8.0 Respiratory equipment and supplies benefits list

8.1.1 Benefit policies

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

8.1.2 Prescriber and provider requirements

Prescriptions or recommendations for coverage must be initiated by the health professionals identified as prescribers or recommenders of the item under the NIHB program. 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:

• INT — Internal Medicine Specialist
• LPN/RPN – Licensed Practical Nurse/Registered Practical Nurse when within their scope of practice in their province or territory
• MD — Physician
• NP — Nurse Practitioner
• RESP — Respirologist
• RN — Registered Nurse (renewals only - initial prescription required from MD, NP, NSWOC, WOCC(C))
• SLP — Speech-Language Pathologist
• SM — Sleep Medicine Physician

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

• GEN — Enrolled general medical supplies and equipment and pharmacy provider
• RP — Enrolled respiratory provider with 1 of the following health care professionals on staff:
  • RRT — Registered Respiratory Therapist
  • RN — Registered Nurse trained in managing respiratory conditions

8.1.3 Prior approval requirements

General prior approval requirements can be found in the general policies.

Prior approval is required for all respiratory equipment and supplies benefits.

To initiate the prior approval process, the Respiratory 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 documentation:

• required information as described in sections 8.2 to 8.5
• device make, model, and cost
• additional relevant information the provider, physician, nurse practitioner or other recognized prescriber or recommender 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.

8.1.4 Exclusions

In addition to the general exclusion policy listed in the general policies, the following items are excluded from the respiratory equipment and supplies benefit and are not considered for coverage or appeal under the NIHB program:

• respiratory benefits for outings while the client is an in-patient in an acute or long-term hospital setting
• custom-made masks for ventilation
• incentive spirometer or volumetric exerciser

8.1.5 Warranties

Provider must honour the manufacturer's warranty.

8.1.6 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.

8.1.7 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.

8.1.8 Services included in the NIHB price

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

• initial assessment and mask fitting to determine the type of benefit required
• complete product set-up and dispensing of the item, including the necessary adjustments and fitting
• follow-ups: all ongoing care including follow-up visits, telephone calls to monitor effectiveness, support compliance and make necessary adjustments, such as mask re-fit
• client education and instructions on the effective use, safety and care of the equipment and supplies
• report generation
• correspondence with NIHB as part of the coverage process
• correspondence with other health care professionals, such as physician, sleep lab, as necessary

Note: The NIHB program does not cover the cost of sleep disorder diagnostic testing.

8.1.9 Terminology

8.2.1 CPAP (continuous positive airway pressure)

The program will accept either:

• a CPAP or automatic CPAP (APAP) rental followed by a purchase
  or
• an initial request for purchase

8.2.2 BPAP (bilevel positive airway pressure)

8.3.1 Suction machine

• rental may be requested 1 month at a time (up to 3 months)
• if suction machine is still required after 3 months, purchase will be considered

Note: the rental fee for the suction machine is to be deducted from the purchase price.

8.4.1 Supplies for PAP

8.4.2 Supplies for tracheostomy

8.4.3 Supplies for secretion clearance

8.5.1 Repairs

8.5.2 Delivery