Guide to vision care benefits for First Nations and Inuit
Effective date: November 13, 2024
Note: Indigenous Service Canada's First Nations and Inuit Health Branch and the Assembly of First Nations have undertaken a joint review of the Non-Insured Health Benefits (NIHB) program, including the vision care benefit. The objectives of this collaborative process are to enhance client access to benefits, identify and address gaps in benefits and improve service delivery to be more responsive to client needs. Revisions to this guide are anticipated as work continues to address recommendations from the joint review of vision care benefits.
This guide provides information on the vision care benefits for eligible First Nations and Inuit covered by Indigenous Services Canada's Non-Insured Health Benefits (NIHB) program. Additional items related to vision care are covered by the NIHB program under other benefit areas, including low vision equipment and supplies, ocular prosthesis, scleral shell, and medications used to treat eye conditions. See section 3.6 Low vision items and services, ocular prosthesis and medications.
Express Scripts Canada provides claims processing services for the NIHB program's vision care benefit. Refer to the Vision Care Regional Fee Grids available on the Express Scripts Canada NIHB provider and client website.
Providers should submit claims directly to the NIHB program through Express Scripts Canada so that clients are not required to pay at the point of service. Clients can contact their NIHB regional office for assistance in locating a vision care provider who will bill the program directly, in accordance with Vision Care Regional Fee Grids, for services provided. In the event that no such providers are available locally, travel support may be considered in order to access a provider who will bill the program directly.
Table of contents
- 1.0 Introduction
- 2.0 Eye examination
- 3.0 Corrective eyewear
- 3.1 Eligible services
- 3.2 Corrective eyewear frequency guidelines
- 3.3 Eyewear coverage amounts
- 3.4 Exceptions and criteria for approval
- 3.4.1 Exception: Polycarbonate lenses
- 3.4.2 Exception: Tints and coatings
- 3.4.3 Exception: Contact lenses
- 3.4.4 Exception: Flex frames
- 3.4.5 Exception: Eyewear for high prescriptions or eye conditions
- 3.4.6 Exception: Early lens replacement due to change in prescription
- 3.4.7 Exception: Repairs or replacement due to breakage, damage or loss
- 3.4.8 Exception: Inability to adjust to multifocal glasses
- 3.5 Exclusions
- 3.6 Low vision items and services, ocular prosthesis and medications
- 4.0 Information for clients and providers: Approvals and payment
- 5.0 Appendices
1.0 Introduction
1.1 Purpose of the guide
This guide provides information on Indigenous Services Canada's Non-Insured Health Benefits (NIHB) program vision care benefit. The purpose of this guide is to outline the terms and conditions, criteria, guidelines and policies under which the NIHB program's vision care benefit operates.
You will find information regarding:
- eligible services
- frequency guidelines
- benefit coverage and exceptions
- payments and reimbursement
In the event that this guide does not address questions regarding general policies, processing of payment requests, or specific conditions, clients or vision care providers may contact their NIHB regional office. Further information can also be found in the Vision Care Claims Submission Kit available on the Express Scripts Canada NIHB provider and client website.
1.2 About the vision care benefit
The NIHB program's vision care benefit provides eligible clients, see Appendix D: Client eligibility, with coverage for eye examinations and corrective eyewear, this includes:
- eye examinations when they are not insured by the province or territory
- corrective eyewear, such as glasses, contact lenses, when prescribed by a vision care professional
- repairs to corrective eyewear
The program provides eligible clients, see Appendix D: Client eligibility, coverage for eligible benefits when coverage is not available to the client under provincial or territorial health insurance, for example, in many provinces and territories, eye examinations may be an insured service for clients based on their age or with certain medical conditions. For more information on coordination of benefits with other plans, refer to section 4.6 Coordination of benefits.
1.3 Benefit criteria
Vision care benefits are covered in accordance with NIHB program policies. Eye examinations and eyewear must be provided by a licensed vision care professional in accordance with provincial or territorial legislation and regulations. Providers who have enrolled as an NIHB provider must notify Express Scripts Canada immediately when a change in their standing or licensure occurs.
Providers must obtain prior approval from the NIHB regional office in the province or territory where the service is provided for a general eye examination outside of the frequency guidelines, see section 2.2 Eye examination frequency guidelines, single eye tests and corrective eyewear, such as glasses or contact lenses. To find out more on prior approval for vison care benefits, refer to section 4.3 Prior approval.
Vision care benefits are eligible for coverage for registered First Nations and recognized Inuit when all the following criteria are met:
- the requested item or service is eligible, see section 2.0 Eye examination and section 3.0 Corrective eyewear
- the prescription is valid if less than 2 years old, signed by the prescribing optometrist and contains the required information according to established professional standards and applicable provincial or territorial legislation and regulations
- the item or service is prescribed and provided according to established professional standards and applicable provincial or territorial legislation and regulations
- any provincial, territorial public or private health insurance plans or programs for which the client is eligible must be accessed first
2.0 Eye examination
2.1 Eligible services
Coverage for eye examination within the frequency guidelines, see section 2.2 Eye examination frequency guidelines, falls into 3 major categories:
- general examination
- follow-up examination based on medical need
- single tests based on medical need
An eye exam is eligible only when it is carried out in person by an optometrist or ophthalmologist.
Eye exams in Nunavut and Northwest Territories are provided under arrangements managed by the territorial governments. In exceptional circumstances, the NIHB program may enrol optometrists to supplement the services provided in these territories.
Providers will not be reimbursed for missed appointments.
2.1.1 General examination
The Non-Insured Health Benefits program covers the following tests as part of a general exam:
- case history
- external examination of the eye
- assessment of visual acuity
- profile of ocular motility
- objective and subjective measurement of refraction
- assessment of binocular coordination
- assessment of amplitude of accommodation, when required
- biomicroscopy and assessment of pupillary reflexes
- tonometry
- confrontation visual fields
- direct ophthalmoscopy
- analysis and diagnosis of findings
Coverage for the general examination is based on frequency guidelines, see section 2.2 Eye examination frequency guidelines. A general eye examination within frequency guidelines is an open benefit and does not require prior approval. A general eye exam outside of frequency may be covered on an exception basis, based on medical need, see section 2.1.4 Diagnosed medical condition affecting the eye.
Note: When submitting claims online, a claim submitted for an open benefit and a claim for a benefit(s) that require prior approval must be submitted separately, see section 4.4 Payments: provider claims and client reimbursements.
2.1.2 Follow-up examination
A follow-up examination is the repetition of one or more tests from the general examination which are needed to assess the condition or progression of the client's oculo-visual condition. Coverage may be approved as an exception and is based on medical need, for example, findings from general exams, chronic health conditions. Details of the client's medical condition and the specific test(s) to be repeated must be provided in writing by the prescriber.
2.1.3 Single tests
Clients may be eligible for single eye tests when their ocular or visual condition requires the use of specific additional tests. Coverage may be provided on an exception basis, based on medical need, where these tests are not covered by the provincial or territorial medical insurance plan.
Note, the program does not have access to client medical records, other than previous coverage provided. Therefore, the request must include written medical justification supporting the need for the single test, such as:
- the client's vision diagnosis
- any pertinent medical conditions
- the current results from the general or follow-up eye exam including the client's vision prescription for tests related to glaucoma or ocular hypertension, include eye pressure readings
- these tests are based on the client's medical condition or to confirm other findings, as noted. They are not eligible for reimbursement without findings from the general or follow-up eye exam
Based on the outcome of these tests, the provider is expected to provide the patient with recommendations and, if necessary, a prescription or plan for treatment.
Prior or post approval requests must document that the criteria listed below are met for each test.
| Test | Criteria | Frequency, if applicable |
|---|---|---|
| Eye exam follow-up |
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| Assessment of visual fields, using visual field analyzer |
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| Colour blindness test |
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| Examination of the peripheral retina under pupil dilation |
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| Gonioscopy of the angle |
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| Study of oculomotor imbalance |
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| Study of contrast sensitivity function over at least 6 spatial frequencies |
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| Measurement of aniseikonia using an eikonometer or afocal magnifying lenses |
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| Precise assessment of visual impairment and trial of optical aids |
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| Corneal topography, with assessment of corneal topography using a computerized video-keratoscope |
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| Electroretinogram measurement or visually evoked potentials |
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| Trial contact lens and assessment of ocular reaction |
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| Cycloplegic refraction test |
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| Tests not listed |
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2.1.4 Clients with diagnosed medical conditions affecting the eye
Clients with diagnosed medical conditions affecting the eye, such as diabetes, glaucoma, cataract, age-related macular degeneration, may be eligible for a general eye examination and additional single tests every year, note that this is covered as an insured service in several provinces. Coverage outside the client's usual frequency based on age, as noted in next section 2.2 Eye examination frequency guidelines, is provided on an exception basis and the prior approval request must include written medical justification.
2.2 Eye examination frequency guidelines
| Eye examination | Frequency guidelines |
|---|---|
| General examTable note 1 |
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| Follow-up exam | reviewed case-by-case, based on medical need |
| Single test | reviewed case-by-case, based on medical need |
| Once the eye exam is complete, clients are encouraged to order eyewear right away to be sure that it meets their current needs. | |
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3.0 Corrective eyewear
3.1 Eligible services
To be eligible for corrective eyewear, such as glasses or contact lenses, within the frequency guidelines, see section3.2 Corrective eyewear frequency guidelines, the client must have a valid prescription from a licensed vision care professional qualified to do so under applicable provincial or territorial legislation and regulations. The prescription must correct for one or more of the following conditions:
- refractive error, myopia, hypermetropia or astigmatism
- presbyopia
- oculo-motor imbalance
The client's prescription must meet at least 1 of the following criteria:
- in at least one eye, require spherical or cylindrical correction of at least 0.50 diopter, or for presbyopia, have an add power of at least 0.75 diopter
- require prismatic correction totalling at least 1.00 prism diopter vertically or at least 2.00 prism diopters horizontally
- protective or light blocking eyewear for clients who have low vision, are legally blind or have only one functional eye, with or without optical correction
3.2 Corrective eyewear frequency guidelines
Coverage for corrective eyewear, such as glasses, or contact lenses, is provided as follows:
| Age group | Frequency |
|---|---|
| Clients under 18 years, ends day before 18th birthday | 1 per calendar year |
| Clients 18 years or over, starts on 18th birthday | 1 every 2 calendar years |
| Once the eye exam is complete, clients are encouraged to order eyewear right away to be sure that it meets their current needs. | |
Frequency of coverage is calculated by calendar year only, not months and days. For example, for a 2-year frequency, a client who received coverage for new eyewear at any time in 2022 will be eligible again starting on January 1, 2024, unless the client qualifies for early replacement per section 3.4.6 Exception: Early lens replacement due to change in prescription.
3.3 Eyewear coverage amounts
The NIHB program provides clients with 2 types of coverage amounts for prescriptions: standard and high index. The coverage amount for which the client is eligible is determined by the client's eye examination and resulting prescription and can be used towards the purchase of any type of prescription eyewear, such as glasses or contact lenses.
A coverage amount includes all costs, including tints and coatings, dispensing fees, frames, lenses and fittings. Determination of pupillary distance is done during eyewear fitting at no cost. If the optometrist or optician bills for this measurement, the fee is included in the coverage amount. No other coverage will be provided except as described in section 3.4 Exceptions and criteria for approval. Refer to the Vision Care Regional Fee Grids available on the Express Scripts Canada NIHB provider and client website.
| Item | Criteria for approval |
|---|---|
| Standard coverage amount |
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| High index coverage amount |
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For coverage of eyewear for clients with exceptional prescriptions or eye conditions, see section 3.4 Exceptions and criteria for approval. Exceptions include:
- polycarbonate lenses
- tints and coatings
- exception contact lenses
- flex frames
- eyewear for high prescriptions or eye conditions
- early lens replacement due to change in prescription
- repairs or replacement due to breakage, damage or loss
- inability to adjust to multifocal eyewear
Any additional costs over the maximum eligible amounts are the responsibility of the client. Providers are to inform the client when the cost of the eyewear selected exceeds the coverage amount or which will require the client to pay the balance.
3.3.1 Residual amount
Any unused portion of a coverage amount, the residual amount, will remain available to clients until the end of the frequency period, see section 3.2 Corrective eyewear frequency guidelines. The residual amount will be applied to any future eyewear purchases within the same frequency period. For example, if during the same frequency period, a client has a residual amount, it will be applied should the client purchase another pair of glasses or requests a lens replacement. Residual amounts cannot be applied to eye exams since they have a separate fee structure.
The program will keep track of the residual amount until the end of the frequency period. Clients can contact their NIHB regional office to find out their residual amount.
3.4 Exceptions and criteria for approval
For all exception items, a written signed prescription or details of the client's medical condition must be provided in writing by an ophthalmologist or optometrist. Additional coverage amount(s) may be approved, where relevant, in addition to the coverage amount(s), see section 3.3 Eyewear coverage amounts for which a client qualifies. A request for an exception must be submitted to the NIHB regional office in the province or territory where the service or item is being provided.
3.4.1 Exception: Polycarbonate lenses
Coverage for polycarbonate lenses is eligible when the client meets the following criteria:
| Item | Criteria for approval |
|---|---|
| Glasses with polycarbonate lenses | Coverage for clients in cases where the client has just 1 functional eye or for clients who, with the best possible correction, have far visual acuity in the weaker eye which is equal to or less than 6/60 (20/200) |
3.4.2 Exception: Tints and coatings
Any client can use their coverage amount towards the purchase of tints or coatings of their choice. However, those with medical justification may qualify for additional amount(s), where relevant, for these items, see section 3.3 Eyewear coverage amounts.
| Item | Criteria for approval |
|---|---|
| Tints | Tinted lenses must have an average transmission over the visible spectrum of 40%, as long as the tinted lenses provide total ultraviolet (UV) protection. Coverage is eligible for the following conditions:
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| Ultraviolet protection filter | Coverage is eligible for the following conditions:
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3.4.3 Exception: Contact lenses
In some cases, contact lenses may be the most appropriate way to correct vision for a client with certain prescriptions. Clients with one of the following conditions, in the table below may qualify for additional coverage for both contact lenses and back-up glasses based on detailed medical justification or a valid prescription from an ophthalmologist or an optometrist.
Note that clients who do not demonstrate one of the conditions, in the table below can choose to use their standard or high index coverage amount towards the fitting and purchase of contact lenses.
| Item | Criteria for approval |
|---|---|
| Exception contact lenses | Coverage for exception contact lenses is eligible if the client has 1 or more of the following conditions:
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| Back-up glasses for exception contact lens wearers only | If a back-up pair of glasses is dispensed, the client qualifies for 1 Standard or High Index coverage amount based on their prescription, see section 3.3 Eyewear coverage amounts or exception coverage amount, see section 3.4 Exceptions and criteria for approval. |
The exception contact lens coverage amount is to be applied towards the purchase of contact lenses. Additional coverage may be provided towards an annual progress examination, see section 2.1.3 Single tests and the purchase of glasses to use as a back-up. The coverage amount specific to the back-up glasses is based on the prescription, see section 3.3 Eyewear coverage amounts.
For coverage of specialty or custom-made contact lenses for ocular pathologies such as corneal irregularities, see section 3.4.5 Exception: Eyewear for high prescriptions or eye conditions.
3.4.4 Exception: Flex frames
Where the client is young or has a medical condition, for example, Down syndrome, craniofacial disorders that makes handling frames difficult, the client may be eligible for coverage of flex frames on top of the coverage amounts, see section 3.3 Eyewear coverage amounts.
| Item | Criteria for approval |
|---|---|
| Flex frames |
|
3.4.5 Exception: Eyewear for high prescriptions or eye conditions
Where a client's prescription or eye condition requires corrective lenses, such as glasses or contact lenses with a very high laboratory cost that exceeds the corresponding standard coverage amount, see section 3.3 Eyewear coverage amounts, additional coverage can be considered on an exception basis. To support consideration of such requests, the following are required to be submitted in writing:
- a valid prescription or medical justification
- a detailed breakdown of laboratory costs by lens feature(s), for example, types of lenses, lens index, coatings and dispensing fees if applicable. Note: for lenses for glasses, laboratory costs must be based on lenses with a refractive index of 1.67 or below
Additional coverage may be provided towards an annual progress examination, see section 2.1.3 Single tests, and the purchase of glasses to use as a back-up.
Exception coverage provided is for the actual cost of the lenses, therefore there will be no residual coverage amount remaining. Exception coverage for eyewear for high prescriptions or eye conditions can be requested using the exception lenses, such as lenses for glasses, contact lenses or the exception frames for glasses item codes. For the codes, refer to the Vision Care Regional Fee Grids available on the Express Scripts Canada NIHB provider and client website.
| Item | Criteria for approval |
|---|---|
| Eyewear for high prescriptions or eye conditions | Coverage for eyewear for high prescriptions or eye conditions may be eligible if the client meets one or more of the following criteria:
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3.4.6 Exception: Early lens replacement due to change in prescription
If a client's prescription changes significantly and replacement lenses are required outside of the regular frequency guidelines, coverage for the replacement of contact lenses or eyeglass lenses using existing frames is eligible when the new prescription demonstrates 1 of the following criteria in at least 1 eye:
| Item | Criteria for approval |
|---|---|
| Replacement of lenses for glasses | Coverage when the client meets the eligibility criteria for eyewear, see section 3.1 Eligible services and meets 1 or more of the following criteria in at least 1 eye:
This applies to standard or high index coverage amount, see section 3.3 Eyewear coverage amounts or exception coverage amounts, see section 3.4 Exceptions and criteria for approval |
| Replacement of contact lenses | Coverage for replacement contact lenses is eligible if the new power meets the eligibility criteria for eyewear, see section 3.1 Eligible services and meets 1 or more of the following criteria in at least 1 eye:
This applies to standard or high index coverage amount, see section 3.3 Eyewear coverage amounts or exception contact lenses, see section 3.4.3 Exception: Contact lenses |
Note:
- For all early lens replacement requests, the eye exam must have been done in the preceding 3 months
- If the frame can be re-used, use codes for lens replacement (VC200, VC201, VC202, VC204)
- If the frame cannot be re-used, the client is considered to qualify for early replacement of their eyewear, see section 3.3 Eyewear Coverage Amounts, using codes VC100 to VC108, depending on the prescription
3.4.7 Exception: Repairs or replacement due to breakage, damage or loss
All frames provided must be of a type that can be repaired and carry a replacement warranty against defective workmanship and materials for a minimum of 1 year from the date of issue. Providers must keep warranty information on all items purchased by the client in the client's record or file. Any costs covered under warranty are not eligible for reimbursement by the program.
Coverage for minor and major repairs may be provided for in the event the client damages their corrective eyewear prior to the start of the next frequency period in which the client will be eligible for new eyewear. Accordingly, coverage amounts for minor and major repairs cannot be used towards the cost of the original eyewear nor to purchase an additional pair. When eyewear is damaged:
- If the lenses can be re-used, and only the frame needs to be repaired, use 1 of the repair codes (VC300 or VC301). Do not use both repair codes
- If the frame can be re-used, without a repair or with only a minor repair, but 1 or both lenses need to be replaced, use lens replacement codes corresponding to the prescription (VC200 to VC204)
- In exceptional circumstances, replacing the lenses or frames instead of a repair will be supported to reduce the wait time for a client without functional eyewear
Coverage for replacement of eyewear in the event of breakage, damage or loss may be considered with justification and supporting documentation of the incident that caused the need for replacement, such as an insurance, police or medical report citing the incident. Replacements resulting from misuse or carelessness will not be considered for adults but may be considered on an exception basis for children.
- Loss or total damage, for children, and for adults with accepted justification, use damage or loss replacement codes (VC302 to VC307) to replace both the lenses and frame
- For damage or loss caused by misuse or carelessness for an adult, only a major repair (VC301) may be claimed towards the repair or replacement of the frames and lenses
When requesting coverage for a minor or major repair, details about the damage are required as part of the request. This includes:
- specific details on the nature of the damage, for example, left frame end piece damaged or right hinge damaged, frame beyond repair and requires replacement. Do not describe the repair as a major repair. Instead use, for example, frame replacement
- what, if any damage is covered under replacement warranty
- the estimated cost to repair, including parts
Coverage for repairs may be provided on the condition that this renders the eyewear acceptable for wear. Maximum coverage for total repair costs can be found in the Vision Care Regional Fee Grids available on the Express Scripts Canada NIHB provider and client website. Eyeglass repair kits for client use at home may be covered using the minor repair code.
| Item | Criteria for approval |
|---|---|
| Repairs, minor |
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| Repairs, major |
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| Replacement of entire glasses or contact lenses in the event of breakage, damage or loss |
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| Item | Frequency |
|---|---|
| Repairs, minor |
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| Repairs, major |
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| Replacement of entire glasses or contact lenses |
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3.4.8 Exception: Inability to adjust to multifocal glasses
Most clients who have more than 1 prescription can have these prescriptions fitted in 1 frame and find this most convenient for their everyday use. Clients who have not previously used multifocal glasses, such as bifocals and progressives, should attempt full-time wear for a trial period of 3 months. If by the end of this trial period, the client remains unable to adjust to using multifocal glasses and provided that the client meets the prescription requirements outlined in section 3.1 Eligible services, the client may qualify for:
- one lens replacement coverage amount as per section 3.4.6 Exception: Early lens replacement due to change of prescription, the new lenses will be fit into the previously dispensed frame. As per the table below, no prescription change is required for clients who are unable to adjust to multifocal glasses
- a full coverage amount to fit the remaining qualifying prescription lenses, see section 3.3 Eyewear coverage amounts or exception coverage amount, see section 3.4 Exceptions and criteria for approval
- the invoice must show that both of the above were provided to the client
A client does not have to undergo a new trial period if they have already done so in the past, or if there are contra-indications owing to a cervical or ocular mobility abnormality attested to by the optometrist or ophthalmologist.
| Multifocal glasses | Criteria for approval |
|---|---|
| Second pair for client unable to adjust to multifocal glasses after trial period | First time users only:
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| Two pairs for a client who has contra-indications to multifocal glasses, or has already tried and been unable to adjust to multifocal glasses in the past |
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3.5 Exclusions
Exclusions are goods and services which will not be covered by the NIHB program under any circumstances and are not subject to the NIHB program's appeal process.
Exclusions include:
- additional eye exams or costs over the coverage eligibility or frequency to obtain employment, a driver's license or to engage in sports activity, or at the request of a third party, for example, completing a report or medical certificate
- eyeglass cleaning kit
- no tears shampoo
- any vision items for aesthetic purposes, for example, non-prescription glasses or cosmetic contacts
- contact lens solution
- replacements for adults as a result of misuse, carelessness or client negligence
- implants, for example, punctal occlusion procedure and intraocular lenses
- refractive laser surgery
- treatments with investigational or experimental status, for example, intense pulse light for dry eye treatment
- vision therapy and associated tests, such as binocular vision testing
- eyewear purchased online or outside Canada
- tele-optometry eye examinations
- automated sight or vision tests, these do not assess eye health
- eyewear protection plan or extended warranty as repairs are covered under section 3.4.7 Exception: Repairs or replacement due to breakage, damage or loss
3.6 Low vision items and services, ocular prosthesis and medications
The Medical Supplies and Equipment benefit provides coverage for low vision items and services, such as low vision aids, orientation and mobility aids, independent living aids and assistive technology aids, as well as functional assessments and training. The Medical Supplies and Equipment benefit also provides coverage for ocular prosthesis and scleral shell. Eligible professionals who dispense these items can enrol for direct billing with the program. To learn more, consult the Medical Supplies and Equipment Guide and Benefit Lists, for low vision items and services, see section 10.2 Low vision aids and for ocular prosthesis and scleral shell, see section 7.2.1 Ocular, or you can contact your NIHB regional office.
Medications used to treat conditions such as macular degeneration and post cataract surgery may be covered under the Pharmacy benefit. To learn more, vision care providers or clients can consult the NIHB Drug Benefit List, available on the Express Scripts Canada NIHB provider and client website, or contact the Drug Exception Centre at 1-800-580-0950. These cannot be claimed as vision care items.
4.0 Information for clients and providers: Approvals and payment
4.1 Ordering eyewear: Note to clients
Clients should be aware that eyewear is custom made. Once the optometrist or optician has made the eyewear, it cannot be used by anyone else. Clients must make arrangements with the provider's office to pick up their eyewear when it is complete. A provider will generally hold eyewear for a maximum of 4 months from the time they were ready for pick up. Clients must sign the claim form or a separate form such as the invoice, to confirm they have picked up their eyewear. If a client must travel outside their community to have their new glasses fitted by the vision care provider, medical transportation coverage may be available. Clients can contact their NIHB regional office for additional information.
Clients do not have to order their eyewear through the same vision care provider who does the exam. If clients choose to have eyewear made elsewhere, such as through a separate optician, they may want to communicate this to their optometrist or optometric clinic at the time of their exam so that the provider does not begin the approval process for eyewear that will not be purchased there. This can help to avoid delays at your chosen eyewear provider.
4.1.1 Cost, coverage and reimbursement: Note to clients
The cost of eyewear varies greatly based on the choices made by the client. In some instances, the cost of eye examination and single eye tests may also vary amongst providers. Clients should ask their provider to confirm the total cost of the eye examination, single test(s) and eyewear selected before the provider provides the service or orders the eyewear. The client is responsible for any cost over the amount covered by the NIHB program.
The client is responsible for informing their provider of any other coverage they might have, for example, a group health insurance plan, and submitting the claim to that plan before a claim is made to the NIHB Program. Where a client is no longer eligible for coverage from another payer, the provider or client can contact the NIHB Call Centre at Express Scripts Canada, for providers – 1-888-511-4666, for clients – 1-888-441-4777, to update their profile. Using coverage from both plans is to the client's advantage, see section 4.6 Coordination of benefits.
Clients have 2 options to seek payment for their exams or eyewear:
- direct billing through the provider: clients are asked to contact their vision care provider or NIHB regional office in advance of any appointment to confirm that the provider is enrolled with NIHB and will bill the NIHB program directly for the cost of the exam or eyewear up to the maximum eligible amount
- reimbursement to the client: a client may opt to pay the provider directly and seek reimbursement from NIHB for eligible benefits, see section 4.4 Payments: Provider claims and client reimbursements, up to the maximum eligible amount
Maximum NIHB-eligible coverage amounts can be found in the Vision Care Regional Fee Grids available on the Express Scripts Canada NIHB provider and client website, or by contacting the NIHB regional office.
4.2 Delivery and shipping policy
The provider should notify the client that they have 4 months from the time the eyewear is ready for pick up and document their attempts to contact the client in the client's file. In the event that the client does not pick up their eyewear, refer to Appendix A: Unclaimed eyewear for more information.
Where arrangements have been made for the provider to travel to the community to provide eye exams and offer clients an opportunity to pick eyewear, shipping of eyewear is an eligible expense. Shipping insurance and signature charge are not eligible and will not be reimbursed. Request for approval of shipping costs should be included in the request for prior approval. In such cases, replacement of eyewear damaged or loss of eyewear in shipping may be considered.
4.3 Prior approval
A general eye examination that is within the frequency guidelines, see section 2.2 Eye examination frequency guidelines, is an open benefit and does not require prior approval. Prior approvals are required for all other vision care benefit requests, for example, single tests, eyewear and are valid until the end of client's frequency period.
Providers are encouraged to check that a client is eligible for an eye exam or eyewear through the client eligibility menu option on their Express Scripts Canada NIHB provider web account or by calling the NIHB Call Centre at Express Scripts Canada. If the client is not eligible or an exception is not granted, the claim cannot be paid.
Providers must obtain prior approvals from the NIHB regional office in the province or territory where the service is provided for a general eye examination that it outside of the frequency guidelines, see section 2.2 Eye examination frequency guidelines, single eye tests and eyewear. The regional office will provide a prior approval number for the purpose of billing the claim, which can include the eye exam, the eyewear, or both. A prior approval also informs the provider and the client of the total amount of coverage that is available and can select eyewear accordingly. Providers should contact the NIHB regional office for additional information on the prior approval process.
Clients are encouraged to:
- check the client eligibility menu option on their Express Scripts Canada NIHB client web account or contact the NIHB Call Centre at Express Scripts Canada to confirm their eligibility for a general eye examination or eyewear
- consult the Vision Care Regional Fee Grids, available on the Express Scripts Canada NIHB Provider and Client Website or contact their NIHB regional office to find out their eligible coverage amount
- inform the provider if they have coverage under any other plan
- inform the provider that they are eligible to receive benefits under the NIHB program
- provide their client identification number
- ask the provider if they will bill NIHB directly and whether they, the client, will be required to pay any amount out-of-pocket, for example, balance billing, or paying the total cost up-front and seek client reimbursement
4.4 Payments: Provider claims and client reimbursements
In order to be reimbursed, the service or item must be an eligible benefit, and the client must have been eligible at the time the service or item was provided. All claims for reimbursement of eligible goods and services must be received within 1 year from the date of service. For greater clarity, the date of service for eye exams is the date the client completed the eye exam and the date of service for eyewear is the date the client picked up the eyewear or the date the provider shipped the eyewear.
Claims should be submitted for payment only after the eye exam has been performed or the eyewear has been picked up or mailed out. Claims for reimbursement should not be submitted before the exam or before the item has been provided to the client.
When submitting online, a claim submitted for an open benefit and a claim for a benefit(s) that require prior approval must be submitted separately to ensure that they are processed and reimbursed successfully by the claims processing system.
Processing of payments, including provider claims and clients reimbursements, for the NIHB program vision care benefit are done through Express Scripts Canada.
All providers are required to complete an NIHB Vision Care Provider Enrolment Package available on the Express Scripts Canada NIHB provider and client website, with Express Scripts Canada. The Vision Care Provider Enrolment Package contains the following forms: A mandatory Vision Care Billing Agreement form and the optional forms, Alternate Mailing Address and Communication Preference Form, and Direct Deposit Request Form. Should Express Scripts Canada not receive completed and signed enrolment documents, your claims will not be processed.
After signing a Vision Care Billing Agreement with Express Scripts Canada for the NIHB program, providers are advised to read and retain a copy of the Vision Care Claims Submission Kit located on the Express Scripts Canada NIHB provider and client website. This kit outlines provider accountability and obligations when submitting claims for payment.
For more detailed instructions and forms for client reimbursement, visit the NIHB Client Reimbursement webpage, found on the Express Scripts Canada NIHB provider and client website. If the client has coverage through a private plan, see section 4.6 Coordination of benefits, the client must also include an explanation of benefits (EOB) form from the other plan and a copy of the original receipt, the primary insurer requires the original receipt.
4.5 Balance billing
Eye exams meeting eligibility criteria are reimbursed according to Vision Care Regional Fee Grids, found on the Express Scripts Canada NIHB provider and client website.
For an eye exam covered under the NIHB program, providers are expected not to:
- bill clients a co-payment or extra charges
- collect a deposit
- seek compensation from a client
- condition the provision of services on payment from a client
- have any recourse against any client or person acting on behalf of a client
Certain situations may require a provider to collect payments from the client upfront, such as a coordination of benefits claim. Clients must be made aware that if an item is not covered by the NIHB program, the client will be required to pay for the item without reimbursement by the program.
4.6 Coordination of benefits
Clients are required to access any public or private health or provincial or territorial programs for which they are eligible prior to submitting their claim to the NIHB program through Express Scripts Canada. For example, eye examinations may be an insured service under the provincial or territorial health plan based on a client's age or medical condition, in this case, the exam is not a benefit to the client under NIHB. Providers should be aware when a client qualifies for an eye exam under the provincial or territorial health plan.
It is the client's responsibility to inform the provider if they have coverage through a private plan, such as a group health insurance plan. When claiming expenses, having coverage under more than 1 plan allows clients to use both plans. When an NIHB-eligible client is covered by another plan, claims must be submitted to the other plan first. Once the other plan has paid, any remaining eligible balance can be submitted to NIHB for reimbursement. The other plan will provide an explanation of benefits (EOB) form which must be submitted to Express Scripts Canada with the provider claim or the client reimbursement form.
Clients can use their full NIHB coverage to pay any remaining balance after the other plan has paid. If a client has other insurance, the client's NIHB eligibility is not reduced. Any balance remaining after another plan has paid can be claimed, up to the client's full NIHB eligible amount. If the client has a residual amount, it will be applied to any future eyewear purchases within the same frequency period, see section 3.3.1 Residual amount.
Where a client's coverage has changed or they are no longer eligible for coverage from another payer, the client or provider must contact the NIHB Call Centre at Express Scripts Canada or the NIHB regional office to update the information on file. When contacting Express Scripts Canada, clients should specify which benefit areas are affected and the effective date of the change to their coverage.
A provider or client can check to see if the client's record indicates third party coverage when using the self-service client eligibility function on the Express Scripts Canada NIHB Provider and Client Web Account or by calling the NIHB Call Centre at Express Scripts Canada. The client eligibility function enables the provider or client to pre-verify client eligibility for an eye exam, corrective eyewear, and repairs, and will also advise the provider or client if the client has third party insurance noted on their NIHB file.
5.0 Appendices
Appendix A: Unclaimed eyewear
A client has a maximum of 4 months to pick up their eyewear from the time that they were notified that the eyewear, such as glasses or contact lenses, was ready for pick up. Clients must sign the claim form or a separate form, such as the invoice, to indicate they have picked up their eyewear. The provider must document their efforts to communicate with the client, in the client's file. In the event that the client does not pick up their eyewear, the client's coverage amount will be reduced by the cost of unclaimed eyewear, up to the coverage amount. After the 4-month period, the provider has 2 options to obtain payment:
-
Where the client has ordered glasses, the provider will dismantle the glasses and invoice the NIHB program only for the lenses and other parts of the glasses which cannot be reused. The frames should go back into the provider's inventory. The lenses must be sent to the regional office. Before the provider can submit a claim to Express Scripts Canada, the provider must contact the regional office to amend the prior approval to unclaimed eyewear. Instead of the client's signature, the provider will indicate that the client did not pick up the glasses within the 4-month time frame, and submit the signed claim for payment to Express Scripts Canada. The regional office will add a note in the client's file stating that the lenses will be held by the regional office until the client claims them, or the frequency period expires, see section (3.2 Corrective eyewear frequency guidelines, whichever comes first. Should the client contact the regional office for the lenses, the regional office will make arrangements to have the lenses sent to an eligible provider to be fit into frames and provided to the client. At that time, the NIHB program by Express Scripts Canada will reimburse the provider for the frame for the client's glasses, up to the maximum allowed by policy, see section 3.3 Eyewear Coverage Amounts. If the lenses are not claimed by the end of the frequency period for the client, where possible, the lenses will be sent to a charitable organization for their use.
Based on the provider's professional opinion, if the eyewear does not consist of any reusable parts, the second option should be used.
- The provider must contact the regional office to amend the prior approval to unclaimed eyewear and mail the glasses or contact lenses to the regional office. The regional office will sign for the eyewear on behalf of the client. The provider will submit a claim to Express Scripts Canada and be reimbursed for the amount approved. The regional office will add a note in the client's file stating that the eyewear will be held by the regional office until the client claims them, or the frequency period expires, see section 3.2 Corrective eyewear frequency guidelines, whichever comes first. Should the client contact the regional office for the eyewear, the regional office will make arrangements to have the eyewear sent to the client or a provider of the client's choice. A note indicating the date that the eyewear was mailed out will be put in the client's file. If the client does not contact the provider within the frequency period, where possible, the provider will send the eyewear to a charitable organization for their use.
It is important to note that the NIHB program will not reimburse providers for any costs for eyewear above the approved amount. For additional information, contact the NIHB regional office in your province or territory.
Appendix B: Contact information - NIHB regional offices
To learn more, contact the NIHB regional office in your province or territory.
Appendix C: Privacy statement
Indigenous Services Canada's NIHB program has a responsibility to protect personal information under its control in accordance with the Privacy Act and its related Treasury Board privacy policy and directives and is responsible for ensuring the personal information collected is limited to that which is necessary to administer the program.
To learn more, contact Indigenous Services Canada's Access to Information and Privacy Coordinator at 819-997-8277 or aadnc.atiprequest-aiprpdemande.aandc@canada.ca. You also have the right to file a complaint with the Office of the Privacy Commissioner of Canada if you think your personal information has been handled improperly.
Appendix D: Client eligibility
The provider must verify that the individual is eligible for benefits under Indigenous Services Canada's NIHB program and identify any other benefit coverage available to the client, if applicable.
To be eligible, a client must be a resident of Canada, and 1 of the following:
- a First Nations individual who is registered according to the Indian Act, commonly referred to as "a person having Indian status"
- an Inuk recognized by one of the Inuit land claim organizations as outlined in Inuit client eligibility for the NIHB program
- a child less than 2 years old, whose parent is an NIHB-eligible client
To learn more, refer to the web page Who is eligible for the NIHB program or contact the NIHB regional office.
More detailed information about Client Identification and Eligibility can be found in section 4 of the Vision Care Claims Submission Kit, available on the Express Scripts Canada NIHB provider and client website.
Appendix E: Appeal process
A denial of benefit can be appealed by the client or the provider on behalf of the client. For the provider to send in an appeal, an authorization letter signed by the client is required. Note: the items identified as exclusions cannot be appealed. Refer to Appealing a decision under the NIHB program or contact the NIHB regional office for information.
Appendix F: Provider Claim Verification Program
As part of the NIHB program's risk management activities, Indigenous Services Canada has mandated its claims processor to maintain a set of pre-payment and post-payment processes, including claim verification activities.
This function incorporates the review of claims against records to confirm compliance with the terms and conditions of the NIHB program. If under any circumstances it is found that a provider has inappropriately billed the program, claim payments will be recovered, either by direct payment from the provider or withheld from future provider claim statements.
Detailed information about the Provider Claim Verification Program can be found in section 6 of the Vision Care Claims Submission Kit, available on the Express Scripts Canada NIHB provider and client website.