9.0 Self-care equipment and supplies benefits list

9.1.1 Benefit policies

General information common to all medical supplies and equipment (MS&E) can be found in section 1.0 General policies.

9.1.2 Prescriber and provider requirements

Prescriptions or recommendations for coverage must be initiated by the health professionals identified as prescribers or recommenders of the specific item as listed in the tables. Items that are prescribed by prescribers or recommenders not recognized by NIHB will lead to denials or reversal of claims.

The following is a list of NIHB-recognized prescriber or recommender abbreviations found in this segment of the benefits list. Refer to the prescriber section of the item tables below to identify the eligible prescriber or recommender of a specific item:

• Dt.P — Registered Nutritionist in Québec
• LCT — Licensed counselling therapist
• LPN/RPN — Licensed Practical Nurse or Registered Practical Nurse when within their scope of practice in their province or territory
• MD — Physician
• MF — Marriage and family therapist
• NP — Nurse Practitioner
• OT — Occupational Therapist
• PA — Psychological associate
• PN — Registered psychiatric nurse
• PSY — Psychologist
• PT — Physiotherapist
• RCSW — Registered clinical social worker
• RD — Registered Dietitian
• RP — Registered psychotherapist
• RM — Registered Midwife
• RN — Registered Nurse
• RRT — Registered Respiratory Therapist
• SLP — Speech-Language Pathologist
• RSW — Registered social worker

The following is a list of NIHB-recognized provider abbreviations found in this segment of the benefits list. Providers must be in good standing with their regulatory body. Refer to the provider section of the item tables below to identify the eligible provider of a specific item:

• GEN — Enrolled general MS&E or pharmacy provider

9.1.3 Prior approval requirements

General prior approval requirements can be found in section 1.0 General policies.

To initiate the prior approval process, the Self-care Prior Approval Form, found on the Express Scripts Canada NIHB Provider and Client Website, must be completed in full and submitted to your NIHB regional office along with the following supporting documentation:

• the prescription or recommendation or referral form signed by an NIHB-recognized prescriber for the requested benefit
• detailed assessment as required
• relevant information the provider, physician, nurse practitioner, occupational therapist, psychologist or physiotherapist may have to support the request
• an explanation of benefits from any third-party coverage available to the client, for example, provincial plan, workers' compensation board, private insurance, education plan, etc.

9.1.4 Exclusions

In addition to the general exclusion policy listed in section 1.0 General policies, the following items are excluded from the self-care benefit and are not considered for coverage or appeal under the NIHB program:

• environmental protection devices and supplies, for example, air cleaners, filters, UV protection garments and lotions, face masks, etc.
• permanently fixed equipment
• equipment with a rated weight capacity that would be unable to bear the client's weight
• lift chairs and recliners
• powered and manual sit-to-stand lifts
• electrotherapy devices (TENS and EMS machines)
• consumer health technologies such as personal health devices like smartwatches and monitors with built-in ECG
• bath steps
• stair lifts
• low wave and shockwave therapies
• sensory and therapy swings
• stools
• medication alarms
• bed alarm systems
• handheld shower heads
• car seats or booster seats
• baby scales
• personal care items (for example, wipes, soap, shampoo, conditioner, etc.)
• household cleaning products
• straps and padding added to kitchen chair
• all ramps (for example, threshold ramps for shower)
• child's regular feeding bottles, teats and cleaning accessories
• extended warranties

9.1.5 Warranties

Providers must honour the manufacturer's warranty.

9.1.6 Repairs

Repairs that are not covered under the warranty are eligible for coverage when supported by proper documentation.

The following rules apply:

• prior approval is required for repairs
• request must include detailed cost breakdown of parts, labour time and rates
• repairs must have a minimum warranty of 90 days

A description of all repairs with dates, detailed cost breakdown of parts, labour time and rates must be kept on file for each client.

Note: The NIHB program will not cover the labour cost for repairs that are covered under the warranty.

9.1.7 Replacement requirements

Recommended replacement guidelines indicate the quantity and frequency at which a benefit item will be eligible for coverage. Recommended replacement guidelines are based on a client's customary medical needs and the typical device's lifespan.

Replacement is subject to the same process as the original purchase.

All replacement requests require a new prescription.

For more general information, see section 1.12 Recommended replacement guidelines.

9.1.8 Services included in the NIHB price

The following services must be included in the NIHB price to be considered for coverage:

• initial assessment to determine the type of benefit required based on health professional recommendations
• dispensing of the benefit including the necessary adjustments and fitting, setup and installation when appropriate
• all ongoing care including follow-up visits, necessary adjustments, telephone calls and correspondence
• client education and instructions on the effective use, safety and care of the equipment and supplies

9.1.9 Terminology

9.2.1 Bathing

9.2.2 Toileting

9.5.1 Breastfeeding aids

The infant's date of birth must be indicated on the prescription or written recommendation.

Electric breast pump purchase or rental is considered for coverage only once the child is born and when a parent or infant presents medico-physical complications hindering the normal physiological process of chestfeeding. Prior authorization and medical documentation are required to support the request.

Information to provide includes:

• the medical justification supporting the need for the electric breast pump
• the date of birth
• the infant's weight
• the length of time the electric breast pump is needed

NIHB has created an Electric Breast Pump Recommendation Form, found on the Express Scripts Canada NIHB Provider and Client Website, that can be printed and taken to the prescriber for ease of application.

9.5.2 Feeding aids

9.5.3 Enteral feeding

9.6.1 Upper body

9.6.2 Lower body

9.7.1 Bed assist rail

9.7.2 Lift

Eligibility criteria for lift devices:

• the client has a chronic and long-term mobility impairment resulting in the need for maximum assistance to transfer safely between their bed and their wheelchair or the bathroom. Note: NIHB will only approve lifts for transfers between these surfaces
• the client's weight is within the weight capacity of the lift device and sling
• the client has been assessed in their home environment by an occupational therapist or physiotherapist and the ability of the caregivers to operate the lift has been taken into consideration
• only one lift device may be eligible for coverage during the recommended replacement guideline and must be the most cost-effective device that meets the client’s medical needs

Ceiling lift-specific eligibility criteria:

• the lift and track must be portable. Ceiling-mounted and fixed lifts are not eligible for coverage
• if the client has a hydraulic lift covered by the program and their medical condition or their environment changes significantly, a request for a ceiling lift may be considered

Hydraulic lift-specific eligibility criteria:

• the lift must be portable
• the lift must fit in the environment of intended use; taking into consideration flooring type, presence of thresholds, and bed clearance

9.7.3 Pole

9.7.4 Trapeze

9.7.5 Transfer

9.8.1 Beds and rails

An electric hospital bed is a medical grade bed with electric controls to adjust both the height of the bed and the position of the head and foot of the bed. Rails are designed for use with a hospital bed and are used to assist with bed mobility, repositioning, transfers or to prevent falls from the bed.

The recommended electric hospital bed must be compatible with the client’s other medical devices when appropriate, such as a lift device or trapeze. The frame must be on wheels and must be constructed of materials that can be easily cleaned and disinfected. The hospital bed must be for a single occupant and meet relevant safety standards. Device weight capacities must be respected.

Bed features not eligible for coverage:

• residential-type beds
• fabric-covered bases, decks, and head or footboards
• massage functions

9.8.2 Mattresses

All hospital bed mattresses must be medical grade and designed for use on a hospital bed for a single occupant. The mattresses must meet the relevant safety standards. They must come with a cover that is easily cleaned and disinfected. Device weight capacities must be respected.

9.8.3 Overlay

An overlay is a pressure-relieving surface designed to be used on top of a mattress. Must be designed for use for a one person at a time. The overlay must meet the relevant safety standards and be constructed of materials that can be easily cleaned and disinfected. Device weight capacities must be respected.

If a hospital bed is being used, a pressure relieving mattress should be considered prior to an overlay.

Overlays cannot be claimed with pressure relieving mattress: code 99401130 or bariatric pressure relieving mattress: code 99401131.

9.10.1 Repairs

9.10.2 Delivery

9.10.3 Installation

Installation is the process of assembling equipment according to the manufacturer's guidelines in the designated area at a client's residence so that it can be used safely.

The following information is required for installation requests:

• a completed and signed prior approval (PA) form listing the item(s) to be installed
• the complete address of where the item will be installed and, if available, the location in the residence, for example: bedroom or bathroom
• the cost of the installation of the equipment (based on the program's fee schedule for installation)

Note: When requested by the NIHB region, providers must submit documentation confirming that the installation was performed. This information must be kept in the client's file. Installation will not be covered by NIHB when this service is provided for free to other paying clients.

Services included in the price:

• the travel time for a technician to drive to and from the client's residence where the equipment is installed
• testing of the installed equipment to ensure it operates correctly
• training provided to the client or caregiver on safe use and equipment maintenance

Exclusions:

• reinstalling an item from one room to another (for example: floor to ceiling pole) or after a move from one primary residence to another
• a request for repair or replacement of a broken part on an existing device is not considered installation (for example: replacing a broken bedrail on a hospital bed)
• permanent installations that involve securing equipment by drilling into walls, ceilings, or floors will not be covered