must be preauthorized by First Nations and Inuit Health Branch (FNIHB) or a First Nations or Inuit Health Authority or organization. The length of time for which the escort is authorized will be determined by the client's medical condition or legal requirements. Medical transportation benefits do not include the payment of a fee, honorarium or salary to medical or nonmedical escorts. 11 P a g e Motion # April 2 nd 2012

17 Addictions Treatment 1. Travel for the treatment of alcohol, drug, and solvent abuse. 2. Travel will be covered to the closest appropriate National Native Alcohol and Drug Abuse Program (NNADAP) funded/referred facility in the home province/territory (some exceptions for out-ofprovince). 3. Clients are to meet all treatment centre entry requirements prior to medical transportation being authorized. 4. Travel by the most economical and practical means. 5. Transportation for family members when their participation is an integral and scheduled portion of the treatment program and approved prior to treatment. 6. Transportation will not be provided if the client discharges themselves from treatment against advice from the treatment centre counsellor, before completing the program. An exception may be considered with proper justification in some circumstances and approval by the Health Canada regional office. Other medically necessary health services 1. Travel to medical services defined as insured services by provincial/territorial health plans (e.g., appointments with physician, hospital care). 2. Diagnostic tests and medical treatments covered by provincial/territorial health plans. 3. To access other NIHB approved benefits (vision, dental and mental health) General Principles 1. Clients must have prior approval to access medical transportation benefits. 2. In emergency situations, when prior approval has not been obtained, expenses may be reimbursed (Required: appropriate medical justification and approval after the fact). 3. Clients must provide proof or confirmation from the health care provider or representative that they have attended the appointment. 4. When a client does not attend a scheduled appointment and medical transportation benefits have been provided, the client may be required to assume the cost of the return trip or of the next trip to access medically necessary health services unless justification is provided to explain why the client was unable to attend or notify the appropriate public carrier of the cancellation. 5. This benefit may be provided when the client is referred by the provincial/territorial health care authority for medically necessary health services to a facility outside of Canada when such services are covered by a provincial/territorial health plan. See Approved Health Benefits Outside of Canada, Section Exceptions (May be considered on an exceptional basis with justification) 1. Diagnostic tests for educational purposes (e.g., hearing tests for children required by the school). 2. Speech assessment and therapy, when coordinated with other approved NIHB medical travel to a provincially/territorially insured service. 3. Medical supplies and equipment benefits where a fitting is required and cannot be made on the reserve or in the community of residence. 4. Transportation for methadone ingestion may be covered for up to four (4) months. Extension with medical justification may be considered. 12 P a g e Motion # April 2 nd 2012

18 5. Provincially/territorially supported preventative screening programs when coordinated with other medical travel and the cost of testing is covered under the provincial/territorial health plan What is not covered / Exclusions Certain types of travel, benefits and services will not be provided as benefits under the NIHB Program under any circumstances and are not subject to the NIHB appeal process. These include: 1. Travel and related benefits (e.g., meals and accommodation, ambulance) where they are the responsibility of another party or provided as an insured service. 2. Compassionate travel (e.g., family visits unless prior approval has been obtained as a part of the treatment plan at a drug and alcohol rehabilitation facility). 3. Travel for clients in the care of a federal, provincial or territorial institution (e.g., incarcerated clients). 4. Court-ordered treatment/assessment, or as a condition of parole, coordinated by the justice system. 5. Travel for clients residing off-reserve in a location where the necessary health service is available locally. 6. Travel for the purpose of a third-party requested medical examination. 7. The return trip home in cases of an illness while away from home other than for approved travel to access medically necessary health services. 8. Travel only to pick-up new or repeat prescriptions, or vision care products. 9. Payment of professional fee(s) for preparation of doctor's note/document preparation to support provision of benefits. 10. Transportation to an adult day care, respite care and/or safe house NIHB Medical Driver Guidelines Whether Band vehicle and drivers or fee for service drivers are used to provide medical transportation benefits, FNIHB or a First Nations or Inuit Health Authority or organization shall ensure: 1. All medical drivers carry and maintain a valid provincial/territorial driving permit and appropriate liability insurance in relation to the carriage of passengers by vehicle or other motorized conveyances; 2. All medical drivers undergo a screening process, including background checks and references, whereby the general trustworthiness of the driver is assessed, bearing in mind that the driver will not only be operating a motor vehicle, but also entrusted with the transport of medical patients and will frequently be alone with such persons for extended periods; 3. All vehicles carry and maintain a valid license, registration and appropriate liability insurance in relation to the carriage of passengers by vehicle or other motorized conveyances; 4. All vehicles used for medical transportation are in good working order, including seat belts and child safety seats, and that all laws applicable to transportation are adhered to by all drivers. 13 P a g e Motion # April 2 nd 2012

19 2.7 NIHB Medical Supplies and Equipment Policies (From Your Health Benefits: A guide for First Nations to Access Non-Insured Health Benefits, 2011) What is covered? When not covered by another plan or program, payment is made to the NIHB approved provider or reimbursed to the client at NIHB rates for approved Medical Supplies and Equipment (MS&E) items in the categories listed below. Most MS&E benefits require prior approval from the Health Canada regional office and a prescription from an eligible prescriber. General Medical Supplies and Equipment Categories 1. Audiology (Hearing Aids and Supplies) 2. Bathing and Toileting Aids 3. Cushions and Protectors 4. Environmental Aids (Dressing and Feeding) 5. Lifting and Transfer Aids 6. Low Vision Aids 7. Miscellaneous Supplies and Equipment 8. Mobility Aids (Walking Aids, Wheelchairs) 9. Orthotics and Custom Footwear 10. Ostomy Supplies and Devices 11. Oxygen Supplies and Equipment 12. Pressure Garments and Pressure Orthotics (Compression Device and Scar Management) 13. Prosthetic Benefits (Breast, Eye, Limbs) 14. Respiratory Supplies and Equipment 15. Urinary Supplies and Devices (Catheter Supplies and Devices, Incontinence Supplies) 16. Wound Dressing Supplies Equipment 1. Medical equipment may be rented or leased on a temporary basis until it is determined that the client will have a continuing long-term need. 2. The Program will request warranties at time of approval. 3. Previously provided items may be replaced if a client's medical needs change; a medical justification to support the early replacement must accompany the request. 4. When a MS&E item is rented, the rental agreement must include maintenance and repair costs, as the NIHB Program does not cover maintenance or repairs of rented equipment. The rental agreement must also include a clause stipulating that should the purchase of the item become an option, the amount spent on the rental will be applied towards the purchase price. The client is responsible for the rented item. 5. MS&E items that have an annual quantity limitation must be provided and billed for no more than a 3- month period at a time. This applies to items claimed with or without prior approval. 14 P a g e Motion # April 2 nd 2012

20 2.7.2 Who may be involved in prescribing medical supplies and equipment? 1. Physicians 2. Licensed practitioners with authorization to prescribe within the scope of practice in their province or territory and that are recognized by the NIHB Program General Principles 1. Eligible benefits are those available through registered pharmacies and MS&E providers for personal use in a home setting or other ambulatory setting. (Ambulatory care settings are environments that are not a "provincially/territorially funded setting (hospital/institution) or funded by any provincial/territorial programs or clinics according to provincial/territorial legislation".) 2. Guidelines outlining recommended quantities or replacements are based on the average medical needs of clients. Requests exceeding these guidelines may be considered on a case-by-case basis if a medical need is demonstrated Exceptions Benefits not on the approved list may be covered when an exceptional need is demonstrated and established by the prescriber. The prescriber will need to provide NIHB with a letter of justification for consideration What is not covered / Exclusions 1. Assistive listening devices (excluding eligible hearing aids) 2. Assistive speech devices (i.e., keyboard speech systems, speech enhancers) 3. Cochlear implants 4. Custom-made mask for ventilation 5. Electric/myoelectric limb prosthetics 6. Exercise devices 7. Experimental equipment 8. Foot products manufactured only from laser or optical scanning or computerized gait and pressure analysis systems 9. Grab bars permanently fixed 10. Hospital beds and mattresses 11. Implants 12. Items for cosmetic purposes 13. Items used exclusively for sports, work or education 14. Incentive spirometer 15. Orthopaedic footwear "off the shelf" 16. Part of a surgical procedure 17. Providing oxygen for indications which do not meet the medical criteria of the NIHB Program (e.g. angina and pain relief from migraines) 18. Respiratory equipment for in-patients of an institution 19. Scooters 20. Short-term compression stockings/ garments (i.e., post-operative: surgical stripping, sclerotherapy, and edema conditions) 15 P a g e Motion # April 2 nd 2012

21 21. Temporary prosthetics required as part of a surgical procedure 16 P a g e Motion # April 2 nd 2012

22 2.8 NIHB Eye and Vision Care Policies (From Your Health Benefits: A guide for First Nations to Access Non-Insured Health Benefits, 2011) What is covered? Eye and Vision Care Benefits covered by the Non-Insured Health Benefits (NIHB)Program includes the following: 1. Eye examinations, when they are not insured by the province/territory (e.g., eye exams for children, elderly and diabetic clients in some provinces/territories); 2. Eyeglasses that are prescribed by a vision-care provider; 3. Eyeglass repairs; 4. Eye prosthesis (an artificial eye); and 5. Other vision care benefits depending on your specific medical needs Eligibility Vision care benefits are available to eligible registered First Nations and recognized Inuit, in accordance with the relevant NIHB Program regional payment schedule when ALL of the following criteria are met: 1. The requested item is a NIHB Vision Care Benefit. 2. Prior approval is granted as per the NIHB Regional Office process. 3. The item is not available to the client through any other federal, provincial, territorial, or other third party health care plan or program. 4. The item is prescribed by an ophthalmologist or an optometrist. The ophthalmologist or optometrist will determine the type of vision care products and services required to meet the client's needs. 5. The prescription must be less than one year old. 6. The item is dispensed by an optometrist or optician. 7. The vision care services/devices must be provided according to established professional standards and applicable provincial/territorial laws. 8. Co-ordination of benefits must be done when other coverage is available to the client. NIHB is always the payer of last resort. All eye and vision care benefits require prior approval from the Health Canada regional office. General Eye and Vision Exams 1. Every 24 months for a person 18 years and over Every 12 months for a person younger than 18 years. 3. When there is a change or correction in vision. 1 A person with diabetes is eligible for a complete eye exam every 12 months. A doctor may recommend additional follow-up exams. 17 P a g e Motion # April 2 nd 2012

23 Specific/Partial Eye Exams 1. May be approved for unique medical conditions on a case-by-case basis. 2. When a severe abnormality in ocular or visual condition requires a thorough assessment using specific tests such as: for medical condition resulting from diabetes. Follow-Up Exams 1. May be approved on a case-by-case basis. 2. When required for certain ocular or visual conditions. Partial and Single Procedure Eye Exams 1. Specific eye exams for diabetics, or other documented medical conditions. First pair of eyeglasses 1. With a written prescription from the optometrist or ophthalmologist. 2. Will be approved with a prescription of at least a spherical equivalent of + or diopters. 3. Lenses and frames up to a maximum amount determined by the Health Canada regional office. 4. Lenses include: unifocal (distance or near vision), aspheric, bifocal, or high index (HIL). Some restrictions apply. 5. Prescriptions more than one (1) year old but less than two (2) years old will be considered on a case-bycase basis. Replacement eyeglasses/lenses 1. Every 24 months for a person 18 years old and over. 2. Every 12 months for a person younger than 18 years. 3. Replacement lenses within the 24 month period if there is a significant change in vision. 4. Lenses include: unifocal (distance or near vision), aspheric, bifocal, or high index (HIL). Some restrictions apply. Eyeglass repairs 1. The total cost of the repair must not be more than it would cost to replace with standard frames One major and one minor within the eyeglasses replacement time frame (12 or 24 months). Who may be involved in providing this care? 1. Licensed Optometrists 2. Ophthalmologist (Eye Specialist) 2 Replacement frames or sets of lenses are not eyeglass repairs. 18 P a g e Motion # April 2 nd 2012

24 1. Opticians (Prepares the eyeglasses that have been prescribed) Exceptions or Special Cases All cases as described below require prior approval and a written prescription with proper medical justification that will be provided by the health practitioner. Monocular Clients 1. Polycarbonate lens or other safety frames and lenses. Replacement Eyeglasses In the case of breakage, damage or loss, written justification and appropriate written proof, such as an accident report, is required for consideration of replacement eyeglasses. Contact Lenses 1. When medically necessary as prescribed for medical eye conditions.(medically necessary conditions include, but are not limited to: astigmatism, anisometropia or antimetropia, corneal irregularities, and treatment of certain ocular pathologies.) 2. Back-up eyeglasses are also included as a benefit. Replacement of Contact Lenses 1. One (1) pair of contacts every 24 months for regular soft, and gas permeable soft and hard lenses. 2. When medically necessary as prescribed for a medical eye condition. 3. Replacement contact lenses if there is a prescription change of + or diopters Trial of Bifocals 1. Attempt full-time use for a three (3) month period and, if unsuccessful, the frames will be used for reading glasses and a separate pair of distance glasses can be dispensed. Medical documentation is required. Tints and Coating for Lenses 1. Anti-Reflective Coating in cases where the client is eligible for high index lenses. 2. Scratch Resistant Coating for polycarbonate, high index lenses and children's glasses. 3. Tints in some cases such as albinism, aniridia, and certain chronic conditions of the anterior segment of the eye causing photophobia. Medical documentation is required. 4. Ultraviolet Protection Filter in some cases such as aphakia, cataracts, retinal degeneration or dystrophy, or photosensitivity. 19 P a g e Motion # April 2 nd 2012

25 Frames Will be evaluated on a case-by-case basis for approval for the following frames: 1. Flex frames (only for those who are neurologically compromised); 2. Frames and unifocal lenses (2 nd set) for those who cannot wear bifocals; or 3. Oversized frames over 57 mm What is not covered / Exclusions 1. Vision care goods and services covered by provincial/territorial health insurance plans 2. Additional carrying cases for glasses or contact lenses 3. Cleaning kit 4. Esthetic products 5. Shampoo (e.g., "no more tears" type shampoo solution) 6. Vision exams required for a job,drivers license or to engage in sports activity 7. Vision exams at the request of a 3 rd party (e.g., completing a report or medical certificate) 8. Contact lenses for esthetic purposes 9. Contact lens solution 10. Industrial safety frames or lenses for sports or professional use 11. Sunglasses with no prescription 12. Progressive or trifocal lenses 13. Photocromic/photocromatic lenses 14. Replacements or repairs as a result of misuse, carelessness or negligence 15. Implants (e.g., punctual occlusion procedure) 16. Refractive laser surgery 17. Treatments with investigational/experimental status 18. Vision training 20 P a g e Motion # April 2 nd 2012

26 2.9 NIHB Dental Benefits Policy (From Your Health Benefits: A guide for First Nations to Access Non-Insured Health Benefits, 2011) What is covered? Dental services covered under the NIHB Program are divided into two (2) schedules: 1. Schedule A lists services that may be provided without predetermination within NIHB Program limits; 2. Schedule B lists services that require predetermination. Payment for treatment is made to the provider/client/third party for the services listed below. Certain dental benefits, as specified below, require predetermination from the Health Canada regional office or the Orthodontic Review Centre (ORC). Diagnostic services (exams and X-rays) Exams: X-rays: 1. Under the age of 17: eligible for up to four (4) examinations in any 12-month period years +: eligible for up to three (3) examinations in any 12-month period. 1. Eligible for six (6) single x-rays in any 12-month period. 2. Eligible for one (1) panoramic (rectangular shot) x-ray in any 120-month period (10 years) without predetermination; up to 2 per lifetime. Preventive services Scaling (cleaning)/root planing (deep cleaning): 1. Under the age of 12: eligible for one (1) unit (15 minutes) in any 12-month period without predetermination years and older: eligible to a maximum of four (4) units in any 12-month period without predetermination. 3. NIHB may consider, on a one-time basis, coverage of a maximum of 16 additional units to address the disease when the client presents with chronic periodontal disease and has been on a maintenance periodontal program but presents with areas of refractory disease. Sealants/Preventive Resins: 1. Under the age of 14: eligible on erupted permanent molar and upper incisors (front four top and bottom teeth). 21 P a g e Motion # April 2 nd 2012

27 Topical fluoride: 1. Under the age of 17: eligible twice (2) in any 12-month period. Polishing: 1. Under the age of 17: eligible twice (2) in any 12-month period years +: eligible once (1) in any 12-month period. Restorative services (fillings) Fillings: 1. The maximum amount allowable for amalgam and tooth coloured fillings is up to the cost of a five (5) surface restoration per tooth. 2. The maximum allowable on primary/baby teeth is up to the cost of a stainless steel/polycarbonate crown. 3. Primary incisor teeth will only be covered under the age of 5 years old. 4. Bonded amalgam fillings are covered at a rate of a non-bonded equivalent. 5. Replacement fillings within a two-year period are subject to question. 6. Retentive pins, cores and posts: one (1) every 36 months. Predetermination is required. 7. Paediatric dentistry (children's dental specialist treatment) is an available benefit to children. Crowns: 1. Crowns must be predetermined and must meet the NIHB Program's Crown policy. Endodontic services (root canals) Anterior root canals (front teeth): 1. Root canals may be completed on anterior teeth without predetermination; however, the NIHB Program's Endodontic policy must be met. Posterior root canals (premolars and molars): 1. Root canals for posterior teeth must be predetermined and must meet the NIHB Program's Endodontic policy. Pulpotomies and pulpectomies (root therapy mostly performed on baby teeth): 1. Primary posterior (canines and molar teeth): eligible without predetermination. 2. Pulpotomies and pulpectomies are not eligible on teeth number 51, 52, 61 62, 71, 72, 81, 82 (baby front teeth). 22 P a g e Motion # April 2 nd 2012

28 Open and drain (pain relief emergency service): 1. Eligible without predetermination. Prosthodontic removable services (dentures, partials) 1. Dentures (complete and partials) are eligible once (1) in any eight (8) year period. Predetermination is required. 2. Includes three (3) months post-insertion care including adjustments and modifications. 3. For immediate dentures (post surgical dentures) an additional reline is permitted. 4. Replacement of dentures within an eight (8) year period requires supporting rationale. 5. Appliances to replace a single missing posterior tooth are not a covered benefit under the NIHB Program. Orthodontic services The NIHB Program covers a limited range of orthodontic services and clients must meet the clinical criteria and guidelines established by the NIHB Program for orthodontic treatment to be covered. There are three (3) elements to the orthodontic services: 1. Craniofacial anomalies such as cleft lip and palate associated with a severe malocclusion and are functionally handicapping 3 for which there are no age restrictions. 2. Early intervention treatment during the transition from baby teeth associated with a severe malocclusion and is functionally handicapping for clients under 18 years of age. 3. Comprehensive treatment for severe and functionally handicapping malocclusions characterized by a combination of a markedly unfavourable relationship between upper and lower jaws and teeth with each other. Eligible clients must be under the age of 18. Oral surgery services (extraction) 1. Simple extractions are part of basic treatment and do not require predetermination. 2. Complicated or surgical extractions require predetermination. Adjunctive Services (sedation) 1. General anaesthetic/sedation services are normally limited to children under 12 years of age. Predetermination is required for this service. 2. There are regional variations in eligibility depending on provincial and territorial government services and rules. 3. General anaesthetic/sedation is not covered for the management of dental anxiety for patients 12 years of age and older. Exceptions may be considered if a client presents with a medical or physical impairment/condition(s). 3 A functionally handicapping relationship is one in which damaging consequences (such as traumatized teeth and gums) will result from those relationships. 23 P a g e Motion # April 2 nd 2012

29 Schedule A These are categories of dental services that do not require predetermination but may have frequency limitations. Examples: 1. Cleanings 2. Denture repairs 3. Exams 4. Extractions (simple) 5. Fillings 6. Open and drain (emergency procedure) 7. Preventive services 8. Root canals (for adult front teeth) 9. X-rays Schedule B These are categories of dental services that require predetermination. Examples: 1. Crowns 2. Dentures 3. Extractions (complicated or surgical) 4. Orthodontic services (braces) 5. Root canals for posterior teeth 6. Sedation Schedule C Exclusions These are categories of dental services that are beyond the scope of the NIHB Program and therefore not considered for appeal. Examples: 1. Cosmetic services (veneers, bleaching) 2. Extensive rehabilitation 3. Halstrom appliances (sleep apnea) 4. Implants 5. Ridge augmentation (for denture fitting) Please note: These schedules are not comprehensive. While most services under the categories listed above are covered, as indicated, not all services under a given category may be covered as per established NIHB policy. If you have questions about whether a particular service is covered, contact your Health Canada regional office or the Orthodontic Review Centre. 24 P a g e Motion # April 2 nd 2012

30 2.9.2 Predetermination 1. Predetermination is a process of prior approval that reviews cases against established NIHB policy criteria and guidelines. 2. In the Yukon, eligible clients are allotted a $1000 ceiling of dental benefits, after they have reached this quota they must apply to NIHB for prior approval or predetermination of any dental work. 3. Predetermination or prior approval may be required in advance for specific dental services regardless of the ceiling. More complex dental procedures and dental services above frequency limitations require predetermination. For example: crowns, dentures and root canal treatment on certain teeth. 4. All cases requiring predetermination should be sent by your dental provider's office to the appropriate Health Canada regional office for review prior to the start of treatment. 5. Orthodontic case requests are to be sent to the Orthodontic Review Centre. 6. Predetermination requests require additional information: x-rays, supporting rationale, tooth charting, etc. The additional information may vary depending on the dental service required. Emergency dental services Emergency dental services do not require predetermination. Services consist of acute dental problems including associated examinations and radiographs, procedures for the immediate relief of pain and infection (pulpotomies and pulpectomies, open and drain), arresting haemorrhage, and preliminary care of trauma to the mouth Who may be involved in providing dental care? Licensed practitioners with authorization to provide dental services within their scope of practice in their province or territory and that are recognized by the NIHB Program (such as dentists, dental specialists and denturists) About the Process Your dental provider has a complete list of eligible services (Schedule A and B). The NIHB Program strongly encourages dental providers to bill the NIHB Program directly. If your dental provider chooses not to bill the NIHB Program directly, please contact the appropriate Health Canada regional dental office, which may provide you with a list of alternate providers in your area. The dentist has an obligation to tell you, as the client, if you will have to pay for services before treatment is started. All basic treatment needs (e.g., cleanings, fillings, extractions, etc) must be completed before any major dental services are requested (e.g., crowns, partials, etc.). A dental professional reviews each request on an individual basis. In the review, consideration is given to: 1. The client's oral hygiene status, periodontal condition, and dental history; 2. the established NIHB Policies, guidelines and criteria; and 3. any additional information provided by the dental provider. 25 P a g e Motion # April 2 nd 2012

31 Your request may require supporting documentation; your dental provider should send the additional information to the appropriate Health Canada regional office or to the Orthodontic Review Centre. Examples of supporting documentation include: 1. Complete treatment plan a. note of existing fillings and requested fillings b. missing teeth 2. Examination findings a. periodontal charting 3. X-rays (date of service within one (1) year) 4. Orthodontic records models. 26 P a g e Motion # April 2 nd 2012

32 2.10 NIHB Pharmacy / Drug Benefits Policies (From Your Health Benefits: A guide for First Nations to Access Non-Insured Health Benefits, 2011) What is covered? When not covered by another program/plan, payment is made for eligible benefit items directly to the NIHBapproved provider or reimbursed to the client at NIHB rates in the areas listed below. Prescription drugs 1. Drugs that require a prescription from an authorized prescriber. 2. Drugs that are listed in the Drug Benefit List at the address below. Over-the-counter drugs (OTC) 1. OTC drugs and health products listed in the Drug Benefit List, which do not require a prescription under provincial or federal legislation, but do require a prescription for coverage under the NIHB Program. Open benefits 2. Drugs that are listed on the NIHB Drug Benefit List and do not have established criteria or prior approval requirements. Limited use benefits 3. Approval for certain groups of clients including: o multivitamins for children up to age 6; and o prenatal supplements and vitamins for women between the age of 12 and 50 years. 4. Benefits which have a quantity and frequency limit. A maximum quantity of a drug is allowed within a specific period of time. For example, a client is eligible to receive a 3-month supply of smoking cessation products which is renewable 12-months from the day the initial prescription was filled. 5. Benefits which require prior approval and for which specific criteria has been established, and must be confirmed by a doctor's completion of the NIHB Limited Use Drugs Request forms. Chronic Renal Failure Patients 1. Eligible to receive a list of supplemental benefits that are not included in the NIHB Drug Benefit List but are required on a long-term basis. a. Includes: epoetinalfa products, calcium products, special multivitamins and select nutritional supplements. 2. Clients will be identified for coverage through the usual prior approval process. 27 P a g e Motion # April 2 nd 2012

33 Palliative Care Formulary 1. Clients diagnosed with a terminal illness and who are near the end of life will be eligible to receive a list of supplemental benefits that are not included in the NIHB Drug Benefit List but are required for palliative care. 2. Clients will be identified for coverage through the usual prior approval process General Principles 1. The policy is to reimburse only the best-price alternative product in a group of interchangeable drug products so it covers the "lowest cost alternative drug" which is commonly known as a generic drug. However, an alternative, such as brand-name drug, may be covered if the client has had an adverse reaction to the generic drug. 2. Maximum quantities have been placed on some drugs for health and safety reasons. 3. Eligible drugs are those that are available through pharmacies and require a prescription for administration in a home setting or other ambulatory setting. Ambulatory care settings are environments that are not a "provincially/territorially funded setting (hospital/institution) or funded by any provincial/territorial programs or clinics according to provincial/territorial legislation" Prior approval Prior approval for a drug is needed for all exceptions and certain limited use benefits. 1. When prior approval is required for a drug, the pharmacist must contact the Non-Insured Health Benefits Drug Exception Centre. 2. When a drug requiring prior approval is needed on an emergency basis, and timely review by the Non- Insured Health Benefits Drug Exception Centre is not possible, the pharmacist may dispense an initial course of treatment for some drugs. 3. The pharmacist must contact the Drug Exception Centre as soon as possible for approval to be backdated to cover the emergency supply. Any further dispensing of the drug will follow the usual prior approval process Who can prescribe drugs? 1. Physicians 2. Licensed practitioners with authorization to prescribe within the scope of practice in their province or territory and that are recognized by the NIHB Program Exceptions 1. Drugs that are not listed in the Drug Benefit List and that are not exclusions may be approved for coverage on a case-by-case basis when an exceptional need is demonstrated. 2. This need must be established by the prescriber by completing an Exception Drug Request form. 3. In the event the request is denied, the client may appeal (see Procedure for Appeals in Section 8). 4. Consideration is made for clients who require more than the maximum allowable for benefits which have a quantity and frequency limit. 28 P a g e Motion # April 2 nd 2012

34 What is not covered / Exclusions 1. Alternative therapies (e.g., glucosamine and evening primrose oil) 2. Anti-obesity drugs 3. Cosmetics 4. Cough preparations containing codeine 5. Darvon and 642 (propoxyphene) 6. Drugs with investigational/experimental status 7. Fertility agents and impotence drugs 8. Hair growth stimulants 9. Household products (e.g., soap and shampoos) 10. Megavitamins 11. Certain narcotic analegesics (e.g. Butalbital) 12. Selected over-the-counter products 13. Vaccinations 29 P a g e Motion # April 2 nd 2012

35 2.11 NIHB Crisis Counselling Policies (From Your Health Benefits: A guide for First Nations to Access Non-Insured Health Benefits, 2011) What is covered? The NIHB Program provides coverage for the following benefits. Service for the community 1. Fees and associated travel costs for the mental health professional(s) may be made available when it is deemed cost-effective to provide such services in a community or in response to a crisis which affects many clients and families within that community. Counselling for Clients or Families 1. When there is a crisis or at-risk situation and there is no other source of immediate funds for services. 2. Fees for professional mental health therapists for an initial assessment and to develop a treatment plan (maximum two (2) hours). 3. Mental health short-term crisis treatment and referral services by, or recognized by, professional mental health therapists including initial assessment and development of a treatment plan. 4. Treatment plans must include duration and cost Who may be involved in providing this care? 1. Registered Therapists (those within the disciplines of Clinical Psychology, Clinical Social Work or Counselling Psychology). 2. Mental Health Therapists who are on the list of approved service providers. Each Health Canada regional office maintains its own list. 3. In exceptional cases, a provider who is under the direction of a registered clinical psychologist, registered clinical social worker or counselling psychologist. 4. Generally, therapists who are registered with professional governing bodies within the province or territory where the benefit is being provided (e.g., Psychology, Social Work). 5. In exceptional circumstances, mental health therapists from other disciplines may also be on a region's list What is not covered / Exclusions 1. Any assessment service that is not considered to be a mental health crisis (e.g., fetal alcohol spectrum disorder, learning disabilities, and child custody and access) 2. Court-ordered assessment/therapy services to clients 3. Early Intervention Programs (for infants with delayed development) 4. Educational and vocational counselling 5. Group counselling 6. Life skills training 7. Long-term counselling/non-crisis counselling 30 P a g e Motion # April 2 nd 2012

36 8. Psychiatric Services 9. Psychoanalysis 10. When another program or agency is responsible for providing the service. The nature of this service is short-term. (Approximately ten (10) sessions) 31 P a g e Motion # April 2 nd 2012

37 3 Background on Yukon Government Insured Health and Hearing Services 3.1 What is Insured Health and Hearing Services? Insured Services ensures delivery of health care benefits as set out in the Health Care Insurance Plan, the Hospital Insurance Services Plan, and the Travel for Medical Treatment Act. The programs offered under insured services include: 1. Children s Drug and Optical Program 2. Chronic Disease Program 3. Extended Health Care Benefits to Seniors 4. Medical Travel 5. Pharmacare. The Yukon Health Care Insurance plan provides coverage for medically required hospital and medical services, and certain dental-surgical procedures. The cost of providing these services to Yukoner s is met through the general revenues of the territory. There are no premiums. The Yukon Health Care Card shows you are entitled to receive health care services in the Yukon. 3.2 Who is an Eligible Recipient? Yukon residents are eligible for the territorially-funded health coverage. To be eligible you must: 1. Be a Canadian citizen or have immigration status; 2. Make your permanent home in Yukon; and 3. Be physically present in Yukon and not absent for more than six months, without a waiver from Insured Health Services. Yukon Health Care Insurance coverage normally becomes effective three months after the date you establish residency in Yukon. Through reciprocal agreements with other provinces and territories, if you are an eligible resident moving to Yukon from another part of Canada, the health insurance of your former province/territory will cover you for up to three months. Students must file a temporary absence notice for health care to continue while they are not resident in the Yukon. Citizens of FNNND who are not eligible recipients under NIHB are eligible for coverage under Yukon Government. The Yukon Government is also responsible for providing medical services in each community. In Mayo they provide the services of Health Centre nurses and a doctor. As well as, the Yukon Government provides the services of personal care workers (e.g., foot care) to FNNND citizens (home care support is provided to citizens by the First Nation itself). 32 P a g e Motion # April 2 nd 2012

38 3.3 YG Medical Travel Policy Scope The Travel for Medical Treatment Program is available to assist eligible persons with the cost of medically necessary transportation. Medically necessary transportation refers to a medical emergency, and to those non-emergency services not available in the home community but necessary for the well-being of the patient. A transportation request must be certified by a medical practitioner and approved by the Medical Travel Program in advance Eligibility Yukon residents registered with the Yukon Health Care Insurance Plan (YHCIP) who meet the program requirements are eligible for medical travel benefits. 1. Exceptions: a. Psychiatric patients are covered under the Mental Health Act. b. Employees injured or taken ill in the course of their employment are covered by Workers Compensation Health and Safety. c. Status Indians (i.e. NIHB eligible recipients), members of the Armed Forces, the RCMP and federal government employees, their spouses or dependants, are covered under other Federal or Yukon Acts. Application for Medical Travel must be certified by a practitioner licensed in the Yukon and forwarded to the Medical Travel Program for approval. Practitioners include Yukon physicians and nurse practitioners in communities with no resident physician. Travel to out-of-territory centres requires the prior approval of the Chief Medical Officer of Health in addition to the Yukon medical practitioner s certification. To be eligible for coverage, all travel must originate from a point of referral (the place where a physician or nurse practitioner has examined the patient and certified the need for medical travel) within the Yukon. The plan does not cover the cost of travel back to the Yukon if travel is initiated while outside the territory (e.g., Alaska, other Canadian provinces, the NWT, Nunavut or any foreign jurisdiction). A Yukon physician and the Medical Officer of Health must give prior approval for medical travel for dental treatment. Coverage is limited to reconstruction or surgical rectification of severe jaw, mouth and palate deformities and/or injuries, and medico-dental syndromes affecting tissues and structures of the jaw and mouth Benefits Travel for medical treatment is provided to eligible persons for medical services insured under YHCIP which are not available in their home community. Coverage includes the cost of return public transportation or a mileage allowance for travel in a private vehicle, to Whitehorse, Edmonton, Calgary or Vancouver. The program covers in-territory travel for the following services: 33 P a g e Motion # April 2 nd 2012

39 1. Assessment and treatment by Hearing Services in Whitehorse 2. Assessment and treatment by Mental Health Services in Whitehorse 3. Assessment and treatment by the Child Development Centre in Whitehorse 4. Assessment and treatment by Therapy Services provided through Whitehorse General Hospital Patients who are not admitted to a facility but require out-patient services may be eligible to receive a $75/day subsidy reimbursement beginning on the second day they receive out-patient services, to a maximum of 90 days. The purpose of the subsidy is to assist patients with the cost of their accommodation, meals, taxis, and any other expenses incurred while on medical travel status. All subsidy claims in excess of 90 days must be reviewed and approved by the Director of Insured Services. Note: A family member or friend may travel on charter medical evacuations providing there is room, no additional cost is incurred and there is no prejudice to the patient s well-being. However, such persons are not escorts and no travel expenses will be paid Exceptions In emergencies the certification requirement may be waived. In such cases, the Chief Medical Officer of Health may authorize immediate travel from any point within the Yukon to a treatment centre also within the Yukon Exclusions/Restrictions Medical travel is not considered necessary in the following circumstances: 1. There are resources available locally for the diagnosis, follow-up, or treatment of the patient. 2. A visiting medical specialist is available who, in the opinion of the medical practitioner, can provide the required services to the patient. 3. Travel to access a service or the professional providing it is a matter of patient preference rather than strict medical need. If a service is not an insured medical service payable by the YHCIP, medical travel is not covered. The following non-insured services are not eligible for medical travel assistance: 1. Cosmetic surgery 2. Chiropractic services 3. Osteopathy 4. Podiatry 5. Acupuncture 6. Hypnotherapy 7. Reversal of sterilization procedures 8. Other health related services not provided by licensed medical practitioners 34 P a g e Motion # April 2 nd 2012

40 3.4 YG Medical Escort Policy Scope Transportation costs for escorts will be paid when the authorized practitioner requests an escort and provides justification for one, subject to the approval of the Medical Officer of Health. The following are taken into consideration when requesting and approving escorts: 1. The physical dependence of the patient upon others 2. The mental capacity of the patient 3. The age of the patient (all children under the age of 19 shall be escorted) 4. The health status of the patient 5. Lack of knowledge of English or other communication problems Eligibility Escorts shall be lay escorts unless a nurse, physician or other professional is required. If a patient requires a professional escort, no expenses for an additional escort will be provided Benefits Lay escorts may be eligible for a $75/day subsidy to assist with the cost of accommodation, meals, taxis and incidentals. When children 18 years of age or under travel with a professional escort, a parent may also be permitted to travels as a lay escort if the authorized practitioner recommends that a parent also be present because of the nature of the procedure or medical requirements. In the case of terminally- or critically-ill children who travel with a professional medical escort, travel costs for both parents may be covered under the program s compassionate clause. A subsidy of $75/day for one parent or $125/day for both parents may be paid starting on the second day that the child receives treatment and care, to a maximum of 90 days Exceptions There is no travel coverage for dental services except for insured services that must be performed in hospital under general anaesthesia. 35 P a g e Motion # April 2 nd 2012

41 3.5 YG Children s Drug andoptical Program Policy Scope The Children's Drug and Optical Program is designed to assist low-income families with the cost of prescription drugs and eye care for children under the age of Eligibility 1. Low-income families with children ages 0 to 18 years are eligible. 2. If the family has other insurance, that insurance must be used first. 3. A benefit card will be issued for each eligible child. 4. The card will be effective from the date of enrolment to March 31 of the same fiscal year. 5. Families must reapply each fiscal year. 6. The benefit card must be presented to the pharmacists or optometrist and the program will be billed for services provided Benefits Children are eligible for one eye examination every two years, glasses every two years to a maximum of $200 and contact lenses where recommended for medical reasons. Families may be responsible for paying a portion of the cost every year. This is a deductible. Once this is paid, the child will be enrolled in the program, which will cover remaining eligible expenses. 36 P a g e Motion # April 2 nd 2012

42 3.6 YG Children s Dental Program Policy Scope Yukon Children's Dental Program provides services to Yukon children, from newborn to Grade 8 or Grade 12, depending on the child's place of residence. Yukon Dental Health Services provides diagnostic, preventative and restorative dental services. Services provides by Yukon Dental Health Services are provided at no-cost to the parent or guardian. Costs of services are covered by Yukon Health and Social Services. Services are provided via the Yukon s Pre-school Dental Program which provides services to children, newborn to 5 years of age and the Yukon Children s School-based Dental Program which provides services to children, from Kindergarten to either Grade 8 or Grade 12, depending on the community the child lives in Eligibility Home-school children and students from Kindergarten to Grade 8 are eligible for services from the Yukon Children s Dental program in Whitehorse and rural communities with a resident dentist. Home-school children and students from Kindergarten to Grade 12 are eligible for services from the Yukon Children s Dental Program in communities without a resident dentist Benefits If your child requires dental treatment following the dental examination, consent for Treatment will be sent home to inform you of your child s dental needs and to obtain your written consent. Treatment cannot be provided without written consent from the parent/guardian. Once this has been provided, your child will then receive the dental treatment prescribed, which may include: 1. Fillings (Silver amalgam or white composite resins) 2. Stainless steel crowns (baby teeth) 3. Pulpotomies (baby teeth) 4. Extractions if required 5. Emergency dental services 6. Parent/Guardian Meetings 7. Scheduled meetings may be arranged with the dental therapist to discuss your children dental health concerns. 37 P a g e Motion # April 2 nd 2012

43 3.7 YG Seniors(Pharmacare and Extended Health) Policy Scope The Pharmacare and Extended Health Benefits programs are designed to assist registered senior citizens with the cost of prescription drugs, dental care, eye care and medical-surgical supplies and equipment Eligibility To qualify for these two programs you must be a Yukon resident at least 65 years of age or aged 60 and married to a living Yukon resident who is at least 65 years of age. To be eligible for benefits you must be registered with the Yukon Health Care Insurance Plan (YHCIP). If you are already registered with YHCIP, an application for will be automatically sent to you the month in which you turn 65. A new health care card will be issued to you once the application form had been returned and processed. It will take approximately three weeks for your card to arrive in the mail. If you have only recently moved to the Yukon you must first register for Yukon Health Care Insurance. The application form for Pharmacare and Extended Benefits care will be issued to you once the registration process has been completed. If takes three months for your Yukon Health Care Insurance coverage and seniors benefits to begin. Private Insurance Coverage: if you receive health insurance benefits through your employer or a third party insurance agency, claims must be submitted to these insurers first. The Pharmacare Program is insurer of last resort. Payment is made on a reimbursement basis. It is an offence to seek full reimbursement from both parties Benefits Pharamacare: The program will pay the total cost of the lowest priced generics of all prescription drugs listed in the Yukon Pharamacare Formulary, including dispensing the fee. Certain non-prescription drugs and goods are also covered by the program, such as: 1. Drugs used in the control of heart disease; nitroglycerine prescriptions, digoxin, and other digitalis related products 2. Anti-inflammatory drugs; analgesics, used for the symptomatic relief of arthritic conditions 3. Insulin syringes Extended Health: Benefits include partial coverage of the following benefits: 1. Medical-Surgical Supplies/Equipment: the plan may provide walking aids, hand inhalers, artificial eyes and limbs, respiratory equipment, commodes and manual wheelchairs. 2. Hearing Aids: One hearing aid or a replacement hearing aid is allowed in a four year period. Repair and adjustment of hearing aids is allowed once every six months. Batteries are not covered. 3. Dental Care: Coverage is limited to $1400 in any two year period, running from April 1, to March 31. The plan may pay for dentures or rebases one in a five year period. If you present your Pharmacare card to 38 P a g e Motion # April 2 nd 2012

44 the dentist, they will submit the bill directly to the health care plan for payment. Should you require high cost procedures, you should sign an application form and have the dental clinic submit it to the Program for prior approval. 4. Eye Examinations and Glasses: The plan may pay for one eye examination, new lenses and a maximum of $ toward the purchase of frames once every two years. Note: Benefits do not include the repair of glasses. The purchase of tinted or contact lenses is not covered unless medically necessary Exclusions Yukon Pharamacare does not cover the cost of products which can be obtained without a prescription, including vitamins, personal care items, laxatives, antacids and most medicines used in the treatment of colds. Medical equipment and supplies require prior approval. Persons receiving benefits under these programs cease to be eligible on the day of their departure of they have been absent from the Yukon for more than 183 consecutive days. (This may be extended to 210 days with prior approval from the Director.) Although Yukon Pharmacare will pay for all your prescription drugs, it is an offence to receive benefits under the plan of someone else s use. If you are a member of Yukon Pharmacare but also have coverage under another drug plan, it is an offense to seek full reimbursement from both plans. 39 P a g e Motion # April 2 nd 2012

45 3.8 YG Chronic Disease Program Policy (Prescription Drug Benefits) Scope Financial assistance is provided for prescription drugs, medical surgical supplies, medical equipment, food supplements or prostheses that are medically required for the management of a condition, and are recommended by a medical practitioner licensed to practice in the Yukon Eligibility The Chronic Disease Program provides prescription drug benefits to Yukon Health Care registrants who have a specific chronic disease or a serious functional disability as provided under the Chronic Disease and Disability Benefits Regulations. Those who have the cost of prescription drugs covered by another private insurance must use that plan first. Those residents eligible to receive benefits under the Chronic Disease Program may apply to the Chronic Disease Program for a reduction or waiver of the deductible depending on income and family size. The application for reduction of the deductible must be renewed each fiscal year based on the most current information, and be approved prior to benefits being received under the program. People receiving benefits under the Chronic Disease Program are no longer eligible to receive benefits if they are absent from the Yukon for more than 183 consecutive days, unless the period is for no more than 210 days. The beneficiary must then satisfy the Director that the Yukon is his or her only permanent residence Benefits The program includes the following benefits: 1. Food supplements are covered when medically required. 2. A prescription drug is defined as a recognized therapeutic agent that has restricted access under the federal Food and Drug Act or the Controlled Drugs and Substances Act. Coverage in this category includes professional dispensing fees. 3. Medical surgical supplies include body supports, prosthetic garments, ostomy supplies, hand inhalers and nebulizers, syringes and glucose test kits, oxygen supply, dressings, and bandages for chronic and recurrent conditions. 4. Medical equipment includes respiratory equipment, manually operated hospital beds, manually operated wheelchairs, walking aids, grab bars and support rails, commodes and glucometers. 5. Other equipment or devices that are medically necessary may be covered at the discretion of the Director and subject to prior approval Exclusions Goods and services are not covered if benefits are already available through a federal and territorial Act or by private or group insurance. There is an annual deductible. Program recipients are required to pay the first $250 of eligible costs per year, to a maximum of $500 per family. The cost of medical equipment will not be covered if the equipment can be borrowed from a hospital or the Canadian Red Cross. Items not covered include: 40 P a g e Motion # April 2 nd 2012

46 1. the cost of installation or set up of medical equipment 2. fitting prostheses and appliances 3. any other professional service charges related to the provision of goods, except dispensing fees for prescription drugs. All purchases made outside the Yukon must have prior approval from the program. Payment for these purchases is handled only on a reimbursement basis and claims must be submitted within one year Procedure The physician must apply for benefits on behalf of the patient. In communities without a resident physician, a community health nurse can make the application. Applications for benefits are normally made before a purchase is made although some circumstances may not permit prior approval. A claim can be made for reimbursement of the cost with the recommendation of a qualified medical practitioner and all documentation. Claims must be made within one year of purchase. 41 P a g e Motion # April 2 nd 2012

47 3.9 YG Alcohol and Drug Services Policy Scope Alcohol and Drug Services offers prevention,detox and treatment services to individuals, families and groups on issues related to substance abuse. Community development and aftercare consultation services are also provided to Yukon communities Eligibility Services are available to all Yukon residents Benefits Detoxification Services: This is a non-medical unit where people can safely withdraw from alcohol and/or drugs. It is open 24 hours per day, 365 days per year. It offers drop-in support and referral. Specific beds are reserved for women. Detox offers supportive counselling, drop-in and phone-in services. The length of stay varies depending on withdrawal severity, health status and treatment plans. All services are at no cost. Necessary personal hygiene items are provided. All admissions are voluntary. Treatment Services: Outpatient/Counselling Services The following outpatient/counselling services are offered: 1. brief screening and assessment of alcohol and drug problems 2. individual counselling 3. support to families 4. services to clients with concurrent disorders 5. aftercare support following inpatient treatment services 6. referral to ongoing treatment 7. self-help groups 8. other support services. Outpatient/Counselling Services also offers recovery support groups. Outreach counselling is also available for Whitehorse agencies. Inpatient Treatment Services Alcohol and Drug Services offers nine, 28-day inpatient (residential) gender-specific adult programs per year. Youth Treatment Alcohol and Drug Services offers counselling services to all Whitehorse secondary schools as well as Whitehorsebased youth groups. 42 P a g e Motion # April 2 nd 2012

48 Counsellors work with youth and their families to provide support and treatment services. Referrals may be made for families of youth to outpatient or inpatient treatment while at the same time providing assessment and treatment to youth. Prevention Services: The following prevention services are offered: 1. Education and prevention services include: a. information for the public b. workshops, training and presentations in the school c. public awareness campaigns d. an addiction-related library for service providers. Community Outreach: Alcohol and Drug Services provides outreach services, such as assistance with program development, aftercare programs and community development, to Yukon communities. 43 P a g e Motion # April 2 nd 2012

49 3.10 YG Mental Health Services Policy Scope Mental Health Services is a community mental health clinic offering assessment, individual and group therapy, supportive counselling and referral services for a wide range of emotional and behavioural problems and mental illnesses. Mental health professionals work to provide assistance in managing depression, anxiety, schizophrenia, and bipolar disorders. Requests for marital counselling, parenting skills and substance abuse counselling are likely to be referred to other agencies specializing in services for these problems. Mental Health Services also provides funding to Yukon Family Services Association (a community counselling agency). Counsellors/therapists from Mental Health Services and Yukon Family Services travel to the communities outside of Whitehorse on a regular basis to provide services Eligibility Mental Health Services provides services to three groups of clients: 1. Adult clients diagnosed with serious and persistent mental illnesses, including clients under the Yukon Review Board; 2. Adult clients who experience other diagnosable mental health; and 3. children and youth. 44 P a g e Motion # April 2 nd 2012

50 3.11 Whitehorse General Hospital First Nations Health Programs Scope The mission of the First Nations Health Programs (FNHP) is to promote the provision of quality, culturally-sensitive holistic health care to Aboriginal People by: 1. Advocating for and guiding Aboriginal People through the acute care health system. 2. Recognizing the impacts of residential school and colonialism on the health of Aboriginal People. 3. Providing social and spiritual support, as well as access to traditional food, medicine and healing practices in an acute care environment. 4. Educating health care providers to increase understanding and awareness of Aboriginal culture to enhance safety and competence. The vision is that the First Nations Health Programs are nationally recognized as innovative leaders in the best practices of culturally-sensitive holistic health care for Aboriginal people. 1. Aboriginal clients feel welcome, culturally safe, supported to heal physically, emotionally, mentally and spiritually. 2. Hospital and community systems are bridged and advocacy efforts have increased community capacity to support Aboriginal People in their own community. 3. Traditional Practices are part of the cultural foundation of the organization and are respected and protected by all. 4. The First Nations Health Programs team works together with energy, respect and understanding and is balanced in the four directions. 5. The First Nations Health Programs team is confident and competent in providing FNHP services Program Hours: 1. Monday to Friday 8 a.m. to 11 p.m. 2. Saturday and Sunday 10 a.m. to 6 p.m. 3. Statutory holidays 10 a.m. to 6 p.m Eligibility The FNHP provide services to all First Nations, Métis and Inuit patients who access the services of Whitehorse General Hospital. The staff at the hospital registration desk will ask every patient if they would like to identify as having Aboriginal ancestry. This will ensure that all Aboriginal people have access to our programs. If you do not self-identify but would like our services, please advise your nurse. 45 P a g e Motion # April 2 nd 2012

51 Benefits/Programs First Nation Elder s Suite/Sleep room: There is a self-contained suite that may be available for use by First Nations families to allow them to have short term emergency accommodations when there are no other alternatives. There is also a sleep room located on the hospital ward that is available for use. Phone: Health and Social Liaison Workers: This program involves six Liaison Workers, with training in Aboriginal health and social work, who visit each First Nations, Inuit or Métis patient that is admitted to the hospital and, as needed, in the Emergency Department. Role: Hours: 1. Provide emotional, spiritual and social support and help with communication between the patient, their family and hospital staff. 2. Provide information about hospital care (diagnosis, treatment, procedures, etc.). 3. Plan, develop and participate in culturally relevant health counselling and support. 4. Advocate for Aboriginal people using acute health care services. 1. Monday to Friday: 8:00 a.m. to 11:00 p.m. 2. Weekends and holidays: 10 a.m. to 6 p.m. 3. There is always a Liaison Worker on call after hours to manage critical situations. Phone: Child Life Worker: The Child Life Worker visits each Aboriginal child between the ages of 0 and 16 admitted to the Hospital. The Child Life Worker works to build a relationship with the child and parents to respond to the child s social needs and to support parents, during their child s stay at the hospital. Role: 1. Acts as a consultant to health care providers in planning care for Aboriginal children and high risk maternity patients. 2. Provides appropriate developmental activities and information to the child. 3. Provides counseling and support to Aboriginal patients and their families regarding identified problems, personal concerns and treatment objectives. 4. Assists with communicating treatment information and discharge plans to parents when needed. 46 P a g e Motion # April 2 nd 2012

52 5. Provides relief for parents finding it difficult to cope. 6. Informs parents of their rights and responsibilities while their child is in hospital. Phone: Traditional Diet Program: Whitehorse General Hospital has been serving traditional foods to Aboriginal patients for over 15 years. Traditional foods are still an important part of the daily lives of many Yukon First Nations people. It is part of an important link between health, culture and identity. Traditional food can help to create a healing and familiar environment for patients when they are in the hospital. A Traditional foods menu is offered to Aboriginal patients during their stay at the Whitehorse General Hospital. Moose and caribou broths, soups, stews and bannock are the most commonly served meals. All meat is donated to the program by local hunters, outfitters or conservation officers. Please talk to your Health & Social Liaison Worker for more information. Phone: Traditional Medicine Coordinator: The Traditional Medicine Coordinator helps to provide awareness of traditional medicines and to assist Aboriginal patients to access traditional healing methods during their hospital stay. Role: 1. Provides information and awareness about the uses of various medicines available from the land. 2. Assesses the patient to determine the need and ability to receive traditional medicine. 3. Consults with health care professionals in planning care for Aboriginal patients. 4. Provides counselling and spiritual support to patients and their families. 5. Gathers medicine from the land. 6. Gathers ongoing knowledge from Elders. Phone: Community Liaison/Discharge Planner: The Community Liaison/Discharge Planner is responsible for the more involved discharge planning for Aboriginal patients who are returning to their homes/communities. Role: 1. Anticipates the needs of the patient and their families when preparing discharge plans. 2. Collaborates with community resources to ensure needed care is available upon discharge. 3. Assists with developing transfer plans for patients that are being transferred to other facilities. 47 P a g e Motion # April 2 nd 2012

53 4. Manages the Community Liaison Program and maintains an effective working relationship with community resources available to patients. Phone: Na'Ku Healing Room: A Healing Room is available as a place for family members to gather, to be with a patient, to pray and practice traditional ceremonies and private rituals. The Healing Room is open for use by all people who respect our traditional beliefs. The Traditional Medicine Program Coordinator will assist the patient and their family with access to traditional methods of healing. There are two suites available for use by First Nations families to allow them to stay overnight in times of need, as well as one Sleep Room on the end of the East Unit. Interpretation Services: Provides Native language translation services when necessary and available. 48 P a g e Motion # April 2 nd 2012

54 3.12 Yukon Hospital Services and Health Care Policies Scope An insured service is one provided by a licensed medical practitioner and deemed to be essential to the health of the patient Eligibility The Yukon Health Care Insurance Plan provides coverage for eligible Yukon residents. A resident of the Yukon Territory is defined as anyone lawfully entitled to be or remain in Canada, whom makes his/her home and is ordinarily present in the Yukon. This does not include tourists, transients or visitors to the Yukon. Yukon residents lose their eligibility of they are absent from the territory longer than six months, unless they obtain a waiver from the Insured Health Service office. As a general rule, anyone who has been registered and in ordinarily present in the Yukon is eligible to receive insured benefits, except those residents who are members of the Canadian Armed Forces, Royal Canadian Mounted Police, or inmates of a federal penitentiary Benefits Health Care Insurance Services Plan: The Health Care Insurance Services Plan is designed to pay for the cost of general practitioners and medical specialists services which are medically required. Those services include: 1. Physicians services in their office, clinic, at the hospital, scene of an accident or in the patient s home 2. Care and treatment by a physician before, during and after an operation, including anaesthesia 3. Physician s care during pregnancy 4. Certain dental-surgical procedures that have to be performed in an approved hospital Hospital Insurance Service Plan: The Hospital Insurance Service Plan is designed to pay the cost of most medically required hospital services. The following hospital in-patient and out-patient services are insured when administered at an approved facility; 1. Accommodation and meals at standard ward rate 2. Necessary nursing station 3. Laboratory, radiological and other diagnostic procedures 4. Drugs, biological and related preparations when administered in the hospital 5. Use of operating room, case room and anaesthetic facilities, including necessary equipment and supplies 6. Radiotherapy services when available 7. Physiotherapy services where available 8. Services rendered by persons who are paid by the hospital 9. Emergency and non-emergency outpatient services Exclusions The following services are not insured physician services: 49 P a g e Motion # April 2 nd 2012

55 1. Services provided by optometrists and dispensing opticians, including the provision of eyeglasses 2. Appliances (e.g., braces and walkers), except for some medical appliances needed by children aged 16 years and under 3. Services provided by podiatrists, osteopaths, orthodontists, and chiropractors 4. Medical examinations not required for health reasons, and/or requests by a third party (e.g., immigration and employment medicals) 5. Plastic and cosmetic surgery, unless the Plan gives prior approval 6. Dental surgery performed outside of a hospital 7. Advice by telephone 8. Long-distance telephone charges incurred by physicians in the course of arranging referrals 9. Preparations of records, report or certificates 10. Laboratory and X-ray procedures performed in facilitates not approved by the Plan 11. Giving or writing prescriptions 12. Supply of drugs 13. Any service that the Administrator determines, on review of medical evidence, is not insured because it is not medically required The following services are not insured hospital services: 1. Special nurses required by the patient or family 2. Preferred accommodation (semi-private or private) 3. Crutches and other such appliances 4. Drugs for use outside the hospital 5. Dental procedures, except in cases where prior approval has been received and where the patient must be admitted to the hospital 6. Nursing home services 50 P a g e Motion # April 2 nd 2012

56 4 FNNND Medical Policies 4.1 Medical Travel Scope FNNND will provide medical travel advances for unforeseen medical emergencies to all eligible citizens travelling under NIHB or YG programs, on the condition that the recipient signs an agreement to repay at the time of receiving the cheque. Drivers and Vehicles: Citizens must rely on self, family and other peer support resources to provide transportation to their appointment, before requesting a driver or vehicle support from FNNND. FNNND will not provide an honorarium to family members taking patients to appointments in outside of Mayo. FNNND will provide a driver and a vehicle only if all other means of transportation to the appointment have been exhausted and the appointment is urgent and cannot be rescheduled (ex. Specialist clinics).only authorized drivers are permitted to drive a FNNND vehicle. Refer to section 4.3 Mileage: FNNND may provide a mileage allowance to patients who are travelling in a private vehicle to approved NIHB appointments outside of Mayo. Money for this allowance will only be advanced if the original signed Appointment Confirmation sheet from the previous medical appointment, in which mileage was advanced, has been submitted to Accounts Payable clerk, and the appointment is an unforeseen medical emergency. An agreement to repay must be signed upon receipt of the cheque. Cheques will be held for a oneyear period, after which they will be destroyed and mileage money will not be paid. Public Transportation: FNNND will provide patients and escorts with taxi allowance to cover the cost of public transportation while outside the Territory to attend medical appointments if these expenses are not covered by NIHB and all other resources have been exhausted Eligibility Clients seeking a medical-travel advance from FNNND for travel under the NIHB or Yukon Government programs must provide confirmation of their appointment issued by approved medical staff. Social Programs Department staff will check eligibility via excel spreadsheet updated and sent weekly from the finance department. Citizens will only be able to receive advancement if they returned an original signed Appointment Confirmation sheet from their previous appointment, the appointment is an unforeseen medical emergency or they meet one of the following criteria Your total yearly medical expenses are in excess of 15% of economic family s yearly after tax income. or You are currently on Social Assistance or 51 P a g e Motion # April 2 nd 2012

57 The combined economic family income is below the low-income threshold. (See definitions for low income rates) FNNND will not receive re-imbursement from NIHB with copies; therefore FNNND will not accept copies or faxes of signed appointment confirmation sheets from citizens. Drivers and Vehicles: If a patient has no vehicle or family member willing or available to drive them to an appointment then FNNND may provide a driver and vehicle. If this occurs, FNNND may require the patient to reschedule their appointment to coincide with other patients scheduled appointments to maximize the use of FNNND resources. Refer to section 4.3. Mileage: Mileage advancement is available to all qualifying FNNND citizens who have prior approval for this benefit from NIHB. This confirmation comes via the Mayo Health Centre and is received by Social Programs Staff. All recipients of mileage advancement must have completed, signed, original forms from their previous appointment and on file with FNNND before receiving the advancement. The appointment must be an unforeseen medical emergency or cannot be changed, so as to provide time for the individual to make the necessary financial arrangements Benefits In order to receive an advance on medical travel, eligible citizens must confirm on their NIHB Appointment Attendance Confirmation, Private Vehicle Reimbursement, and Client Reimbursement for Meals/Food forms that FNNND is the party to be reimbursed. It is the client's responsibility to submit these forms to FNNND Social Programs Department before his or her appointment Exclusions 1. If an FNNND citizen has his/her gas, mileage and/or other travel costs covered through another department or through their work, they cannot claim the same trip for medical travel. Any citizen found to be engaged in the fraudulent behaviour of submitting claims or receiving money for the same trip will be required to pay back the coverage, may be denied future coverage and may be subject to disciplinary action according to the personnel policy. 2. First Nations citizens who are not FNNND citizens are not eligible for gas advancements or mileage allowances. It is the responsibility of their home community to cover these costs Notes 1. FNNND is not responsible for securing accommodations and meal vouchers unless it is an unforeseen medical emergency. 52 P a g e Motion # April 2 nd 2012

58 4.2 FNNND Non-Medical Escort Policy Scope To provide assistance to non-medical escorts accompanying patients to medical appointments outside Mayo Eligibility Any non-medical escort accompanying an FNNND citizen to a medical appointment outside Mayo Benefits 1. Citizens travelling for medical reasons but without an appointed medical escort, and have a recommendation for a non-medical escort from an authorized medical practitioner, can apply to FNNND Social Programs for the services of a non-medical escort. 2. Non-medical escorts will be paid an honorarium only if they are not immediate family members. The rate will be 1.5 x the standard honorarium rate per day. 3. Since NIHB requires that same-sex drivers/escorts and patients share accommodation, FNNND will cover the cost of an additional room if the driver/escort and patient are not related. This will be evaluated on a case-by-case basis. 4. FNNND Social Programs employees acting in the capacity of medical escort will be paid their hourly rate for a maximum of 7.5 hours per day Exclusions 1. Immediate family members acting in the capacity of non-medical escort will not be provided with a per diem subsidy, or honorarium Notes 1. Social Programs will advocate for the citizen with the nursing station or NIHB to receive a non-medical escort if required. They will take into account: a. The age of the patient; b. The health of the patient; c. The duration and location of the medical appointment(s); and d. The ability of the patient to navigate the medical appointment process (e.g., language barriers); e. Travel outside of Yukon Territory. 2. Escorts do not need to be FNNND citizens. 3. Please see the escort guidelines in the Appendix. 53 P a g e Motion # April 2 nd 2012

59 4.3 FNNND Driver Policy Scope To provide driving assistance to patients attending medical appointments outside of Mayo Eligibility Any driver accompanying an FNNND citizen to a medical appointment outside of Mayo Benefits 1. FNNND will only consider providing a driver if all other means of travelling to the appointment are exhausted. The appointment must be medically necessary and cannot be rescheduled. 2. Drivers will be paid an honorarium of the standard daily rate, only if they are not immediate family members. 3. Since NIHB requires that same-sex drivers and patients share accommodation, FNNND will cover the cost of an additional room if the driver and patient are not related. This will be evaluated on a case-bycase basis Exclusions 1. Immediate family members acting in the capacity of driver will not be provided with an honorarium or per diem subsidy Notes 1. Wherever possible FNNND expects that the role of non-medical escort and driver will be filled by the same individual. 2. It is at the discretion of Social Programs Department to confirm if a driver will be provided. 3. Drivers do not need to be FNNND citizens. 4. For insurance purposes we will encourage drivers/citizens to travel in NND vehicles. 5. If the driver and citizen choose to travel in a private vehicle the driver must provide proof of appropriate liability insurance and the citizen must sign a waiver releasing NND of responsibility in the event of an accident 6. Please see the driver guidelines in the Appendix P a g e Motion # April 2 nd 2012

60 4.4 Family Member Medical Travel Policy Scope To provide assistance to family members participating in medevacs Eligibility A FNNND family member who has travelled with the patient in an air or ground ambulance Benefits 1. In the event that an immediate family member is provided transportation outside Mayo or the Territory to accompany a patient on a medevac, FNNND will assist that individual with return transportation home. 2. The assistance will be in the form of return scheduled airfare, or in the case of a medevac to Whitehorse, FNNND will endeavour to arrange for ground transportation back to Mayo Procedure 1. The family member should contact FNNND as soon as reasonably possible to alert them of their situation. 2. FNNND will assist the family member with the NIHB process and appeals process, if applicable. 55 P a g e Motion # April 2 nd 2012

61 4.5 Patient Medivac Travel Policy Scope To provide assistance to FNNND citizens who are patients in medevacs Eligibility A FNNND citizen who has travelled in an air or ground ambulance Benefits 1. In the event that a FNNND citizen is provided medical transportation outside of Mayo or the Territory on a medevac, FNNND will assist that individual with return transportation home. 2. The assistance will be in the form of return scheduled airfare, or in the case of a medevac to Whitehorse, FNNND will endeavour to arrange for ground transportation back to Mayo Procedure 1. The citizen should contact FNNND as soon as reasonably possible to alert them of their situation. 2. FNNND will assist the citizen with the NIHB process and appeals process, if applicable. 56 P a g e Motion # April 2 nd 2012

62 4.6 FNNNDMedical Equipment and Supplies Policy Scope When NIHB or YG does not cover all, or part of, medically necessary equipment or supplies, FNNND will consider supplementing the cost of equipment or supplies for qualifying citizens by paying the remaining amount owing or the entire cost. If citizens are covered by private health insurance, they are expected to access that covereage before coming to FNNND for support. Medically necessary equipment and supplies are those prescribedto a citizen by a doctor or approved medical practitioner Eligibility All Na-Cho Nyak Dun Citizens resident in the Yukon. FNNND will assist with the cost of these necessary items according to the following criteria. Your total yearly medical expenses are in excess of 15% of economic family s yearly after tax income or You are currently on Social Assistance or The combined economic family income is below the low-income threshold. (See definitions for low income rates) Benefits Benefits considered for support include (but are not limited to): 1. Special nutritional supplements (e.g., Ensure) required due to illness and based upon a doctor s note. A purchase order will be issued bi-weekly to a local grocery store. The purchase order will be void if not used. 2. Hearing aids (repair and/or replacement) 3. Raised toilet seats 4. Transfer chairs 5. Motorized wheels chairs (scooters) 6. Additional diabetic supplies (e.g., socks, shoes) 7. Life alert bracelets Procedure 1. If an eligible recipient has been denied Medical Equipment or Supplies from NIHB, then FNNND Social Programs will assist them with the NIHB appeals process. 2. If the NIHB appeals process is unsuccessful then the FNNND will supplement the amount not covered by NIHB (full or partial cost of the medical equipment or supplies). 3. If the supplies or equipment are greater than $ or are required longer-term (greater than 2 months) then the decision is to be made by Council. 57 P a g e Motion # April 2 nd 2012

63 4. Supplies or equipment that are long term will be provided for two (2) month periods. Patients must reapply to FNNNDSocial programs Department every two months with a medical practictioner requesition. FNNND may consult with a medical professional, to facilitate a decision to continue or discontinue the support Notes 1. Large expense items (e.g., motorized wheelchairs) will be considered on a case-by-case basis. 2. FNNND may seek to find funding from alternate sources (such as in the case of large expense items). 3. FNNND will explore options for leasing or renting equipment in the case of large expense items. 4. FNNND may consult with the prescribing physician to find suitable, less expensive alternatives. 5. Non-consumable products (such as transfer chairs) remain the property of FNNND if they have been fully funded by FNNND. 6. No benefits of this policy, once approved, will be applied retroactively. 58 P a g e Motion # April 2 nd 2012

64 4.7 FNNNDEye and Vision Care Policy Scope The FNNND will subsidize the cost of medically necessary,prescriptionlenses, frames or contacts for each citizen once every 24 months to a maximum of $250. The funding is expected to supplement the cost of glasses which are covered by NIHB Eligibility All Na-Cho Nyak Dun Citizens resident in the Yukon. FNNND will assist with the cost of these necessary items according to the following criteria. Your total yearly medical expenses are in excess of 15% of economic family s yearly after tax income. or You are currently on Social Assistance or The combined economic family income is below the low-income threshold. (See definitions for low income rates) Benefits Benefits considered for support include: 1. Eye glasses or contact lenses Exclusions FNNND will not cover: 1. Glasses or contacts for aesthetic purposes 2. Vision exams required by potential employers 3. Eye exams Procedure 1. The citizen is expected to access NIHB, YG or private health insurance prior to requesting funding from FNNND 2. If the citizen has been denied funding from NIHB, FNNND Health and Social Assistance will assist them with the appeals process Notes 1. No benefits of this policy, once approved, will be applied retroactively. 59 P a g e Motion # April 2 nd 2012

65 4.8 FNNND Dental Support Policy Scope This policy is intended to support citizens in the event that NIHB provides only partial or no coverage for a medically necessary dental services and supplies Eligibility All NIHB eligible recipients who are Na-Cho Nyak Dun Citizens resident in the Yukon. FNNND will assist with the cost of these necessary items according to the following criteria. Your total yearly medical expenses are in excess of 15% of economic family s yearly after tax income. or You are currently on Social Assistance or The combined economic family income is below the low-income threshold. (See definitions for low income rates) Benefits Based on documentation received from a dental provider, FNNND will consider subsidizing dental services for FNNND covered under NIHB but who have been denied funding. FNNND will assist with the cost of dental services on a case-by-case basis. Benefits considered for support include, but are not limited to: 1. Dental services and supplies 2. Denture repair and/or replacement 3. Crowns, caps, etc Procedure 1. FNNND will assist the citizen with the appeals process for NIHB. If the appeal is granted from NIHB, all funds must be repaid to FNNND. 2. Any request for supplementary dental services requires a written treatment plan from the dentist or denturist indicating what services are absolutely necessary, the appropriate codes from their fees guide, and an estimate of cost. 3. All services must be approved in advance by the Social Programs Manager (or delegate). 4. Purchase orders or vouchers for treatment may be issued to the dentist or denturist once approval is received. 5. The citizen must ensure that all applicable forms are completed and returned to FNNND for reimbursement to FNNND. 60 P a g e Motion # April 2 nd 2012

66 4.8.5 Notes 1. Items such as dentures and other dental fixtures will be eligible for replacement according to the NIHB replacement schedule. 2. No benefits of the policy, once approved, will be applied retroactively 61 P a g e Motion # April 2 nd 2012

67 4.9 FNNND Drug Policy Scope Prescription drugs prescribed/recommended to a citizen, by a licensed health-care provider, that are not covered under NIHB, Yukon Government and/or private health insurance will be considered for coverage by FNNND. FNNND will assist with the cost of these necessary drugs on a case-by-case basis Eligibility All Na-Cho Nyak Dun Citizens resident in the Yukon. FNNND will assist with the cost of these necessary items according to the following criteria: Your total yearly medical expenses are in excess of 15% of economic family s yearly after tax income. or You are currently on Social Assistance or The combined economic family income is below the low-income threshold. (See definitions for low income rates) Benefits Benefits considered for support include (but not limited to): 1. Prescribed medications not covered under NIHB, Yukon Government and/or private health insurance 2. Liquid vitamins 3. Alternative medications (e.g., natural/herbal) 4. Sleeping pills 5. Brand name drugs not covered under NIHB, Yukon Government and/or private health insurance when a generic brand is deemed inappropriate by a doctor and a prescription is written. 6. Mental health prescriptions Procedure 1. FNNND Social Programs will first help with the appeals process for NIHB. 2. FNNND will cover the cost of the medically necessary drug on a case by case basis. 3. Lifetime prescriptions will be subsidized for a 12 month period. Patients must reapply to FNNND Social Programs Department every year. FNNND may consult with a doctor, to facilitate a decision to continue or discontinue the support. 4. Non-lifetime prescriptions ie. Sleeping pills, mental health prescriptions to be re-evaluated every 2 months. 62 P a g e Motion # April 2 nd 2012

68 4.9.5 Notes 1. FNNND will fund the generic over the name brand drug unless the prescriber specifies the name brand drug. The FNNND may consult with the medical practitioner to clarify this issue. 2. All benefits of this policy, once approved, will be applied retroactively 63 P a g e Motion # April 2 nd 2012

69 4.10 Medical Emergency Support Policy Scope This policy will provide support to NND families dealing with medical emergencies and end of life circumstances. The funding covers the cost of a hotel room and a daily per diem for the family to be with the patient in the event of a medivac outside Mayo or Territory Eligibility All Na-Cho Nyak Dun Citizens resident in the Yukon Benefits FNNND will provide the immediate family of the medical emergency patient with compassionate travel in the form of round trip airfare, and/or roundtrip gas PO, as per NND gas PO guidelines, as well as one room and a collective per diem of $50/day for a maximum of five days Exclusions 1. This applies to qualified medical emergencies only, as per the definition in section Procedure 1. The family should inform FNNND Social Programs Department as soon as reasonably practical. 2. NND Social Programs Staff will contact the next-of-kin or family designate to identify the person to receive this assistance. 64 P a g e Motion # April 2 nd 2012

70 4.11 Long-Term Support Policy Scope This policy will provide emergency, temporary support to FNNND citizens dealing with NIHB approved long-term medical stays outside of Mayo or Territory Eligibility All Na-Cho Nyak Dun Citizens resident in the Yukon. FNNND will assist with the cost of these necessary items according to the following criteria: Your total yearly medical expenses are in excess of 15% of economic family s yearly after tax income. or You are currently on Social Assistance or The combined economic family income is below the low-income threshold. (See definitions for low income rates) To be evaluated weekly Benefits In order to receive an advance under long term support, eligible citizens must confirm on their NIHB or YG Appointment Attendance Confirmation, Private Vehicle Reimbursement, and Client Reimbursement for Meals/Food forms that FNNND is the party to be reimbursed. It is the client's responsibility to submit these forms to FNNND Social Programs Department before the advance. FNNND will provide emergency advances, on a temporary basis, for long term medical stays out side of Mayo to all eligible citizens travelling under NIHB or YG programs, on the condition that the recipient signs an agreement to repay at the time of receiving the cheque and that the stay is an approved NIHB or YG appointment Exclusions 1. This does not apply to support during medical emergencies Procedure 1. FNNND Health and Social Programs Department will first help to access funds from NIHB, if required. 2. The duration of support provided will be determined on a case by case basis. 3. Social Programs Staff will inform NIHB and/or YG that FNNND is to be identified as the recipient of the re-imbursement Notes A long-term medical stay is defined as two weeks or longer. 65 P a g e Motion # April 2 nd 2012

71 66 P a g e Motion # April 2 nd 2012

72 4.12 Palliative Care Worker Policy Scope This policy will provide support to individuals who are acting in a palliative care role for FNNND citizens resident in Yukon Eligibility All individuals providing palliative care to Na-Cho Nyak Dun Citizens resident in the Yukon. All other sources of income (i.e. EI benefits) must be exhausted prior to making an appeal to FNNND Benefits People who are providing live-in palliative care to an FNNND citizen will receive payment based on Level 1, of the pay scale to a maximum of 7.5 hours/day Exclusions 1. The live-in support must have triggered a clear change in living situation and lifestyle change, for the express purpose of providing palliative care. 2. The worker is required to have a valid and current first aid certificate as well as CPR training. It is strongly recommended that the care giver also have palliative care training Procedure 1. This policy is exercised on a case by case basis at the discretion of the Social Programs Department. 67 P a g e Motion # April 2 nd 2012

73 5 Appeals Processes 5.1 NIHB Appeals Process An eligible First Nations client, their parent, legal guardian, or representative may initiate an appeal process when a benefit has been denied through the NIHB Program. In the event that they are unable, a client may have someone act on their behalf to initiate an appeal process as long as written authorization is obtained from the person seeking coverage. There are three (3) levels of appeal available; namely Level 1, Level 2, and Level 3. For a case to be reviewed as an appeal, a signed note or letter from the client, parent or legal guardian, accompanied by supporting information from the service provider or prescriber must be submitted to the NIHB Program. In many cases, the service provider will be required to provide part of the information being requested. The usual information requested by NIHB is: 1. The condition for which the benefit is being requested; 2. The diagnosis and prognosis, including what other alternatives have been tried; 3. Relevant diagnostic test results; and 4. Justification for the proposed treatment and any additional supporting information. The client, parent or legal guardian should submit their letter of appeal and supporting documentation by mail, clearly marked "APPEAL-CONFIDENTIAL". Upon receiving the appeal submission, the NIHB Program will arrange to have the case reviewed by a medical, dental, orthodontic or vision care professional for a decision by NIHB management. The decision will be made based on the specific needs of the client, medical justification, the availability of alternatives and NIHB policy. The client, parent or legal guardian will be provided with a written explanation of the decision made by the NIHB Program. If the client, parent or legal guardian has not heard within one month of submitting the appeal, they may contact the Health Canada regional office for an update Appeal for Drug Benefits Level 1 To initiate an appeal, the client should submit their documentation to: Director, Benefit Review Services Division First Nations and Inuit Health Branch - Health Canada Non-Insured Health Benefits Directorate Postal Locator 4005A, 55 Metcalfe Street, 5 th Floor Ottawa, ON K1A 0K9 Level 2 If the client does not agree with the Level 1 Appeal decision, the client may choose to have the appeal reviewed at the second level. The submission should be addressed to: 68 P a g e Motion # April 2 nd 2012

74 Director, Benefit Management Division First Nations and Inuit Health Branch - Health Canada Non-Insured Health Benefits Directorate Postal Locator 4005A 55 Metcalfe Street, 5 th Floor Ottawa, ON K1A 0K9 Level 3 If the client does not agree with the Level 2 Appeal decision, the client may choose to have the appeal reviewed at the third and final level. The submission should be addressed to: NIHB Director General First Nations and Inuit Health Branch - Health Canada Non-Insured Health Benefits Directorate Postal Locator 4006A 55 Metcalfe Street, 6 th Floor Ottawa, ON K1A 0K Appeal for Dental, Medical Supplies and Equipment, Vision, Mental Health and Medical Transportation Benefits A client has a right to appeal a denial of a benefit under the NIHB Program. There are three levels of appeal available. Appeals must be submitted in writing and can be initiated by the client, legal guardian or interpreter. At each stage the appeal must be accompanied by supporting information to justify the exceptional need. At each level of appeal, the information will be reviewed by an independent appeal structure that will provide recommendations to the program based on client s needs, availability of alternatives and NIHB policies. At all levels of appeal, the client will be provided with a written explanation of the decision taken. Level 1 To initiate an appeal, the client should submit their documentation to: NIHB Regional Manager, clearly marked "APPEALS-CONFIDENTIAL" and mail it to the Health Canada regional office in the client's province or territory of residence. Level 2 If the client does not agree with the Level 1 Appeal decision, the client may choose to have the appeal reviewed at the second level. The submission should be addressed to: FNIH Regional Director, and mailed to the Health Canada regional office in the Whitehorse. Level 3 If the client does not agree with the Level 2 Appeal decision, the client may choose to have the appeal reviewed at the third and final level. The submission should be addressed to: 69 P a g e Motion # April 2 nd 2012

75 NIHB Director General First Nations and Inuit Health Branch - Health Canada Non-Insured Health Benefits Directorate Postal Locator 4006A 55 Metcalfe Street, 6 th Floor Ottawa, ON K1A 0K Appeal for Orthodontic Services Appeals for orthodontic services must be received by the Orthodontic Review Centre before the child reaches the age of 19. No appeals will be considered after the client's 19 th birthday. For an appeal for orthodontic coverage, the following information and diagnostic records must be provided: 1. Diagnostic Orthodontic Models -- soaped and trimmed (mounted or unmounted); 2. Cephalometric -- radiograph(s) and tracing; 3. Photographs -- 3 intra oral and 3 extra oral; 4. Panoramic radiograph or full mouth survey; 5. Treatment plan, estimated duration of active and retention phases of treatment and costs submitted either on a NIHB Orthodontic Summary Sheet, CAO Standard Orthodontic Information Form or letter on the Orthodontist's letterhead; 6. Completed NIHB Dental Claim Form; and 7. Parent or legal guardian signature (including Band name and number and/or date of birth). To initiate an appeal, the client, the parent, legal guardian, or representative must submit their documentation addressed to: Level 1 Orthodontic Review Centre Director, Benefit Review Services Division First Nations and Inuit Health Branch - Health Canada Non-Insured Health Benefits Directorate Postal Locator 4005A 55 Metcalfe Street, 5 th Floor Ottawa, ON K1A 0K9 Level 2 Orthodontic Review Centre Director, Benefit Management Division, First Nations and Inuit Health Branch - Health Canada Non-Insured Health Benefits Directorate Postal Locator 4005A 55 Metcalfe Street, 5 th Floor Ottawa, ON K1A 0K9 70 P a g e Motion # April 2 nd 2012

76 Level 3: Orthodontic Review Centre NIHB Director General First Nations and Inuit Health Branch - Health Canada Non-Insured Health Benefits Directorate Postal Locator 4005A 55 Metcalfe Street, 5 th Floor Ottawa, ON K1A 0K9 For more information, visithttp:// or contact the Orthodontic Review Centre. 71 P a g e Motion # April 2 nd 2012

77 5.2 FNNND Appeals Process An eligible FNNND citizen, their parent, legal guardian, or appointed representative may initiate an appeal process when a benefit has been denied by the FNNND Social programs Department. In the event that they are unable, an eligible citizen may have someone act on their behalf to initiate an appeal process as long as written authorization is obtained from the person seeking coverage. For a case to be reviewed as an appeal, a signed note or letter from the client, parent, legal guardian, or appointed representative must be submitted to the FNNND Health and social programs Department. The type of information required in the letter includes: 1. The condition for which the benefit is being requested; 2. The diagnosis and prognosis, including what other alternatives have been tried; 3. Relevant diagnostic test results; and 4. Justification for the proposed treatment 5. Any additional supporting information. The client, parent, legal guardian or appointed representative should submit their letter of appeal to the manager of the Health and Social Programs Department clearly marked "APPEAL-CONFIDENTIAL". Upon receiving the appeal submission, the Social Programs Manager will review the case and make a decision if the amount of the coverage requested is less than allowable spending authority amount as per the Finance Administration Policy. If the requested benefit amount is greater than this amount, the case will be referred to the Executive Director and if need be Council for review and decision. The decision will be made based on the specific needs of the client, medical justification, the availability of alternatives and FNNND policy. The client, parent, legal guardian or appointed representative will be provided with a written explanation of the decision made by Social Programs and/or Council. Council shall have final and ultimate authority with respect to any questions or clarifications arising from the implementation of this policy, provided that the appropriate appeals process has taken place. 72 P a g e Motion # April 2 nd 2012

78 6 Appendices Please Note: These appendices are for information only. In the event of any discrepancy between these appendices and the, the takes precedence. 73 P a g e Motion # April 2 nd 2012

79 6.1 Medical Travel Form First Nation of Na-Cho Nyak Dun Box 220 Mayo, Yukon Territory Y0B 1M0 Telephone: (867) Fax: (867) MEDICAL TRAVEL FORM (Please attach verification of Appointment) Name: Address/Telephone #: Type of Appointment: Medical Dental Emergency Medicav Date of Appt. a/o Medivac: Travel Date: Return Travel Date: Please process Medical Travel by: Medical Program Dept. Code: For the Client Chq PO NIHB Requesting: Chq PO NIHB Requesting: Airfare/ Bus fare Hotel or Private Accommodation Travel Mileage Meals Comments Escort Name: Make cheque payable: Yes No Is NIHB covering Medical Travel: Yes No Travel Mileage Attached to FNNNDFN (attached): Yes No Emergency Medical PO issued attached: Yes No Please ensure that the Attendance Confirmation form is signed and returned to Na-Cho Nyak Dun Finance Department when you return from your Medical Appointment so that we may proceed with being reimbursed by Yukon Non-Insured Health Benefits Program. Verified by: Job Title: Date: Approved by Health Social Manager, a/o Op./ Executive Director: Revised August 28, P a g e Motion # April 2 nd 2012