Non-Insured Health Benefits program: First Nations and Inuit Health Branch: Annual report 2021 to 2022

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Section 1: Overview
Section 2: Client population
Section 3: NIHB program benefit expenditures
Section 4: NIHB pharmacy expenditure and utilization data
Section 5: NIHB medical supplies and equipment (MS&E) expenditure and utilization data
Section 6: NIHB dental expenditure and utilization data
Section 7: NIHB medical transportation expenditures and utilization data
Section 8: NIHB vision care benefits
Section 9: NIHB mental health counselling benefits
Section 10: 10 year regional expenditure trends
Section 11: NIHB program administration
Section 12: NIHB policy and program initiatives
Section 13: Technical notes

Section 1: Overview

Introduction

The Non-Insured Health Benefits (NIHB) program provides registered First Nations and recognized Inuit with coverage for a range of medically necessary health benefits including prescription drugs and over-the-counter (OTC) medications, dental and vision care, medical supplies and equipment, mental health counselling, and transportation to access medically required health services that are not available on reserve or in the community of residence. This report covers the 2021 to 2022 fiscal year. A fiscal year runs from April 1 to March 31. During 2021 to 2022, NIHB provided access to benefits coverage for 915,895 eligible clients.

In line with Canada's commitments under the United Nations Declaration of the Rights of Indigenous Peoples and the Truth and Reconciliation Commission's Calls to Action, Indigenous Services Canada (ISC) works with Indigenous organizations including the Assembly of First Nations and the Inuit Tapiriit Kanatami, to advance shared priorities focused on improving and closing the gaps in health outcomes for Indigenous Peoples.

Now in its twenty-eighth edition, the 2021 to 2022 NIHB Annual Report provides national and regional data on the NIHB program client population, expenditures, benefit types and benefit utilization. This Report is published in accordance with the NIHB program's performance management responsibilities and is intended for the following target audiences:

First Nations and Inuit organizations and governments at community, regional and national levels
Regional and Headquarters managers and staff of Indigenous Services Canada and
Others in government and in non-government organizations with an interest in the provision of health services to First Nations and Inuit communities.

British Columbia Tripartite Agreement

The British Columbia Tripartite Framework Agreement on First Nation Health Governance was signed by Canada, the First Nations Health Council (FNHC) and the British Columbia Ministry of Health on October 13, 2011. Consistent with the commitments set out in the Framework agreement, between July 2, 2013 and October 1, 2013 the First Nations Health Authority (FNHA) assumed responsibility for the design, management, delivery and/or funding of the delivery of health services to First Nations residing in British Columbia. Since that time, First Nations individuals residing in BC have received their health benefits through the FNHA's Health Benefits Program, which replaced the NIHB program in BC.

Section 2: Client population

To be an eligible client of the NIHB program, an individual must be a resident of Canada and one of the following:

a First Nations person who is registered under the Indian Act
an Inuk recognized by an Inuit Land Claim organization
a child less than 24 months old whose parent is a registered First Nations person or a recognized Inuk

As of March 31, 2022, there were 915,895 First Nations and Inuit clients eligible to receive benefits under the NIHB program, an increase of 1.9% from March, 2021.

First Nations and Inuit population data are drawn from the Status Verification System (SVS) which is operated by the NIHB program. SVS data on First Nations clients are based on information provided by Indigenous Services Canada. SVS data on Inuit clients are based on information provided by the Governments of the Northwest Territories and Nunavut, and Inuit organizations including the Inuvialuit Regional Corporation, Nunavut Tunngavik Incorporated and the Makivik Corporation.

Amendments to the Indian Act have meant that more individuals are able to claim or restore their status as registered Indians. The Gender Equity in Indian Registration Act, which came into force on January 31, 2011, and An Act to amend the Indian Act in response to the Superior Court of Quebec decision in Descheneaux c. Canada, which came into force December 12, 2017, aim to eliminate known sex-based inequities in registration. Additonal amendments came into force on August 15, 2019 which eliminated the 1951 cut-off provision of the Indian Act in order to extend entitlement to grandchildren born or adopted prior to September 4, 1951. Because of this, many people became entitled to be registered as an Indian in accordance with the Indian Act. Once registered, these individuals are eligible to receive benefits through the NIHB program.

The creation of the Qalipu Mi'kmaq First Nations band was announced on September 26, 2011 as a result of a settlement agreement that was negotiated between the Government of Canada and the Federation of Newfoundland Indians (FNI). Through the formation of this band, members of the Qalipu Mi'kmaq became recognized under the Indian Act and eligible for registration.

Eligible client population by region: March 2022

Ontario had the largest proportion of the eligible population, representing 24.4% of the national total, followed by Manitoba at 17.8% and Saskatchewan at 17.6%.

Note that population values are based on region of band registration, which is not necessarily the client's current region of residence. The majority of British Columbia clients previously covered by the NIHB program are now covered by the B.C. First Nations Health Authority (FNHA) and are not represented in this chart. The remaining NIHB clients in B.C. are Inuit clients, or clients associated with B.C. bands, but residing in other provinces and territories of Canada, where they are covered under the NIHB program.

**Figure 2.1 Eligible client population by region**

Eligible population by client type and region: March 2021 and March 2022

Of the 915,895 total eligible clients at the end of the 2021 to 2022 fiscal year, 864,642 (94.4%) were First Nations clients while 51,227 (5.6%) were Inuit clients. The number of First Nations clients increased by 1.9% and the number of Inuit clients increased by 1.3%

From March 2021 to March 2022, Quebec had the highest percentage change in total eligible clients with a 4.8% increase, followed by British Columbia and Ontario with increases of 3.5% and 2.3% respectively.

Table 2.1 Eligible population by client type and region
Region	First Nations		Inuit		Total		% change
Region	March/21	March/22	March/21	March/22	March/21	March/22	% change
Atlantic	66,351	67,839	431	438	66,782	68,277	2.2%
Quebec	74,319	77,824	1,766	1,891	76,085	79,715	4.8%
Ontario	217,907	222,813	877	896	218,784	223,709	2.3%
Manitoba	160,719	162,346	235	242	160,954	162,588	1.0%
Saskatchewan	158,693	161,423	92	95	158,785	161,518	1.7%
Alberta	127,490	128,891	740	766	128,230	129,657	1.1%
B.C.	16,628	17,214	391	408	17,019	17,622	3.5%
Yukon	7,598	7,659	144	142	7,742	7,801	0.8%
N.W.T.	18,542	18,633	9,305	9,323	27,847	27,956	0.4%
Nunavut	0	0	36,611	37,026	36,611	37,026	1.1%
National	848,247	864,642	50,592	51,227	898,839	915,895	1.9%
Source: SVS adapted by Business Support, Audit and Negotiations Division

Eligible client population over time: March 2013 to March 2022

Over the past 10 years, the total number of eligible clients in the SVS has decreased by 1.1%, from 926,044 in March 2013 to 915,895 in March 2022. NIHB client population was significantly impacted during this period by the creation of the FNHA in British Columbia, which resulted in approximately 133,430 clients in B.C. being removed from the NIHB client population when they became eligible to receive benefits through the FNHA.

**Chart 2.1: Eligible client population, March 2013 to March 2022**

Over the past five years, the NIHB program's total number of eligible clients increased by 7.4% from 867,749 in March 2018 to 915,895 in March 2022. Quebec had the largest increase in eligible clients over this period, with a growth rate of 12.4%. Saskatchewan and Ontario followed with growth rates of 8.4% and 7.9% respectively.

Table 2.2: Eligible client population by region, March 2018 to March 2022
Region	March 2018	March 2019	March 2020	March 2021	March 2022
Atlantic	65,573	63,873	65,335	66,782	68,277
Quebec	72,151	72,882	74,346	76,085	79,715
Ontario	210,295	212,176	215,751	218,784	223,709
Manitoba	155,850	157,325	159,862	160,954	162,588
Saskatchewan	152,324	154,323	157,162	158,785	161,518
Alberta	123,812	125,209	127,098	128,230	129,657
B.C.	18,184	17,417	16,561	17,019	17,622
Yukon	7,604	7,579	7,673	7,742	7,801
N.W.T.	26,877	27,771	27,816	27,847	27,956
Nunavut	35,079	34,757	35,914	36,611	37,026
Total	867,749	873,312	887,518	898,839	915,895
Annual % change	1.7%	0.6%	1.6%	1.3%	1.9%
Source: SVS adapted by Business Support, Audit and Negotiations Division

Annual population growth, Canadian population and eligible client population: 2013 to 2022

From 2013 to 2022, the Canadian population increased by 10.8% while the NIHB eligible First Nations and Inuit client population decreased by 1.1%. Factoring out the impact of the removal of FNHA clients, the NIHB ten year eligible population increase was 20.0%, with an average annual growth of 1.8%.

The higher than average NIHB program client population growth rate in 2013 can be attributed to the registration of clients newly eligible under Bill C-3, and to new Qalipu Mi'kmaq First Nations clients in the Atlantic Region.

**Chart 2.2: Annual population growth, Canadian population and eligible client population**

Year	2013	2014	2015	2016	2017	2018	2019	2020	2021	2022
NIHB client Population	926,044	808,686	824,033	839,129	853,088	867,749	873,312	887,518	898,839	915,895
Growth rate	3.3%	-12.7%	1.9%	1.8%	1.7%	1.7%	0.6%	1.6%	1.3%	1.9%
Canadian population	35,152,370	35,535,348	35,832,513	36,264,604	36,708,083	37,058,856	37,589,262	38,007,166	38,226,498	38,929,902
Growth rate	1.2%	1.1%	0.8%	1.2%	1.2%	1.0%	1.4%	1.1%	0.6%	1.8%

Eligible client population by age group, gender and region: March 2022

The NIHB program recognizes the importance of representative data for our gender diverse client population. As of 2020, clients can choose Male, Female or Another Gender as a gender identifier when applying for or updating their registration with Indigenous Services Canada, which is captured in population and benefit utilization data. As the total number of clients who have chosen Another Gender to-date is low, data for clients identifying as neither male nor female are included in national population totals only this year, in keeping with government practices for safe-guarding the privacy of individuals.

Of the 915,895 NIHB eligible clients on the SVS as of March 31, 2022 49.2% were male (450,755), 50.8% were female (465,114) and a small percentage of clients selected another gender in the first year of availability for this gender designation (26).

The average age of the eligible client population was 35 years of age. By region, this average ranged from a low of 28 years of age in Nunavut to a high of 41 years of age in British Columbia.

The average age of the male and female eligible client population was 34 years and 36 years respectively. The average age for males ranged from a low of 28 years in Nunavut to a high of 40 years in British Columbia. The average age for females varied from a low of 29 years in Nunavut to a high of 43 years in British Columbia.

The NIHB eligible client population is relatively young with nearly two-thirds (61.9%) under the age of 40. Of the total population, almost one-third (29.1%) are under the age of 20.

The senior population, defined as clients 65 years of age and over, has been slowly increasing as a proportion of the total NIHB client population. In 2012, seniors represented 6.8% of the overall NIHB population. Most recently in 2022, seniors accounted for 9.9%.

Table 2.3: Eligible client population by age group, gender and region

Region	Atlantic			Quebec			Ontario			Manitoba
Age group	Male	Female	Total	Male	Female	Total	Male	Female	Total	Male	Female	Total
0-4	1,153	1,063	2,216	1,141	1,076	2,217	3,068	2,781	5,849	2,908	2,672	5,580
5-9	1,944	1,928	3,872	2,556	2,408	4,964	6,713	6,559	13,272	7,796	7,420	15,216
10-14	2,585	2,541	5,126	3,033	2,898	5,931	8,330	8,036	16,366	8,741	8,568	17,309
15-19	2,565	2,429	4,994	2,991	2,752	5,743	8,589	8,104	16,693	8,033	7,814	15,847
20-24	2,681	2,531	5,212	2,976	2,910	5,886	8,947	8,666	17,613	7,623	7,201	14,824
25-29	2,776	2,806	5,582	3,384	3,293	6,677	9,610	9,336	18,946	7,692	7,440	15,132
30-34	2,684	2,571	5,255	3,126	3,093	6,219	9,081	8,952	18,033	6,973	6,942	13,915
35-39	2,400	2,366	4,766	2,747	2,793	5,540	7,908	7,796	15,704	5,564	5,443	11,007
40-44	2,175	2,250	4,425	2,567	2,494	5,061	7,105	7,421	14,526	4,755	4,636	9,391
45-49	2,204	2,265	4,469	2,315	2,451	4,766	6,823	6,935	13,758	4,437	4,532	8,969
50-54	2,366	2,415	4,781	2,469	2,590	5,059	6,932	7,321	14,253	4,411	4,657	9,068
55-59	2,208	2,426	4,634	2,460	2,790	5,250	7,074	7,699	14,773	3,957	4,152	8,109
60-64	1,833	2,187	4,020	2,264	2,640	4,904	6,083	7,082	13,165	3,031	3,385	6,416
65+	3,922	5,003	8,925	4,710	6,788	11,498	12,652	18,106	30,758	5,111	6,694	11,805
Total	33,496	34,781	68,277	38,739	40,976	79,715	108,915	114,794	223,709	81,032	81,556	162,588
Average age	37	39	38	37	40	39	37	40	39	32	33	32

Region	Saskatchewan			Alberta			B.C.			Yukon
Age group	Male	Female	Total	Male	Female	Total	Male	Female	Total	Male	Female	Total
0-4	3,472	3,374	6,846	2,891	2,727	5,618	208	179	387	97	109	206
5-9	7,296	7,133	14,429	5,990	5,790	11,780	306	320	626	198	200	398
10-14	8,675	8,361	17,036	7,187	6,873	14,060	442	439	881	273	230	503
15-19	7,985	7,931	15,916	6,485	6,352	12,837	473	513	986	259	249	508
20-24	7,625	7,573	15,198	6,020	5,784	11,804	650	660	1,310	308	279	587
25-29	7,675	7,595	15,270	6,314	5,819	12,133	752	666	1,418	318	319	637
30-34	7,288	7,127	14,415	5,563	5,496	11,059	785	753	1,538	313	323	636
35-39	5,841	5,842	11,683	4,720	4,638	9,358	783	762	1,545	317	278	595
40-44	4,957	4,801	9,758	3,801	4,002	7,803	686	698	1,384	259	242	501
45-49	4,346	4,536	8,882	3,337	3,510	6,847	617	630	1,247	245	225	470
50-54	4,200	4,440	8,640	3,209	3,425	6,634	633	684	1,317	306	253	559
55-59	3,575	3,945	7,520	2,806	3,188	5,994	534	689	1,223	320	321	641
60-64	2,724	3,169	5,893	2,185	2,582	4,767	450	639	1,089	256	299	555
65+	4,209	5,823	10,032	3,644	5,319	8,963	980	1,691	2,671	404	601	1,005
Total	79,868	81,650	161,518	64,152	65,505	129,657	8,299	9,323	17,622	3,873	3,928	7,801
Average age	31	32	32	31	33	32	40	43	41	39	41	40

Region	N.W.T			Nunavut			Total
Age group	Male	Female	Total	Male	Female	Total	Male	Female	Total
0-4	417	362	779	1,787	1,713	3,500	17,142	16,056	33,198
5-9	879	861	1,740	2,160	2,032	4,192	35,838	34,651	70,489
10-14	1,085	983	2,068	2,083	2,040	4,123	42,434	40,969	83,403
15-19	1,006	1,025	2,031	1,888	1,788	3,676	40,274	38,957	79,231
20-24	1,000	1,019	2,019	1,716	1,628	3,344	39,546	38,251	77,797
25-29	1,429	1,354	2,783	1,550	1,547	3,097	41,500	40,175	81,675
30-34	1,356	1,403	2,759	1,532	1,486	3,018	38,701	38,146	76,847
35-39	1,136	1,062	2,198	1,144	1,160	2,304	32,560	32,140	64,700
40-44	938	944	1,882	964	965	1,929	28,207	28,453	56,660
45-49	799	860	1,659	825	842	1,667	25,948	26,786	52,734
50-54	971	1,004	1,975	852	906	1,758	26,349	27,695	54,044
55-59	850	926	1,776	712	759	1,471	24,496	26,895	51,391
60-64	644	777	1,421	493	516	1,009	19,963	23,276	43,239
65+	1,242	1,624	2,866	923	1,015	1,938	37,797	52,664	90,461
Total	13,752	14,204	27,956	18,629	18,397	37,026	450,755	465,114	915,895
Average age	36	38	37	28	29	28	34	36	35
Source: SVS adapted by Business Support, Audit and Negotiations Division

Population analysis by age group March 2022

The overall NIHB client population is relatively young compared to the general Canadian population. The share of the NIHB client population under 20 years of age was 29.1% compared to 21.1% for the Canadian population. The average age of NIHB clients is 35 compared to 42 years of age for the Canadian population.

**Chart 2.3: Proportion of Canadian population and of the NIHB client population by age group**

A comparison of March 2018 to March 2022 eligible client population shows an aging population. The client population 40 and above, as a proportional share of the overall client population, increased from 35.6% in 2018 to 38.1% in 2022.

**Chart 2.4: Proportion of eligible NIHB client population by age group**

Section 3: NIHB program benefit expenditures

NIHB program sustainability: 2021 to 2022

Cost and service pressures on the Canadian health system have been linked to factors such as an aging population and the increased demand for and utilization of health goods, particularly pharmaceuticals, and services. In addition to these factors, NIHB program expenditures are driven by the number of eligible clients and their medical needs. A significant proportion of NIHB clients live in small and remote communities, and require medical transportation to access health services that are not available locally.

Factors influencing NIHB program expenditures
Client base	Market forces	Evidence/Input
Changing demographics, including high population growth, an aging population, and uncertainty about the registration of new or existing clients Health status, including high prevalence of chronic and infectious diseases Geographic distribution of client population and accessibility of health services	Introduction and price of new therapies and procedures Provincial/Territorial decisions and insurance industry dynamics Shift from hospital treatments (insured) to non-insured coverage Economic factors, including inflation, volatility in the price of gas and oil, and employment status Geographic accessibility of health benefits and services Changes in scope of practice Relationships with health professional associations	Prescribing and treatment decisions of regulated health professionals Evolving evidence on treatment options Preventive intervention versus restorative oral treatment Input from First Nations and Inuit partner organizations

NIHB expenditures by benefit ($ millions) 2021 to 2022

In 2021 to 2022, total NIHB program benefit expenditures were $1,695.3 million. This represents an increase of 13.7% over NIHB expenditures of $1,490.6 million in 2020 to 2021. Medical transportation costs represented the largest proportion of expenditures at 35.5% ($602.2 million), followed by pharmacy benefit costs at 34.0% ($576.3 million) and dental benefit costs at 17.8% ($302.2 million).

NIHB medical transportation, pharmacy and dental benefit expenditures accounted for 87.3% of all NIHB expenditures in 2021 to 2022.

**Chart 3.1: NIHB expenditures by benefit ($ millions)**

Not reflected in the $1,695.3 million in NIHB expenditures are approximately $69.9 million in administration costs. More detail is provided in Section 11.

NIHB expenditures and growth by benefit: 2021 to 2022

NIHB program benefit expenditures increased by 13.7%, or $204.7 million from fiscal year 2020 to 2021. The highest net increase in expenditures were in the NIHB medical transportation and dental benefits at $76.5 and $65.9 million respectively. Factors affecting benefit expenditure growth are discussed in subsequent sections of this report.

Table 3.1 NIHB expenditures and growth by benefit
Benefit	Total Expenditures ($ 000's) 2020-2021	Total Expenditures ($ 000's) 2021-2022	% Change From 2020-2021
Medical Transportation	$525,719	$602,208	14.5%
Pharmacy	$550,900	$576,251	4.6%
MS&E	$51,524	$60,448	17.3%
Dental	$236,293	$302,183	27.9%
Vision Care	$39,907	$47,819	19.8%
Mental Health Counselling	$73,958	$93,890	27.0%
Other	$12,314	$12,496	1.5%
Total Expenditures	$1,490,615	$1,695,295	13.7%
Source: FST and FIRMS adapted by Business Support, Audit and Negotiations Division

Expenditures in the "other" category are related to program oversight, including arrangements with the FNHA to provide funding for additional clients who became eligible after the 2013 transfer of responsibilities, due to changes in federal legislation, as well as contribution agreements with Indigenous partner organizations.

NIHB expenditures by benefit and region ($ 000's): 2021 to 2022

Manitoba accounted for the highest proportion of total expenditures at $391.2 million, or 23.1% of the national total, followed by Saskatchewan at $335.6 million (19.8%), and Ontario at $325.5 million (19.2%). By comparison, the lowest expenditures were in the Atlantic region at $84.2 million (5.0%).

Headquarters expenditures by benefit type represent costs paid for claims processing services. Headquarters expenditures in the other category are comprised of operational expenditures associated with NIHB program oversight and policy development. This includes arrangements with the FNHA to provide funding for additional clients who became eligible following the transfer of responsibilites in 2013, due to changes in federal legislation, as well as contribution agreements with Indigenous partner organizations, such as the Assembly of First Nations and Inuit Tapiriit Kanatami, and regional Indigenous organizations. Headquarters expenditures account for 1.9% ($28.1 million) of total NIHB expenditures, and do not include the $69.9 million in headquarters administration costs outlined in Section 11.

Table 3.2 NIHB expenditures by benefit and region
Region	Medical Transportation	Pharmacy	MS&E	Dental	Vision Care	Mental Health Counselling	Other	Total
Atlantic	$15,776	$40,657	$4,508	$11,801	$4,158	$7,001	$326	$84,227
Quebec	$26,775	$58,827	$2,855	$19,092	$3,938	$5,604	$282	$117,373
Ontario	$114,814	$112,069	$8,700	$59,326	$8,113	$21,762	$710	$325,494
Manitoba	$184,200	$112,353	$13,330	$57,381	$7,334	$16,333	$247	$391,177
Saskatchewan	$103,152	$120,000	$13,352	$63,408	$10,581	$24,881	$211	$335,584
Alberta	$67,206	$86,680	$11,658	$58,790	$9,405	$14,771	$360	$248,869
North	$90,286	$31,499	$5,647	$26,830	$4,081	$3,333	$405	$162,080
Headquarters	$0	$10,169	$399	$3,108	$210	$204	$9,954	$24,044
Total	$602,208	$576,251	$60,448	$302,183	$47,819	$93,890	$12,496	$1,695,295
Source: FST adapted by Business Support, Audit and Negotiations Division

NIHB annual expenditures ($ Millions) and percentage change

In 2021 to 2022, NIHB program expenditures totalled $1,695.3 million, an increase of 13.7% from $1,490.6 million in 2020 to 2021. Since 2012 to 2013, total expenditures have grown by 53.5%. The annualized rate of growth over this period was 4.7%. There has been wide variation in growth rates between 2012 to 2013 and 2021 to 2022, from a low of -7.1% in 2013 to 2014* to a high of 13.7% in 2021 to 2022.

Fluctuations in NIHB expenditures growth rates are impacted by a number of factors as set out in figure 3.1. Changes in the eligible client population have a direct impact on growth. Notable examples include the transfer of responsibility for First Nations clients residing in B.C. to the FNHA in 2013 to 2014, the creation of the Qalipu Mi'kmaq band in 2011, and an increase in eligible clients as a result of amendments to the Indian Act. The coronavirus (COVID-19) outbreak and provincial/territorial public health restrictions on the provision of in-person services in fiscal year 2020 to 2021, along with larger than typical utilization of NIHB benefits in fiscal 2021 to 2022 once restrictions were ended, impacted growth in the past two years.

*If expenditures for FNHA eligible clients are excluded from 2012 to 2013 and 2013 to 2014 total NIHB expenditures, then the growth rate for 2013 to 2014 would have been 2.8%.

**Chart 3.2 NIHB annual expenditures ($ Millions) and percentage change**

NIHB annual expenditures by benefit ($ 000's)

In the 10 year period ending 2021 to 2022, expenditures for NIHB mental health services and medical transportation benefits have grown more than other benefit areas. NIHB mental health expenditures had the highest percentage growth at 554.9%, from $14.3 million in 2012 to 2013 to $93.9 million in 2021 to 2022. NIHB medical transportation had the highest expenditure growth from $351.4 million in 2012 to 2013 to $602.2 million in 2021 to 2022, a change of 71.4%.

Over the same period, NIHB medical supplies and equipment (MS&E) expenditures increased by 63.3% and NIHB dental expenditures increased by 35.7%.

Decreases in the other expenditures category in 2013 to 2014 can be attributed to the transfer of responsibility for provincial health care insurance premiums for First Nations clients residing in British Columbia to the FNHA in 2013.

Table 3.3: NIHB annual expenditures by benefit ($ 000's)
Benefit	2012/13	2013/14	2014/15	2015/16	2016/17	2017/18	2018/19	2019/20	2020/21	2021/22
Medical Transportation	$351,424	$352,036	$357,963	$375,904	$417,035	$459,505	$495,034	$537,179	$525,719	$602,208
Pharmacy	$425,806	$383,614	$392,479	$425,773	$457,489	$482,789	$488,604	$532,045	$550,900	$576,251
MS&E	$37,009	$30,670	$29,233	$30,657	$37,031	$40,167	$47,346	$54,256	$51,524	$60,448
Dental	$222,706	$207,179	$201,886	$217,109	$235,831	$248,992	$269,008	$282,908	$236,293	$302,183
Vision Care	$32,167	$31,459	$29,704	$30,017	$32,370	$33,578	$36,467	$45,968	$39,907	$47,819
Mental Health Counselling	$14,337	$14,152	$15,581	$16,193	$21,728	$33,066	$42,656	$55,126	$73,958	$93,890
Other	$21,257	$5,406	$4,005	$4,858	$5,974	$11,143	$11,450	$12,001	$12,314	$12,496
Total	$1,104,591	$1,026,397	$1,031,488	$1,100,512	$1,207,458	$1,309,240	$1,390,563	$1,519,483	$1,490,615	$1,695,295
Annual % Change	2.8%	-7.1%	0.5%	6.7%	9.7%	8.4%	6.2%	9.3%	-1.9%	13.7%
Source: FIRMS and FST adapted by by Business Support, Audit and Negotiations Division

Per capita NIHB expenditures by region: 2021 to 2022

Expenditures per capita are total NIHB expenditures divided by the number of eligible clients, regardless of whether clients submitted a claim in the reporting period.

The national per capita expenditures for all benefits in 2021 to 2022 were $1,825. Manitoba had the highest per capita cost at $2,406. The Northern region followed with a per capita cost of $2,227. The higher than average per capita cost for these regions is partly attributable to high medical transportation costs due to the large number of First Nations and Inuit clients living in remote or fly-in only northern communities. By contrast, the Atlantic region had the lowest per capita cost of $1,234, due to the comparatively low medical transportation expenditures in the region.

**Chart 3.3: Per capita NIHB expenditures by region**

Section 4: NIHB pharmacy expenditure and utilization data

The NIHB program covers a comprehensive range of prescription drugs and over-the-counter medications listed on the NIHB Drug Benefit List (DBL). Prescription and over-the-counter medications are evidence-based and covered in accordance with program policies.

In 2021 to 2022, the NIHB program paid for pharmacy claims made by a total of 528,541 First Nations and Inuit clients. The total spent for these claims was $576.3 million or 34.0% of total NIHB expenditures. Of all the NIHB program benefits, the pharmacy benefit accounts for the second largest share of expenditures and is the benefit most utilized by clients.

Distribution of NIHB pharmacy expenditures ($ Millions): 2021 to 2022

The NIHB pharmacy benefit is comprised of multiple components. Prescription drugs paid through the Health Information and Claims Processing Services (HICPS) system was the largest piece, accounting for $453.8 million or 78.7% of all NIHB pharmacy expenditures, followed by over-the-counter (OTC) and controlled access (CAD) drugs (HICPS) which totalled $98.0 million or 17.0%.

Regional Drugs, at $1.8 million or 0.3% of pharmacy benefit costs, refers to prescription drugs and OTC medications paid through Indigenous Services Canada regional offices.

Contribution agreements, which accounted for $12.5 million or 2.2% of total pharmacy benefit costs, are used to fund the provision of pharmacy benefits through agreements such as those with the Mohawk Council of Akwesasne in Ontario and the Bigstone Cree Nation in Alberta.

Other costs totalled $10.2 million or 1.8% in 2021 to 2022. Included in this total are headquarters contract and claims processing expenditures related to the HICPS system.

**Chart 4.1: Distribution of NIHB pharmacy expenditures ($ Millions)**

Total NIHB pharmacy expenditures by type and region ($ 000's): 2021 to 2022

Prescription drug costs paid through the HICPS system represented the largest component of total NIHB Pharmacy costs accounting for $453.8 million or 78.7%. The Saskatchewan region had the largest proportion of these costs at 21.3%, followed by Ontario at 19.9% and Manitoba at 19.8%.

The next highest component was over-the-counter (OTC) and controlled access drug (CAD) costs at $98.0 million or 17.0%. The regions of Manitoba (22.9%), Saskatchewan (22.3%) and Ontario (16.9%) had the largest proportions of these costs in 2021 to 2022.

Table 4.1: Total NIHB pharmacy expenditures by type and region ($ 000's)
Region	Operating				Total Operating Costs	Total Contribution Costs	Total Costs
Region	Prescription Drugs	OTC/CAD Drugs	Drugs Regional	Other Costs	Total Operating Costs	Total Contribution Costs	Total Costs
Atlantic	$33,197	$7,460	$0	$0	$40,657	$0	$40,657
Quebec	$48,352	$10,474	$0	$0	$58,827	$0	$58,827
Ontario	$90,167	$16,605	$0	$0	$106,772	$5,297	$112,069
Manitoba	$89,930	$22,422	$0	$0	$112,353	$0	$112,353
Saskatchewan	$96,744	$21,854	$1,359	$0	$119,957	$42	$120,000
Alberta	$65,568	$13,961	$0	$0	$79,529	$7,151	$86,680
North	$26,356	$4,716	$427	$0	$31,499	$0	$31,499
Headquarters	$0	$0	$0	$10,169	$10,169	$0	$10,169
Total	$453,767	$98,038	$1,787	$10,170	$563,761	$12,490	$576,251
Source: FST adapted by Business Support, Audit and Negotiations Division

Annual NIHB pharmacy expenditures

NIHB pharmacy expenditures increased by 4.6% during fiscal year 2021 to 2022. Over the past five years, growth in pharmacy expenditures has ranged from a high of 8.3% in 2019 to 2020 to a low of 1.0% in 2018 to 2019.

The five year annualized growth rate for NIHB pharmacy expenditures is 4.3%. The introduction of lower cost generic drugs as they become available on the market have kept pharmacy benefit growth moderate. As well, NIHB has negotiated Product Listing Agreements (PLA) with drug manufacturers to allow for the coverage of certain medications at a reduced price through the use of rebates. On March 31, 2022, NIHB had 272 PLA in effect.

**Chart 4.2: Annual NIHB pharmacy expenditures and percentage change**

Table 4.2: NIHB pharmacy expenditures ($ 000's) by region
Region	2017 to 2018	2018 to 2019	2019 to 2020	2020 to 2021	2021 to 2022
Atlantic	$29,741	$30,448	$35,365	$37,323	$40,657
Quebec	$46,227	$46,623	$50,747	$53,282	$58,827
Ontario	$93,635	$93,896	$97,437	$105,300	$112,069
Manitoba	$91,060	$92,084	$100,059	$106,851	$112,353
Saskatchewan	$109,900	$107,487	$115,074	$116,188	$120,000
Alberta	$71,083	$73,976	$83,526	$84,920	$86,680
North	$25,355	$27,042	$28,337	$29,479	$31,499
Headquarters	$15,696	$16,963	$21,354	$14,220	$10,169
Total	$467,094	$471,641	$510,691	$550,901	$576,251
Source: FST and FIRMS adapted by Business Support, Audit and Negotiations Division

Per capita NIHB pharmacy expenditures by region: 2021 to 2022

Expenditures per capita are total NIHB pharmacy expenditures divided by the number of eligible clients, regardless of whether clients submitted a claim in the reporting period.

In 2021 to 2022, the national per capita expenditure for NIHB Pharmacy benefits was $618. This was an increase of 3.5% from the $597 recorded in 2020 to 2021.

Saskatchewan had the highest per capita NIHB Pharmacy expenditures at $743, followed by Quebec at $738.

The Northern region had the lowest per capita expenditures at $433 followed by Ontario at $501. Relatively low per capita expenditures in the North are attributed to lower than average utilization rates and also a younger population utilizing lower cost medications.

**Chart 4.3 Per capita NIHB pharmacy expenditure by region**

NIHB pharmacy utilization rates by region

Utilization rates represent the number of clients who received at least one pharmacy benefit paid through the HICPS system in the fiscal year, as a proportion of the total number of eligible clients. In 2021 to 2022, the national utilization rate was 58% for NIHB Pharmacy benefits paid through the HICPS system.

The rates understate the actual level of utilization as the data do not include pharmacy services provided through contribution agreements and benefits provided through community health facilities. For example, the HICPS system does not capture any data on services used by the Bigstone Cree Nation client population in Alberta and the Akwesasne client population in Ontario. If these populations were removed, the utilization rate for pharmacy benefits in Alberta would have been 65.1% and for Ontario the utilization rate for pharmacy benefits would have been 51.8% in 2021 to 2022. If both the Bigstone and Akwesasne client populations were removed from the overall NIHB population, the national utilization rate for pharmacy benefits would have been 59.0%.

Table 4.3: NIHB pharmacy utilization rates by region
Region	Pharmacy utilization
Region	2017 to 2018	2018 to 2019	2019 to 2020	2020 to 2021	2021 to 2022
Atlantic	63%	67%	63%	60%	61%
Quebec	62%	61%	62%	58%	59%
Ontario	54%	49%	52%	48%	49%
Manitoba	69%	67%	68%	62%	65%
Saskatchewan	71%	69%	70%	63%	65%
Alberta	67%	65%	67%	60%	61%
Yukon	60%	60%	60%	58%	57%
N.W.T.	58%	55%	55%	54%	54%
Nunavut	49%	49%	49%	46%	46%
National	62%	60%	61%	57%	58%
Source: HICPS and SVS adapted by Business Support, Audit and Negotiations Division

NIHB pharmacy claimants by age group, gender and region: 2021 to 2022

Of the 915,895 clients eligible to receive benefits under the NIHB program, a total of 528,541 claimants received at least one pharmacy item paid through the Health Information and Claims Processing Services (HICPS) system in 2021 to 2022. Of this total, 302,298 were female (57%) and 226,243 were male (43%). This compares to the total eligible population where 51% were female and 49% were male.

The average age of pharmacy claimants was 38 years. The average age for female and male claimants was 38 and 37 years of age, respectively.

Table 4.4: NIHB pharmacy claimants by age group, gender and region

Region	Atlantic			Quebec			Ontario			Manitoba
Age group	Male	Female	Total	Male	Female	Total	Male	Female	Total	Male	Female	Total
0-4	568	497	1,065	616	608	1,224	723	632	1,355	1,721	1,629	3,350
5-9	887	944	1,831	1,155	1,209	2,364	1,648	1,704	3,352	3,809	3,968	7,777
10-14	1,004	1,079	2,083	1,248	1,355	2,603	2,129	2,269	4,398	3,953	4,365	8,318
15-19	1,120	1,658	2,778	1,248	1,804	3,052	2,601	3,891	6,492	3,769	5,071	8,840
20-24	1,101	1,891	2,992	1,205	2,034	3,239	2,843	4,913	7,756	3,664	5,474	9,138
25-29	1,319	2,149	3,468	1,394	2,346	3,740	3,707	6,008	9,715	3,918	5,886	9,804
30-34	1,297	1,867	3,164	1,326	2,192	3,518	3,897	5,653	9,550	3,898	5,591	9,489
35-39	1,219	1,668	2,887	1,281	1,947	3,228	3,558	4,856	8,414	3,308	4,432	7,740
40-44	1,148	1,564	2,712	1,294	1,694	2,988	3,412	4,652	8,064	3,023	3,794	6,817
45-49	1,233	1,657	2,890	1,281	1,742	3,023	3,453	4,467	7,920	3,019	3,729	6,748
50-54	1,500	1,763	3,263	1,485	1,822	3,307	3,759	4,736	8,495	3,149	3,852	7,001
55-59	1,481	1,806	3,287	1,531	2,028	3,559	4,056	5,068	9,124	2,936	3,508	6,444
60-64	1,296	1,672	2,968	1,524	1,982	3,506	3,606	4,671	8,277	2,412	2,894	5,306
65+	2,782	3,600	6,382	3,157	4,473	7,630	6,584	9,731	16,315	3,574	4,956	8,530
Total	17,955	23,815	41,770	19,745	27,236	46,981	45,976	63,251	109,227	46,153	59,149	105,302
Average age	41	41	41	41	42	41	43	43	43	35	35	35

Region	Saskatchewan			Alberta			North			Total
Age group	Male	Female	Total	Male	Female	Total	Male	Female	Total	Male	Female	Total
0-4	1,874	1,874	3,748	1,462	1,408	2,870	764	721	1,485	7,768	7,408	15,176
5-9	3,610	3,918	7,528	2,738	2,954	5,692	1,021	951	1,972	14,934	15,723	30,657
10-14	3,879	4,222	8,101	3,150	3,262	6,412	970	1,012	1,982	16,430	17,673	34,103
15-19	3,687	5,343	9,030	2,906	3,964	6,870	895	1,678	2,573	16,353	23,601	39,954
20-24	3,616	5,894	9,510	2,777	4,199	6,976	954	1,998	2,952	16,291	26,676	42,967
25-29	3,963	6,077	10,040	3,164	4,331	7,495	1,159	2,156	3,315	18,783	29,255	48,038
30-34	3,998	5,796	9,794	2,969	4,078	7,047	1,212	2,144	3,356	18,804	27,658	46,462
35-39	3,424	4,797	8,221	2,713	3,501	6,214	1,024	1,649	2,673	16,695	23,129	39,824
40-44	3,104	3,918	7,022	2,364	2,963	5,327	978	1,471	2,449	15,480	20,325	35,805
45-49	2,881	3,721	6,602	2,215	2,702	4,917	932	1,345	2,277	15,166	19,608	34,774
50-54	3,010	3,669	6,679	2,157	2,602	4,759	1,173	1,550	2,723	16,408	20,250	36,658
55-59	2,630	3,280	5,910	1,959	2,501	4,460	1,080	1,434	2,514	15,839	19,901	35,740
60-64	2,120	2,717	4,837	1,621	2,070	3,691	877	1,191	2,068	13,561	17,381	30,942
65+	3,244	4,567	7,811	2,486	3,732	6,218	1,754	2,371	4,125	23,731	33,710	57,441
Total	45,040	59,793	104,833	34,681	44,267	78,948	14,793	21,671	36,464	226,243	302,298	528,541
Average age	34	35	35	34	35	35	38	38	38	37	38	38
Source: HICPS and SVS adapted by Business Support, Audit and Negotiations Division

Distribution of eligible NIHB population, pharmacy expenditures and pharmacy incidence by age group: 2021 to 2022

In 2021 to 2022, 3.6% of all clients were in the 0 to 4 age group, but this group accounted for only 0.4% of all pharmacy claims made and only 0.6% of total pharmacy expenditures. In contrast, 9.9% of all eligible clients were in the 65+ age group, but accounted for 24.4% of all pharmacy claims submitted and 17.9% of total pharmacy expenditures.

During 2021 to 2022, the average claimant aged 65 or more submitted 91 claims compared to 70 claims for their counterpart in the 60 to 64 age group and 5 claims for the average claimant in the 0 to 4 age group.

**Chart 4.4: Distribution of eligible NIHB population, pharmacy expenditures and pharmacy incidence by age group**

Age	Eligible clients	Expenditures	Incidence
0-4	3.6%	0.6%	0.4%
5-9	7.7%	1.1%	0.7%
10-14	9.1%	2.0%	1.1%
15-19	8.7%	2.9%	1.8%
20-24	8.5%	3.9%	2.9%
25-29	8.9%	6.6%	5.6%
30-34	8.4%	8.1%	7.7%
35-39	7.1%	8.1%	8.1%
40-44	6.2%	8.3%	8.1%
45-49	5.8%	9.1%	8.6%
50-54	5.9%	10.3%	10.0%
55-59	5.6%	11.1%	10.7%
60-64	4.7%	10.1%	10.1%
65+	9.9%	17.9%	24.4%
Total	100.0%	100.0%	100.0%

An examination of pharmacy benefit cost per NIHB claimant indicates that these expenditures vary according to age. For example, in 2021 to 2022 the average cost per child aged 0 to 9 years was $213. The cost increased steadily for every age group, with claimants aged 35-39 having an average cost of $1,126, comparable to the total average claimant cost of $1,044. Claimants aged 60-64 years had the highest cost per claimant with an average of $1,804 for all pharmacy claims received throughout the fiscal year.

NIHB top ten therapeutic classes by number of claimants: 2021 to 2022

Table 4.5 ranks the top ten therapeutic classes according to number of claimants. In 2021 to 2022, Non-Steroidal Anti-Inflammatory Drugs (NSAID) had the highest number of distinct claimants at 179,640. Penicillins ranked second in number of claimants with 125,355 followed by Miscellaneous Analgesics and Antipyretics with 124,546 claimants.

Table 4.5: NIHB top ten therapeutic classes by number of claimants
Therapeutic Classification	Claimants	% Change from 2020-21	Examples of Product in the Therapeutic Class
Non-Steroidal Anti-Inflammatory Drugs (NSAID)	179,640	6.4%	Voltaren (Diclofenac)
Penicillins	125,355	9.9%	Amoxil (Amoxicillin)
Miscellaneous Analgesics and Antipyretics	124,546	8.6%	Tylenol (Acetaminophen)
Antidepressants	115,809	7.8%	Effexor (Venlafaxine)
Proton Pump Inhibitors	108,494	3.4%	Losec (Omeprazole)
Opioid Agonists	95,978	-0.2%	Statex (Morphine Sulphate)
HMG-COA Reductase Inhibitors (Statins)	78,313	5.5%	Lipitor (Atorvastatin)
Beta-Adrenergic Agonists	76,002	11.1%	Ventolin (Salbutamol)
Angiotensin-Converting Enzyme Inhibitors	70,001	2.1%	Altace (Ramipril)
Vitamins	68,655	6.4%	Vitamin D (Cholecalciferol)
Source: HICPS adapted by Business Support, Audit and Negotiations Division

NIHB OTC (including CAD) drug claims incidence by therapeutic class: 2021 to 2022

Table 4.6 looks at the number of claims by therapeutic classification for over-the-counter (OTC) drugs.

Vitamins accounted for the largest number of OTC drug claims in 2021 to 2022 at 1.4 million paid claims, or 32.2% of all OTC claims. Central nervous systems agents had the next highest share of OTC claims at 960,399 (22.2%) followed by gastrointestinal drugs at 340,960 claims (7.9%).

Table 4.6: NIHB OTC (including CAD) drug claims incidence by therapeutic class
Category	Claims	% Change from 2020-2021	Examples
Vitamins	1,395,495	5.1%	Vitamin D (Cholecalciferol)
Central Nervous System Agents	960,399	1.6%	Tylenol (Acetaminophen)
Gastrointestinal Drugs	340,960	6.8%	Senokot (Sennosides)
Blood Formation and Coagulation	318,465	6.3%	Iron (Ferrous Gluconate)
Diabetic Devices	287,573	1.0%	Lancets
Hormone & Synthetic Substitutes	222,518	-2.2%	Lantus (Insulin Glargine)
Skin & Mucous Membrane Agents	170,110	8.9%	Nix (Permethrin)
Diagnostic Agents	140,366	-6.5%	Blood Glucose Test Strips
Antihistamines	124,383	3.2%	Reactine (Cetirizine)
Autonomic Drugs	85,608	9.6%	Nicoderm (Nicotine)
Source: HICPS adapted by Business Support, Audit and Negotiations Division

Section 5: NIHB Medical Supplies and Equipment (MS&E) expenditure and utilization data

A range of medical supplies and equipment (MS&E) items are covered by the NIHB program. Items covered through the MS&E benefit are intended to address NIHB clients' medical needs in relation to basic activities of daily living (ADL) such as eating, bathing, dressing, toileting and transferring, and include:

Audiology supplies and equipment
Limb and body orthotics supplies and equipment
Footwear supplies and equipment
Oxygen supplies and equipment
Pressure devices supplies and equipment
Prosthetics supplies and equipment
Respiratory supplies and equipment
Self-care supplies and equipment
Low vision supplies and equipment
Mobility supplies and equipment
Communication supplies and equipment
Medical surgical supplies and equipment

MS&E benefits are evidence-based and covered in accordance with program policies. Most items must be approved in advance by the NIHB regional office before they are distributed by an NIHB provider.

Prior to the 2020 to 2021 NIHB Annual Report, expenditure and utilization data for the MS&E benefit were combined with pharmacy benefits in reporting.

In 2021 to 2022, the NIHB program paid for MS&E claims made by a total of 97,834 First Nations and Inuit clients. The total spent for these claims was $60.4 million or 3.6% of total NIHB expenditures.

Distribution of NIHB MS&E expenditures ($ Millions): 2021 to 2022

The NIHB MS&E benefit is comprised of multiple components. The cost of medical equipment paid through the HICPS system was the largest component, accounting for $40.9 million or 67.7% of all NIHB MS&E expenditures, followed by medical supplies paid through HICPS which totalled $17.7 million or 29.3%.

Contribution agreements, which accounted for $0.7 million or 1.2% of total MS&E benefit costs, are used to fund the provision of benefits through agreements such as those with the Mohawk Council of Akwesasne in Ontario and the Bigstone Cree Nation in Alberta.

Regional MS&E, which refers to MS&E items paid through Indigenous Services Canada regional offices, accounted for $0.7 million or 1.1%.

Other costs totalled $0.4 million or 0.7% of MS&E expenditures in 2021 to 2022. Included in this total are headquarters contract and claims processing expenditures related to the HICPS system.

**Chart 5.1: Distribution of NIHB MS&E expenditures ($ Millions)**

Total NIHB MS&E expenditures by type and region ($ 000's): 2021 to 2022

Medical equipment costs paid through the HICPS system represented the largest component of total NIHB MS&E costs accounting for $40.9 million or 67.7%. Manitoba had the largest proportion of these costs at 22.6%, followed by Saskatchewan at 21.9% and Alberta at 19.9%.

The next highest component was medical supplies costs at $17.7 million or 29.3%. Saskatchewan (24.6%), Manitoba (20.0%) and Alberta (19.6%) had the largest proportions of these costs in 2021 to 2022.

All other MS&E expenditures, including contribution agreement costs, account for only 3.0% of total MS&E expenditure.

Table 5.1: Total NIHB MS&E expenditures by type and region ($ 000's)
Region	Operating				Total Operating Costs	Total Contribution Costs	Total Costs
Region	MS&E Regional	Medical Supplies	Medical Equipment	Other Costs	Total Operating Costs	Total Contribution Costs	Total Costs
Atlantic	$7	$1,210	$3,291	$0	$4,508	$0	$4,508
Quebec	$0	$965	$1,890	$0	$2,855	$0	$2,855
Ontario	$28	$2,506	$5,621	$0	$8,155	$545	$8,701
Manitoba	$542	$3,544	$9,244	$0	$13,330	$0	$13,330
Saskatchewan	$22	$4,355	$8,975	$0	$13,352	$0	$13,352
Alberta	$25	$3,476	$8,157	$0	$11,658	$0	$11,658
North	$61	$1,665	$3,738	$0	$5,464	$183	$5,647
Headquarters	$0	$0	$0	$399	$399	$0	$399
Total	$685	$17,721	$40,915	$399	$59,721	$728	$60,449
Source: FST adapted by Business Support, Audit and Negotiations Division

Annual NIHB MS&E expenditures

NIHB MS&E expenditures increased by 17.3% during fiscal year 2021 to 2022. The coronavirus (COVID-19) outbreak and provincial/territorial public health restrictions on the provision of in-person services in fiscal year 2020 to 2021, along with larger than typical utilization of the benefit in fiscal 2021 to 2022 once restrictions were ended, impacted growth in the past two years. Over the past five years, growth in MS&E expenditures has ranged from a high of 17.3% in 2021 to 2022 to a low of -3.2% in 2020 to 2021.

The five year annualized growth rate for NIHB MS&E expenditures is 8.5%.

**Chart 5.2: Annual NIHB MS&E expenditures**

Table 5.2: Annual MS&E expenditures by region ($ 000's)
Region	2017 to 2018	2018 to 2019	2019 to 2020	2020 to 2021	2021 to 2022
Atlantic	$3,279	$3,900	$4,359	$4,177	$4,508
Quebec	$2,163	$2,345	$2,564	$2,379	$2,855
Ontario	$5,915	$6,662	$7,322	$7,297	$8,701
Manitoba	$6,985	$9,166	$11,966	$11,146	$13,330
Saskatchewan	$9,426	$10,762	$11,889	$11,908	$13,352
Alberta	$8,260	$9,127	$10,250	$9,647	$11,658
North	$4,018	$4,529	$4,884	$4,024	$5,647
Headquarters	$120	-$10	-$12	$592	$399
Total	$40,167	$46,481	$53,222	$51,525	$60,449
Source: FST adapted by Business Support, Audit and Negotiations Division

Per capita NIHB MS&E expenditures by region: 2021 to 2022

Expenditures per capita are total NIHB MS&E expenditures divided by the number of eligible clients, regardless of whether clients submitted a claim in the reporting period.

In 2021 to 2022, the national per capita expenditure for NIHB MS&E benefits was $66. This was an increase of 16.5% from the $56 recorded in 2020 to 2021.

Alberta had the highest per capita NIHB MS&E expenditures at $90, followed by Saskatchewan and Manitoba at $83 and $82.

Quebec had the lowest per capita MS&E expenditures at $36 followed by Ontario at $39. Relatively low per capita expenditures in Quebec and Ontaio are attributed to provincial programs which provide financial assistance for the provision of certain medical equipment items to all residents.

**Chart 5.3: Per capita NIHB MS&E expenditures by region**

NIHB MS&E utilization rates by region

Utilization rates are the number of clients who received at least one MS&E benefit paid through the HICPS system in the fiscal year, as a proportion of the total number of eligible clients.

In 2021 to 2022, the national utilization rate was 11% for NIHB MS&E benefits paid through the HICPS system.

The rates understate the actual level of utilization as the data do not include MS&E services provided through contribution agreements and benefits provided through community health facilities.

Table 5.3: NIHB MS&E utilization rates by region
Region	MS&E Utilization
Region	2017/18	2018/19	2019/20	2020/21	2021/22
Atlantic	7%	8%	10%	10%	12%
Quebec	5%	6%	7%	7%	9%
Ontario	4%	5%	5%	5%	7%
Manitoba	9%	10%	11%	12%	14%
Saskatchewan	7%	8%	10%	10%	13%
Alberta	6%	7%	8%	8%	10%
North	6%	5%	5%	8%	11%
National	6%	7%	8%	8%	11%
Source: HICPS and SVS adapted by Business Support, Audit and Negotiations Division

NIHB MS&E claimants by age group, gender and region: 2021 to 2022

Of the 915,895 clients eligible to receive benefits under the NIHB program, a total of 97,834 claimants, representing 10.7% of the NIHB client population, received at least one MS&E item paid through the Health Information and Claims Processing Services (HICPS) system in 2021 to 2022. Of this total, 55,791 were female (57%) and 42,043 were male (43%). This compares to the total eligible population where 51% were female and 49% were male.

The average age of MS&E claimants was 51 years. The average age for female and male claimants was 52 and 50 years of age, respectively.

Table 5.4: NIHB MS&E claimants by age group, gender and region

Region	Atlantic			Quebec			Ontario			Manitoba
Age Group	Male	Female	Total	Male	Female	Total	Male	Female	Total	Male	Female	Total
0-4	46	27	73	20	10	30	48	28	76	141	105	246
5-9	90	66	156	57	46	103	137	109	246	352	306	658
10-14	97	73	170	76	72	148	168	145	313	419	343	762
15-19	89	96	185	70	83	153	173	174	347	391	417	808
20-24	83	119	202	37	89	126	164	241	405	346	542	888
25-29	154	184	338	86	148	234	213	344	557	429	774	1,203
30-34	166	202	368	121	149	270	275	366	641	483	790	1,273
35-39	152	209	361	131	161	292	321	422	743	554	794	1,348
40-44	178	238	416	176	150	326	375	429	804	620	777	1,397
45-49	254	333	587	204	240	444	494	602	1,096	846	1,006	1,852
50-54	348	458	806	268	302	570	605	775	1,380	953	1,273	2,226
55-59	378	505	883	322	394	716	812	968	1,780	1,076	1,320	2,396
60-64	396	527	923	371	434	805	801	1,037	1,838	1,014	1,317	2,331
65+	1,304	1,686	2,990	1,145	1,676	2,821	2,623	3,556	6,179	2,346	3,301	5,647
Total	3,735	4,723	8,458	3,084	3,954	7,038	7,209	9,196	16,405	9,970	13,065	23,035
Average Age	53	55	54	55	57	56	55	56	56	48	50	49

Region	Saskatchewan			Alberta			North			TOTAL
Age Group	Male	Female	Total	Male	Female	Total	Male	Female	Total	Male	Female	Total
0-4	149	113	262	78	50	128	97	83	180	581	418	999
5-9	334	255	589	159	126	285	189	160	349	1,320	1,073	2,393
10-14	415	351	766	185	183	368	156	137	293	1,523	1,308	2,831
15-19	428	530	958	183	200	383	129	117	246	1,467	1,625	3,092
20-24	356	793	1,149	180	289	469	93	204	297	1,264	2,287	3,551
25-29	455	892	1,347	249	357	606	109	258	367	1,699	2,963	4,662
30-34	573	919	1,492	288	405	693	161	253	414	2,077	3,109	5,186
35-39	525	830	1,355	336	396	732	144	254	398	2,171	3,079	5,250
40-44	565	748	1,313	387	369	756	175	261	436	2,494	2,992	5,486
45-49	641	876	1,517	387	503	890	188	316	504	3,022	3,895	6,917
50-54	816	1,113	1,929	569	607	1,176	305	447	752	3,897	5,010	8,907
55-59	884	1,132	2,016	560	726	1,286	344	459	803	4,405	5,556	9,961
60-64	876	1,169	2,045	574	744	1,318	295	417	712	4,349	5,674	10,023
65+	1,985	2,934	4,919	1,334	2,179	3,513	1,000	1,365	2,365	11,774	16,802	28,576
Total	9,002	12,655	21,657	5,469	7,134	12,603	3,385	4,731	8,116	42,043	55,791	97,834
Average Age	47	48	47	49	52	51	49	50	49	50	52	51
Source: HICPS and SVS adapted by Business Support, Audit and Negotiations Division

Distribution of eligible NIHB population, MS&E expenditures and MS&E incidence by age group: 2021 to 2022

In 2021 to 2022, 3.6% of all clients were in the 0 to 4 age group, but this group accounted for only 1.2% of all MS&E claims made and only 1.6% of total MS&E expenditures. In contrast, 9.9% of all eligible clients were in the 65+ age group, but they accounted for 36.0% of all MS&E claims submitted and 35.2% of total MS&E expenditures.

The average MS&E claimant submitted 4 claims in 2021 to 2022, a rate that is relatively consistent over all age groups.

**Chart 5.4: Distribution of eligible NIHB population, MS&E expenditures and MS&E incidence by age group**

Age	Eligible Clients	Expenditures	Incidence
0-4	3.6%	1.6%	1.2%
5-9	7.7%	3.9%	3.2%
10-14	9.1%	3.1%	2.6%
15-19	8.7%	2.7%	2.5%
20-24	8.5%	2.4%	2.7%
25-29	8.9%	2.9%	3.4%
30-34	8.4%	3.5%	4.0%
35-39	7.1%	3.8%	4.2%
40-44	6.2%	4.5%	4.7%
45-49	5.8%	6.3%	6.2%
50-54	5.9%	8.6%	8.3%
55-59	5.6%	10.5%	10.3%
60-64	4.7%	11.0%	10.5%
65+	9.9%	35.2%	36.0%
Total	100.0%	100.0%	100.0%

NIHB medical supplies expenditures by category: 2021 to 2022

In 2021 to 2022, medical surgical supplies such as incontinence items accounted for 74.3% of all medical supply expenditures, a decrease from the 78.5% recorded in 2020 to 2021. Audiology supplies, such as hearing aid batteries, represented 5.2% of all medical supply expenditures, followed by self-care supplies such as enteral feeding bags at 4.8%.

**Chart 5.5: NIHB medical supplies expenditures by category**

NIHB medical equipment expenditures by category: 2021 to 2022

In 2021 to 2022, mobility equipment such as wheelchairs accounted for 21.7% of all medical equipment expenditures, an increase from the 20.9% recorded in 2020 to 2021. Audiology equipment, such as hearing aids, represented 21.3% of all medical equipment expenditures, followed by respiratory equipment such as CPAP machines at 11.6%.

**Chart 5.6: NIHB medical supplies expenditures by category**

Section 6: NIHB dental expenditure and utilization data

The NIHB program covers a broad range of dental services including:

diagnostic services such as examinations and radiographs
preventive services such as scaling, polishing, fluorides and sealants
restorative services such as fillings and crowns
endodontic services such as root canal treatments
periodontal services such as deep scaling
removable prosthodontic services such as partial or complete dentures
oral surgery services such as extractions
orthodontic services such as braces
adjunctive services such as general anesthesia and sedation.

In 2021 to 2022, a total of 314,110 First Nations and Inuit clients accessed dental benefits through the NIHB program, based on claims paid through the HICPS system. The total expenditure for dental benefits was $302.2 million or 17.8% of total NIHB expenditures. The dental benefit accounts for the third largest program expenditure.

Some dental services require predetermination prior to the initiation of treatment. Predetermination is a review that determines if the proposed dental service is covered under the program's guidelines and criteria, as described in the NIHB Dental Benefits Guide. This review is undertaken by the Dental Predetermination Centre (DPC).

Distribution of NIHB dental expenditures ($ millions): 2021 to 2022

NIHB dental expenditures are comprised of multiple distinct components. Fee-for-service dental costs paid through the HICPS system represented the largest expenditure portion, accounting for $275.2 million or 91.1% of all NIHB dental costs.

The next highest component was contribution agreements, which accounted for $15.1 million or 5.0% of total dental expenditures. Contribution agreements are used to fund the provision of dental benefits through agreements such as those with the Mohawk Council of Akwesasne in Ontario and the Bigstone Cree Nation in Alberta.

Expenditures for contract dentists providing services to clients in remote communities totalled $8.7 million or 2.9% of total costs.

Other costs totalled $3.1 million or 1.0% in 2021 to 2022. The majority of these costs are related to benefit claims processing through the HICPS system.

**Chart 6.1: Distribution of NIHB dental expenditures ($ millions)**

Total NIHB dental expenditures by type and region ($ 000's): 2021 to 2022

Of the $302.2 million in NIHB dental expenditures in 2021 to 2022, Saskatchewan (21.0%), Ontario (19.6%), Alberta (19.5%) and Manitoba (19.0%) had the largest overall proportion. Saskatchewan had the highest total dental expenditures at $63.4 million and the Atlantic region had the lowest total dental expenditures at $11.8 million.

Table 6.1: Total NIHB dental expenditures by type and region ($ 000's)
Region	Operating			Total operating costs	Total contribution costs	Total costs
Region	Fee-for-service	Contract dentists	Other costs	Total operating costs	Total contribution costs	Total costs
Atlantic	$11,801	$0	$0	$11,801	$0	$11,801
Quebec	$19,092	$0	$0	$19,092	$0	$19,092
Ontario	$50,265	$2,133	$0	$52,398	$6,927	$59,326
Manitoba	$50,380	$6,163	$0	$56,544	$837	$57,381
Saskatchewan	$59,132	$0	$0	$59,132	$4,275	$63,408
Alberta	$55,906	$37	$0	$55,942	$2,848	$58,790
North	$26,221	$358	$0	$26,578	$251	$26,830
Headquarters	$0	$0	$3,108	$3,108	$0	$3,108
Total	$275,246	$8,691	$3,108	$287,045	$15,138	$302,183
Source: FST adapted by Business Support, Audit and Negotiations Division

Annual NIHB dental expenditures

NIHB dental expenditures increased by 27.9% during fiscal year 2021 to 2022. The coronavirus (COVID-19) outbreak and provincial/territorial public health restrictions on the provision of in-person services in fiscal year 2020 to 2021, along with larger than typical utilization of the benefit in fiscal 2021 to 2022 once restrictions were ended, significantly impacted growth in the past two years.

Over the last five years, annual growth rates for NIHB dental expenditures have ranged from a high of 27.9% in 2021 to 2022 to a low of negative 16.5% in 2020 to 2021.

**Chart 6.2: NIHB Dental expenditures and annual percentage change**

NIHB dental expenditures by region

Table 6.2: NIHB dental expenditures by region ($ 000's)
Region	2017 to 2018	2018 to 2019	2019 to 2020	2020 to 2021	2021 to 2022
Atlantic	$10,610	$10,841	$11,545	$9,455	$11,801
Quebec	$17,961	$17,882	$18,733	$14,934	$19,092
Ontario	$52,101	$53,667	$55,386	$49,251	$59,326
Manitoba	$41,949	$48,099	$52,622	$49,414	$57,381
Saskatchewan	$50,635	$55,603	$57,639	$47,507	$63,408
Alberta	$47,637	$51,617	$54,993	$47,799	$58,790
North	$25,141	$26,211	$26,546	$20,703	$26,830
Headquarters	$2,770	$3,423	$5,361	$3,070	$3,108
Total	$249,038	$269,008	$282,908	$236,293	$302,183
Source: FST and FIRMS adapted by Business Support, Audit and Negotiations Division

Per capita NIHB dental expenditures by region: 2021 to 2022

Expenditures per capita are total NIHB dental expenditures divided by the number of eligible clients, regardless of whether clients submitted a claim in the reporting period.

In 2021 to 2022, national per capita NIHB dental expenditures were $327, an increase of 25.8% from $259 in 2020 to 2021.

Alberta had the highest per capita dental expenditures at $453, followed by Saskatchewan at $393 and the Northern region at $369. The Atlantic region had the lowest per capita dental expenditures at $173 per eligible client.

Per capita values reflect NIHB dental expenditures only, and do not include additional dental services that may be provided to First Nations and Inuit populations through other Indigenous Services Canada programs or through transfers and other arrangements.

**Chart 6.3: Per capita NIHB dental expenditures by region**

NIHB dental utilization rates by region

Utilization rates reflect the number of clients who, during the fiscal year, received at least one dental service paid through the HICPS system as a proportion of the total number of eligible clients.

In 2021 to 2022, the national utilization rate for dental benefits paid through the HICPS system was 34%. National NIHB dental utilization rates in 2020 to 2021 were impacted by provincial/territorial public health restrictions on the provision of in-person services due to the coronavirus (COVID-19) outbreak.

Dental utilization rates vary across the regions with the highest dental utilization rates found in Alberta and Quebec at 40% and 38% respectively. The lowest dental utilization rate was in Ontario (30%). Please note that the dental utilization rates understate the actual level of access, as these data do not include contract dental services provided in some regions or dental services provided through contribution agreements. For example, HICPS data does not capture any services utilized by the Bigstone Cree Nation. If this client population was removed from the Alberta Region's population, the utilization rate for dental benefits for Alberta would have been 43% in 2021 to 2022. The same scenario would apply for the Ontario Region. If the Akwesasne client population in Ontario were to be removed, the utilization rate for dental benefits in Ontario would have been 32%. The utilization rate also does not reflect services received through Indigenous Services Canada programs such as Community Oral Health Services which include dental therapy services and the Children's Oral Health Initiative (COHI).

Over the two year period between 2020 to 2021 and 2021 to 2022, 412,876 distinct clients received NIHB dental services through HICPS, resulting in an overall 45% utilization rate over this period.

Table 6.3: NIHB dental utilization rates by region.
Region	Dental utilization					NIHB dental utilization last two years 2020 to 2022
Region	2017-2018	2018-2019	2019-2020	2020-2021	2021-2022	NIHB dental utilization last two years 2020 to 2022
Atlantic	34%	37%	36%	30%	35%	43%
Quebec	44%	43%	42%	34%	38%	48%
Ontario	32%	32%	32%	26%	30%	37%
Manitoba	33%	39%	37%	27%	32%	43%
Saskatchewan	38%	39%	38%	32%	37%	49%
Alberta	40%	42%	42%	36%	40%	52%
Yukon	36%	37%	35%	29%	32%	44%
N.W.T.	41%	41%	39%	32%	36%	47%
Nunavut	38%	40%	38%	27%	32%	44%
National	36%	37%	37%	30%	34%	45%
Source: HICPS and SVS adapted by Business Support, Audit and Negotiations Division

NIHB dental claimants by age group, gender and region: 2021 to 2022

Of the 915,895 clients eligible to receive dental benefits through the NIHB program, 314,110 claimants (34%) received at least one dental procedure paid through the HICPS system in 2021 to 2022.

Of this total, 177,607 were female (57%) and 136,503 were male (43%), compared to the total eligible NIHB population where 51% were female and 49% were male.

The average age of dental claimants was 33 years, indicating clients tend to access dental services at a slightly younger age compared to pharmacy services (38 years of age). The average age for female and male claimants was 34 and 32 years of age respectively.

Approximately 33% of all dental claimants were under 20 years of age. 36% of male claimants were in this age group compared to 30% of female claimants. Approximately 7% of all claimants were seniors aged 65 and over in 2021 to 2022.

Table 6.4: NIHB dental claimants by age group, gender and region.

Region	Atlantic			Quebec			Ontario			Manitoba
Age group	Male	Female	Total	Male	Female	Total	Male	Female	Total	Male	Female	Total
0-4	97	135	232	209	222	431	618	570	1,188	796	782	1,578
5-9	497	573	1,070	1,198	1,167	2,365	2,604	2,632	5,236	2,627	2,710	5,337
10-14	756	837	1,593	1,501	1,523	3,024	3,087	3,246	6,333	2,912	3,167	6,079
15-19	1,068	1,158	2,226	1,138	1,256	2,394	2,888	3,069	5,957	2,564	3,211	5,775
20-24	827	1,077	1,904	940	1,228	2,168	2,330	2,989	5,319	1,963	2,621	4,584
25-29	910	1,275	2,185	1,101	1,505	2,606	2,389	3,408	5,797	2,031	2,851	4,882
30-34	795	1,106	1,901	963	1,319	2,282	2,153	3,046	5,199	1,799	2,602	4,401
35-39	741	981	1,722	863	1,196	2,059	1,852	2,591	4,443	1,410	2,031	3,441
40-44	654	878	1,532	838	1,080	1,918	1,643	2,397	4,040	1,257	1,711	2,968
45-49	699	936	1,635	778	1,115	1,893	1,665	2,299	3,964	1,220	1,715	2,935
50-54	781	1,016	1,797	894	1,102	1,996	1,745	2,404	4,149	1,254	1,684	2,938
55-59	740	1,031	1,771	895	1,218	2,113	1,840	2,619	4,459	1,154	1,554	2,708
60-64	653	923	1,576	822	1,082	1,904	1,599	2,477	4,076	892	1,185	2,077
65+	1,195	1,656	2,851	1,359	2,042	3,401	2,786	4,710	7,496	1,099	1,684	2,783
Total	10,413	13,582	23,995	13,499	17,055	30,554	29,199	38,457	67,656	22,978	29,508	52,486
Average age	39	40	39	36	38	37	35	38	37	30	32	31

Region	Saskatchewan			Alberta			North			TOTAL
Age group	Male	Female	Total	Male	Female	Total	Male	Female	Total	Male	Female	Total
0-4	1,055	1,072	2,127	971	958	1,929	658	627	1,285	4,427	4,401	8,828
5-9	2,948	3,215	6,163	2,912	3,134	6,046	1,061	1,126	2,187	13,964	14,690	28,654
10-14	3,489	3,810	7,299	3,491	3,640	7,131	1,085	1,332	2,417	16,472	17,713	34,185
15-19	2,875	3,563	6,438	2,765	3,190	5,955	1,062	1,398	2,460	14,484	16,997	31,481
20-24	2,196	3,246	5,442	1,855	2,446	4,301	924	1,359	2,283	11,142	15,121	26,263
25-29	2,153	3,312	5,465	1,796	2,560	4,356	942	1,409	2,351	11,440	16,486	27,926
30-34	2,048	3,183	5,231	1,688	2,400	4,088	854	1,334	2,188	10,423	15,176	25,599
35-39	1,752	2,482	4,234	1,451	2,039	3,490	701	1,003	1,704	8,879	12,481	21,360
40-44	1,478	1,938	3,416	1,234	1,729	2,963	587	837	1,424	7,776	10,714	18,490
45-49	1,390	1,918	3,308	1,054	1,554	2,608	510	737	1,247	7,398	10,414	17,812
50-54	1,383	1,896	3,279	1,081	1,449	2,530	592	808	1,400	7,838	10,481	18,319
55-59	1,166	1,616	2,782	955	1,353	2,308	496	668	1,164	7,337	10,212	17,549
60-64	886	1,205	2,091	721	1,089	1,810	363	499	862	5,987	8,551	14,538
65+	1,011	1,604	2,615	901	1,494	2,395	518	841	1,359	8,936	14,170	23,106
Total	25,830	34,060	59,890	22,875	29,035	51,910	10,353	13,978	24,331	136,503	177,607	314,110
Average age	29	31	30	28	31	29	30	32	31	32	34	33
Source: HICPS adapted by Business Support, Audit and Negotiations Division

NIHB fee-for-service dental expenditures by service category: 2021 to 2022

In 2021 to 2022, expenditures for restorative services (crowns, fillings, etc.) were the highest of all dental service categories at $124.4 million. Diagnostic services (examinations, radiographs, etc.) at $32.8 million and preventive services (scaling, sealants, etc.) at $30.5 million were the next highest service categories. Rounding out the top 5 were oral surgery (extractions, etc.) at $28.5 million and endodontic services (root canal treatments, etc.) at $20.4 million.

Table 6.5: Fee-for-service top 5 dental service categories ($ Millions) and percentage change
Dental Sub-Benefit	2020-2021	2021-2022	% Change from 2020-2021
Restorative Services	$92.0	$124.4	35.2%
Diagnostic Services	$26.9	$32.8	21.8%
Preventive Services	$23.6	$30.5	29.3%
Oral Surgery	$22.0	$28.5	29.6%
Endodontic Services	$17.2	$20.4	18.5%
Source: HICPS adapted by Business Support, Audit and Negotiations Division

In 2021 to 2022, the three highest dental procedures by expenditure were composite restorations ($106.3 million), scaling ($22.8 million) and extractions ($20.2 million).

Table 6.6: Fee-for-service top 5 dental procedures ($ Millions) and percentage change
Dental Procedure	2020-2021	2021-2022	% Change from 2020-2021
Composite Restorations	$79.4	$106.3	33.9%
Scaling	$17.9	$22.8	27.0%
Extractions	$15.9	$20.2	26.8%
Root Canal Therapy	$15.7	$18.5	17.7%
Intraoral Radiographs	$10.0	$12.3	22.1%
Source: HICPS adapted by Business Support, Audit and Negotiations Division

Distribution of eligible NIHB population, dental expenditures and incidence by age group: 2021 to 2022

The ratio of incidence to expenditures is relatively consistent across most age groupings; however, there are notable exceptions. For children aged 5 to 14, a larger number of low-cost procedures, such as fillings, are provided, so this group accounts for 25.0% of claims, but only 19.3% of expenditures.

**Chart 6.4: Distribution of eligible NIHB population, dental expenditures and incidence by age group**

Age	Eligible Clients	Expenditures	Incidence
0-4	3.6%	3.4%	3.6%
5-9	7.7%	6.9%	9.8%
10-14	9.1%	9.0%	11.6%
15-19	8.7%	11.5%	10.9%
20-24	8.5%	9.7%	8.8%
25-29	8.9%	9.7%	9.1%
30-34	8.4%	8.7%	8.2%
35-39	7.1%	6.9%	6.6%
40-44	6.2%	5.8%	5.6%
45-49	5.8%	5.7%	5.4%
50-54	5.9%	5.9%	5.5%
55-59	5.6%	5.5%	5.0%
60-64	4.7%	4.4%	4.1%
65+	9.9%	6.9%	6.0%
Total	100.0%	100.0%	100.0%

Section 7: NIHB Medical transportation expenditures and utilization data

In 2021 to 2022, Non-Insured Health Benefits Medical Transportation expenditures were $602.2 million or 35.5% of total NIHB expenditures. The medical transportation benefit is the largest program expenditure.

NIHB medical transportation benefits are intended to assist eligible clients to access medically necessary health services that are not available on reserve or in their community of residence.

Medical transportation benefits are managed by Indigenous Services Canada regional offices, or by First Nations or Inuit Health Authorities, organizations or territorial governments who manage the benefit through contribution agreements.

Medical transportation benefits include:

ground travel (private vehicle, commercial taxi, fee-for-service driver and vehicle, band vehicle, bus, train, snowmobile taxi, and ground ambulance)
air travel (scheduled flights; chartered flights; helicopter; and air ambulance)
water travel (motorized boat; boat taxi; and ferry)
living expenses (meals and accommodations)
transportation costs for health professionals to provide services to isolated communities

Medical transportation benefits may be provided for clients to access the following types of medically required health services:

medical services insured by provincial/territorial health plans (e.g., appointments with physician, diagnostic tests, hospital care)
alcohol, solvent, drug abuse and detox treatments
traditional healers
eligible benefits and services covered by the NIHB program

Medical transportation benefits may also be provided for a medical escort, such as a nurse, or a non-medical escort, such as family member or caregiver, to travel with a client who needs assistance. As of 2017, NIHB provides coverage for a non-medical escort for all pregnant women who require transportation outside their community to deliver their babies.

In addition to client travel, medical transportation expenditures also include costs associated with transporting health care professionals to under-serviced and/or remote and isolated communities to facilitate access to medically necessary services.

Distribution of NIHB medical transportation expenditures ($ Millions): 2021 to 2022

In 2021 to 2022, NIHB medical transportation expenditures totalled $602.2 million.

Contribution agreements for the management of medical transportation benefits by First Nations bands, territorial governments and other organizations represented the largest component, accounting for $284.7 million, or 47.3% of total benefit expenditures.

Of benefits managed by the NIHB program, living expenses at $84.5 million (14.0%), air ambulance at $73.3 million (12.2%) and scheduled flights at $66.8 million (11.1%) were the largest expenditures, accounting for a combined total of over 37%.

Rounding out medical transportation expenditures are costs for land ambulance at $54.0 million (9.0%), land and water transportation at $25.8 million (4.3%) and chartered flights at $13.2 million (2.2%).

**Chart 7.1: Distribution of NIHB medical transportation expenditures ($ Millions)**

Annual NIHB medical transportation expenditures

NIHB medical transportation expenditures increased by 14.6% in 2021 to 2022 compared to the previous year. The coronavirus (COVID-19) outbreak and provincial/territorial public health restrictions on the provision of in-person services in fiscal year 2020 to 2021, along with larger than typical utilization of the medical transportation benefit in fiscal 2021 to 2022 once restrictions were ended, impacted growth in the past two years. Over the past five years, overall medical transportation costs have grown by 31.1% from $459.5 million in 2017 to 2018 to $602.2 million in 2021 to 2022.

On a regional basis, the highest 5 year growth rate was in Saskatchewan where expenditures grew by 60.3% from $64.4 million in 2017 to 2018 to $103.2 million in 2021 to 2022. This was followed by the Atlantic region with an increase of 41.5% from $11.1 million in 2017 to 2018 to $15.8 million in 2021 to 2022.

Manitoba had the highest total medical transportation expenditures at $184.2 million in 2021 to 2022, followed by Ontario at $114.8 million and Saskatchewan at $103.2 million.

Table 7.1: NIHB Medical transportation expenditures by region ($ 000's)
Region	2017 to 2018	2018 to 2019	2019 to 2020	2020 to 2021	2021 to 2022
Atlantic	$11,147	$11,820	$13,910	$13,263	$15,776
Quebec	$23,918	$24,642	$25,729	$25,379	$26,775
Ontario	$86,091	$98,605	$106,638	$90,646	$114,814
Manitoba	$155,370	$156,961	$168,686	$155,790	$184,200
Saskatchewan	$64,363	$75,330	$83,947	$84,951	$103,152
Alberta	$51,187	$56,870	$61,669	$59,492	$67,206
North	$67,413	$70,806	$76,601	$96,194	$90,286
Total	$459,489	$495,034	$537,179	$525,715	$602,208
Source: FST and FIRMS adapted by Business Support, Audit and Negotiations Division

NIHB medical transportation expenditures by type and region ($ 000's): 2021 to 2022

In 2021 to 2022 Manitoba had the highest overall NIHB medical transportation expenditures at $184.2 million, primarily as a result of air transportation, which totalled $100.5 million. High medical transportation costs in the region reflect in part the large number of First Nations clients living in remote or fly-in only northern communities.

Ontario had the second highest medical transportation expenditures total in 2021 to 2022 at $114.8 million. Saskatchewan and the Northern region followed at $103.2 million and $90.3 million, respectively.

Table 7.2: NIHB medical transportation expenditures by type and region ($ 000's)
Type	Atlantic	Quebec	Ontario	Manitoba	Saskatchewan	Alberta	North	Total
Scheduled Flights	$2,365	$188	$21,346	$32,938	$7,657	$949	$1,332	$66,775
Air Ambulance	$31	$57	$41	$58,387	$9,193	$3,525	$2,104	$73,339
Chartered Flights	$1	$0	$294	$9,174	$1,285	$2,421	$0	$13,175
Land Ambulance	$440	$210	$1,021	$8,329	$29,947	$14,041	$1	$53,989
Land & Water	$952	$85	$3,254	$3,248	$15,542	$1,754	$927	$25,762
Living Expenses	$1,804	$41	$37,968	$25,639	$11,167	$6,127	$1,727	$84,473
Total Operating	$5,592	$581	$63,924	$137,716	$74,791	$28,817	$6,092	$317,513
Total Contributions	$10,184	$26,194	$50,890	$46,484	$28,361	$38,389	$84,194	$284,696
Total	$15,776	$26,775	$114,814	$184,200	$103,152	$67,206	$90,286	$602,208
% Change from 2020-2021	18.9%	5.5%	26.7%	18.2%	21.4%	13.0%	-6.1%	14.6%
Source: FST and FIRMS adapted by Business Support, Audit and Negotiations Division

NIHB medical transportation operating expenditures by type ($ Millions): 2021 to 2022

In 2021 to 2022, living expenses, which include accommodations and meals, represented the largest portion of NIHB's medical transportation operating expenditures at $84.5 million or 26.6% of the total national operating expenditures. Air ambulance was the second highest at $73.3 million, or 23.1% of operating expenditures. Scheduled air followed at $66.8 million or 21.0%, and land ambulance made up $54.0 million or 17.0% of medical transportation operating costs.

Private vehicle expenditures ($4.2 million) are the costs reimbursed when a private vehicle used by a client to access eligible health services, based on a per kilometer allowance.

**Chart 7.3: NIHB medical transportation operating expenditures by type ($ Millions)**

Per capita NIHB medical transportation expenditures by region: 2021 to 2022

Expenditures per capita are total NIHB medical transportation expenditures divided by the number of eligible clients, regardless of whether clients submitted a claim in the reporting period.

In 2021 to 2022, the national per capita expenditure for NIHB medical transportation benefits was $658, an increase of 9.2% from the $602 recorded in 2020 to 2021.

The Northern region had the highest per capita expenditure in medical transportation at $1,240, followed by Manitoba at $1,133. These expenditures reflect the large number of First Nations and Inuit clients living in remote or fly-in communities that need to urban centres to access health services.

In contrast, the Atlantic region had the lowest per capita expenditure at $231. Compared to other regions, this lower per capita cost is reflective of the geography of the region, which allows easier access to health services with less need for air travel.

**Chart 7.4: Per capita NIHB medical transportation expenditures by region**

Section 8: NIHB vision care benefits

The NIHB program provides coverage for vision care benefits as set out in the NIHB Guide to Vision Care Benefits, including:

eye examinations when they are not insured by the province or territory
corrective eyewear (glasses, contact lenses) when prescribed by a vision care professional
eyeglass repairs

Some items such as ocular prosthesis and low vision aids are covered by NIHB as medical supplies and equipment benefits.

In 2021 to 2022, a total of 156,680 First Nations and Inuit clients accessed vision care benefits through the NIHB program, based on claims paid through the HICPS system. The total expenditure for vision care benefits was $47.8 million or 2.8% of total NIHB expenditures.

Distribution of NIHB vision care expenditures ($ millions): 2021 to 2022

NIHB vision care expenditures are comprised of several distinct components. Fee-for-service vision care costs paid through HICPS system represented the largest expenditure portion, accounting for $43.6 million or 91.2% of all NIHB vision care costs.

The next highest component was contribution agreements, which accounted for $4.2 million or 8.7% of total vision care costs. Contribution agreements are used to fund First Nations or Inuit communities and organizations and/or Territorial Governments directly for the provision of vision care benefits.

Regional vision care, at $35,300 or 0.1% of vision care benefit costs, refers to vision care claims paid through Indigenous Services Canada regional offices.

**Chart 8.1: Distribution of NIHB vision care expenditures ($ Millions)**

NIHB vision care expenditures and growth by region ($ 000's): 2021 to 2022

NIHB vision care expenditures totalled $47.8 million in 2021 to 2022, an increase of 20.8% from the previous year.

Saskatchewan had the highest vision care costs at $10.6 million, or 22.1% of total vision care expenditure, followed by Alberta at $9.4 million (19.7%) and Ontario at $8.1 million (17.0%). Headquarters expenditures are costs related to claims processing through the HICPS system.

Table 8.1: NIHB vision care expenditures and growth by region ($ 000's)
Region	Operating		Total Operating Costs	Contributions	Total costs
Region	Fee-for-service	Regional	Total Operating Costs	Contributions	Total costs
Atlantic	$4,158	$0.4	$4,158	$0	$4,158
Quebec	$3,938	$0.5	$3,939	$0	$3,939
Ontario	$7,507	$0.6	$7,507	$606	$8,113
Manitoba	$6,818	$0.0	$6,818	$516	$7,334
Saskatchewan	$10,581	$0.0	$10,581	$0	$10,581
Alberta	$8,038	$0.0	$8,038	$1,367	$9,405
North	$2,384	$34.3	$2,418	$1,663	$4,081
Headquarters	$210	$0.0	$210	$0	$210
Total	$43,633	$35.8	$43,669	$4,151	$47,819
Source: FST adapted by Business Support, Audit and Negotiations Division

Annual NIHB vision care expenditures and percentage change

NIHB vision care expenditures increased by 20.8% during fiscal year 2021 to 2022. Expenditures in 2020 to 2021 were artificially low due in large part to the impact of the coronavirus (COVID-19) outbreak and provincial/territorial public health restrictions on the provision of in-person services. Over the past five years, growth in vision care expenditures has ranged from a high of 26.1% in 2019 to 2020 to a low of -13.9% in 2020 to 2021.

The five year annualized growth rate for NIHB vision care expenditures is 7.3%.

**Chart 8.2: Annual NIHB vision care expenditures**

On a regional basis, the highest growth rate over this five year period was in Quebec where expenditures grew by 116.5% from $1.8 million in 2017 to 2018 to $3.9 million in 2021 to 2022. Saskatchewan had largest net increase in expenditures over this period, where costs grew by $4.5 million.

Table 8.2: NIHB vision care expenditures ($ 000's) by region
Region	2017 to 2018	2018 to 2019	2019 to 2020	2020 to 2021	2021 to 2022
Atlantic	$3,632	$3,885	$4,150	$3,436	$4,158
Quebec	$1,819	$1,908	$2,736	$2,814	$3,938
Ontario	$6,848	$6,744	$7,860	$7,346	$8,113
Manitoba	$4,479	$4,699	$6,935	$6,042	$7,334
Saskatchewan	$6,905	$7,822	$9,844	$8,493	$10,581
Alberta	$6,764	$7,696	$10,514	$8,030	$9,405
North	$3,131	$3,713	$3,929	$3,206	$4,081
Total	$33,578	$36,467	$45,968	$39,594	$47,819
Source: FST adapted by Business Support, Audit and Negotiations Division

Per capita NIHB vision care expenditures by region: 2021 to 2022

Expenditures per capita are total NIHB vision care expenditures divided by the number of eligible clients, regardless of whether clients submitted a claim in the reporting period.

In 2021 to 2022, the national per capita expenditure in NIHB vision care benefits was $52.

Alberta had the highest per capita expenditure at $73, followed by Saskatchewan at $66 and the Atlantic region at $61. The lowest per capita NIHB vision care benefit expenditure was in Ontario at $36.

**Chart 8.3: Per capita NIHB vision care expenditures by region**

NIHB vision care claimants by age group, gender and region: 2021 to 2022

Of the 915,895 clients eligible to receive benefits under the NIHB program, a total of 156,680 claimants, representing 17.4% of the NIHB client population, had at least one vision care claim paid through the Health Information and Claims Processing Services (HICPS) system in 2021 to 2022. Of this total, 95,158 were female (60.7%) and 61,522 were male (39.3%). This compares to the total eligible population where 51% were female and 49% were male.

The average age of vision care claimants was 37 years. The average age for female and male claimants was 37 and 36 years of age, respectively.

Table 8.3: NIHB vision care claimants by age group, gender and region

Region	Atlantic			Quebec			Ontario			Manitoba
Age Group	Female	Male	Total	Female	Male	Total	Female	Male	Total	Female	Male	Total
0-4	81	58	139	23	15	38	42	33	75	49	32	81
5-9	448	369	817	315	242	557	570	483	1,053	738	715	1,453
10-14	762	596	1,358	565	426	991	1,124	882	2,006	1,523	1,242	2,765
15-19	745	535	1,280	630	413	1,043	1,296	922	2,218	1,699	1,135	2,834
20-24	708	422	1,130	592	356	948	1,446	863	2,309	1,277	830	2,107
25-29	736	405	1,141	688	360	1,048	1,644	876	2,520	1,411	743	2,154
30-34	621	411	1,032	645	314	959	1,451	800	2,251	1,315	708	2,023
35-39	563	318	881	588	302	890	1,241	752	1,993	1,006	576	1,582
40-44	509	358	867	525	324	849	1,273	769	2,042	939	554	1,493
45-49	608	410	1,018	674	344	1,018	1,372	843	2,215	967	652	1,619
50-54	659	471	1,130	618	419	1,037	1,441	883	2,324	1,019	588	1,607
55-59	707	478	1,185	683	414	1,097	1,543	893	2,436	970	642	1,612
60-64	663	450	1,113	681	411	1,092	1,422	836	2,258	794	530	1,324
65+	1,326	943	2,269	995	653	1,648	2,120	1,300	3,420	1,168	683	1,851
Total	9,136	6,224	15,360	8,222	4,993	13,215	17,985	11,135	29,120	14,875	9,630	24,505
Average Age	40	40	40	41	41	41	41	40	41	36	34	35

Region	Saskatchewan			Alberta			North			TOTAL
Age Group	Female	Male	Total	Female	Male	Total	Female	Male	Total	Female	Male	Total
0-4	135	84	219	96	85	181	13	17	30	440	325	765
5-9	1,287	1,032	2,319	947	840	1,787	124	129	253	4,444	3,822	8,266
10-14	2,332	1,842	4,174	1,750	1,416	3,166	321	242	563	8,417	6,673	15,090
15-19	2,525	1,774	4,299	1,722	1,259	2,981	390	270	660	9,054	6,330	15,384
20-24	2,292	1,360	3,652	1,520	994	2,514	395	210	605	8,285	5,062	13,347
25-29	2,288	1,295	3,583	1,607	1,038	2,645	425	209	634	8,855	4,955	13,810
30-34	2,144	1,277	3,421	1,510	913	2,423	415	226	641	8,167	4,680	12,847
35-39	1,696	923	2,619	1,228	782	2,010	340	179	519	6,723	3,862	10,585
40-44	1,479	959	2,438	1,107	706	1,813	326	155	481	6,205	3,857	10,062
45-49	1,479	944	2,423	1,056	670	1,726	347	192	539	6,565	4,085	10,650
50-54	1,393	964	2,357	977	699	1,676	389	269	658	6,562	4,332	10,894
55-59	1,309	875	2,184	947	599	1,546	396	260	656	6,608	4,189	10,797
60-64	1,108	674	1,782	776	505	1,281	332	238	570	5,808	3,669	9,477
65+	1,694	1,031	2,725	1,009	642	1,651	655	404	1,059	9,025	5,681	14,706
Total	23,161	15,034	38,195	16,252	11,148	27,400	4,868	3,000	7,868	95,158	61,522	156,680
Average Age	35	34	34	34	33	34	41	41	41	37	36	37
Source: HICPS and SVS adapted by Business Support, Audit and Negotiations Division

NIHB vision care expenditures by category: 2021 to 2022

In 2021 to 2022, new eyewear, such as eyeglasses, accounted for $37.1 million or 85.7% of all HICPS vision care expenditures. Eye exams were $5.5 million or 12.8%, followed by repairs at $362 thousand or 0.8%.

Table 8.4: NIHB vision care claimants and expenditures ($ 000's) by category
Category	Claimants	Expenditures	% Change from previous year
New Eyewear	134,106	$37,068,360	34.8%
Eye Exams	79,762	$5,534,093	37.7%
Repairs	3,515	$361,610	32.9%
Early Replacement	946	$153,801	23.5%
Add ons	5,562	$81,491	31.6%
Other	159	$33,848	62.8%
Source: HICPS adapted by Business Support, Audit and Negotiations Division

Section 9: NIHB mental health counselling benefits

The NIHB program provides coverage for mental health benefits as set out in the NIHB Guide to Mental Health Counselling Services. The NIHB program's mental health counselling benefit is intended to provide coverage for professional mental health counselling to complement other mental wellness services that may be available to clients or in communities. Mental health counselling is eligible for coverage when it is provided by an NIHB recognized mental health professional such as a registered psychologist. The mental health counselling benefit is offered in a way that:

recognizes NIHB mental health counselling benefit as a component of a mental wellness continuum that includes other Indigenous Services Canada, community-based and provincial or territorial mental health programming and services
supports culturally competent mental health counselling

In 2021 to 2022, a total of 26,450 First Nations and Inuit clients accessed mental health counselling benefits through the NIHB program, based on claims paid through the HICPS system. The total expenditure for mental health counselling benefits was 93.9 million or 5.5% of total NIHB expenditures.

Distribution of NIHB mental health counselling expenditures ($ millions): 2021 to 2022

NIHB mental health counselling expenditures are comprised of several distinct components. Fee-for-service mental health counselling costs paid through HICPS system represented the largest expenditure portion, accounting for $61.2 million or 65.2% of all NIHB mental health counselling costs.

The next highest component was contribution agreements, which accounted for $28.0 million or 29.8% of total mental health counselling costs. Contribution agreements are used to fund First Nations or Inuit communities and organizations and/or Territorial Governments directly for the provision of mental health counselling benefits.

Regional mental health counselling, at $4.7 million or 5.0% of mental health counselling benefit costs, refers to mental health counselling claims paid through Indigenous Services Canada regional offices.

**Chart 9.1: Distribution of NIHB mental health counselling expenditures ($ Millions)**

NIHB mental health couselling expenditures and growth by region ($ 000's): 2021 to 2022

NIHB mental health counselling expenditures totalled $93.9 million in 2021 to 2022, an increase of 27.2% from the previous year.

Saskatchewan had the highest mental health counselling costs at $24.9 million, or 26.5% of total mental health counselling expenditures, followed by Ontario at $21.8 million (23.2%) and Manitoba at $16.3 million (17.4%). Headquarters expenditures are costs related to claims processing through the HICPS system.

Table 9.1: NIHB mental health counselling expenditures by region ($ 000's)
Region	Operating		Total Operating Costs	Total Contribution Costs	Total Costs	% Change from 2020-2021
Region	Fee-For-Service	Regional	Total Operating Costs	Total Contribution Costs	Total Costs	% Change from 2020-2021
Atlantic	$3,005	$193	$3,198	$3,804	$7,001	16.0%
Quebec	$4,157	$0	$4,157	$1,447	$5,604	24.7%
Ontario	$20,291	$0	$20,291	$1,471	$21,762	40.5%
Manitoba	$11,254	$0	$11,254	$5,079	$16,333	18.3%
Saskatchewan	$15,318	$0	$15,318	$9,563	$24,881	48.4%
Alberta	$5,712	$4,473	$10,185	$4,586	$14,771	15.0%
North	$1,265	$0	$1,265	$2,068	$3,333	-14.4%
Headquarters	$204	$0	$204	$0	$204
Total	$61,205	$4,666	$65,871	$28,019	$93,890	27.2%
Source: FST adapted by Business Support, Audit and Negotiations Division

NIHB mental health counselling expenditures and annual percentage change

NIHB mental health counselling expenditures increased by 27.5% during fiscal year 2021 to 2022. Over the past five years, mental health counselling costs have grown by 183.9% from $33.1 million in 2017 to 2018 to $93.9 million in 2021 to 2022. Budget 2017 provided funding to expand the benefit by removing the requirement that counselling be provided in response to a crisis. Over the past five years, growth in mental health counselling expenditures has ranged from a high of 52.2% in 2017 to 2018 to a low of 27.5% in 2021 to 2022.

The five year annualized growth rate for NIHB mental health counselling expenditures is 23.2%.

**Chart 9.2: NIHB mental health counselling expenditures and annual percentage change**

On a regional basis, the highest growth rates over this period were in the Atlantic region where expenditures grew by 481.3% from $1.2 million in 2017 to 2018 to $6.0 million in 2021 to 2022. This was followed by Saskatchewan with an increase of 279.4% from $6.6 million in 2017 to 2018 to $16.8 million in 2021 to 2022.

Table 9.2: NIHB mental health expenditures ($ 000's)
Region	2017 to 2018	2018 to 2019	2019 to 2020	2020 to 2021	2021 to 2022
Atlantic	$1,204	$1,932	$3,428	$6,037	$7,001
Quebec	$1,861	$2,382	$3,138	$4,493	$5,604
Ontario	$6,028	$9,053	$12,116	$15,491	$21,762
Manitoba	$8,124	$9,705	$11,475	$13,803	$16,333
Saskatchewan	$6,559	$7,867	$11,783	$16,770	$24,881
Alberta	$7,761	$9,545	$11,020	$12,843	$14,771
North	$1,528	$2,172	$2,167	$3,895	$3,333
Total	$33,066	$42,656	$55,126	$73,652	$93,890
Source: FST and FIRMS adapted by Business Support, Audit and Negotiations Division

Per capita NIHB mental health counselling expenditures by region ($ 000's): 2021 to 2022

Expenditures per capita are total NIHB mental health counselling expenditures divided by the number of eligible clients, regardless of whether clients submitted a claim in the reporting period. Note that mental health counselling per capita expenditures in the North are underrepresented as mental health counselling services for clients in Nunavut and the Northwest Territories are funded via contribution agreements.

In 2021 to 2022, the national per capita expenditure for the NIHB mental health counselling benefit was $108 per NIHB-eligible client.

Saskatchewan had the highest per capita expenditure at $154, followed by Alberta at $114. Per capital expenditure was lowest in the North, at $46.

**Chart 9.3: Per capita NIHB mental health counselling expenditures by region ($ 000's)**

NIHB mental health counselling claimants by age group, gender and region: 2021 to 2022

Of the 915,895 clients eligible to receive benefits under the NIHB program, a total of 26,450 claimants, representing 2.9% of the NIHB client population, had at least one mental health counselling claim paid through the Health Information and Claims Processing Services (HICPS) system in 2021 to 2022. Of this total, 18,256 were female (69.0%) and 8,194 were male (31.0%). This compares to the total eligible population where 51% were female and 49% were male. Note that this table underrepresents mental health counselling utilization in the North as mental health counselling services for clients in Nunavut and the Northwest Territories are funded via contribution agreements. As such, claims for these regions are not captured in the HICPS system

The average age of mental health counselling claimants was 34 years. The average age for female and male claimants was 34 and 32 years of age, respectively.

Table 9.3: NIHB mental health counselling claimants by age group, gender and region

Region	Atlantic			Quebec			Ontario			Manitoba
Age Group	Female	Male	Total	Female	Male	Total	Female	Male	Total	Female	Male	Total
0-9	28	25	53	17	15	32	196	190	386	41	42	83
10-14	106	50	156	80	44	124	506	336	842	196	129	325
15-19	133	54	187	74	37	111	732	327	1,059	282	160	442
20-24	167	63	230	131	46	177	663	279	942	301	116	417
25-29	205	71	276	140	56	196	834	359	1,193	303	130	433
30-34	141	64	205	128	51	179	710	301	1,011	253	86	339
35-39	114	51	165	127	43	170	633	283	916	219	74	293
40-44	102	23	125	96	39	135	504	221	725	147	65	212
45-49	73	26	99	79	30	109	439	198	637	100	41	141
50-54	64	26	90	48	31	79	359	141	500	87	38	125
55-59	41	11	52	76	21	97	317	126	443	63	32	95
60-64	25	12	37	47	13	60	218	77	295	37	12	49
65+	29	15	44	31	10	41	231	68	299	50	19	69
Total	1,228	491	1,719	1,074	436	1,510	6,342	2,906	9,248	2,079	944	3,023
Average Age	32	31	32	35	34	35	34	31	33	31	29	30

Region	Saskatchewan			Alberta			North			TOTAL
Age Group	Female	Male	Total	Female	Male	Total	Female	Male	Total	Female	Male	Total
0-9	70	58	128	79	74	153	28	37	65	464	448	912
10-14	288	197	485	273	178	451	43	20	63	1,506	956	2,462
15-19	465	153	618	300	173	473	48	19	67	2,049	930	2,979
20-24	444	156	600	268	124	392	61	25	86	2,063	814	2,877
25-29	523	196	719	304	119	423	70	14	84	2,408	956	3,364
30-34	539	208	747	327	139	466	53	18	71	2,186	877	3,063
35-39	377	164	541	269	104	373	44	19	63	1,812	748	2,560
40-44	299	172	471	187	102	289	24	9	33	1,376	636	2,012
45-49	274	118	392	132	64	196	27	12	39	1,136	493	1,629
50-54	235	121	356	115	50	165	27	10	37	944	423	1,367
55-59	202	94	296	99	33	132	9	11	20	818	334	1,152
60-64	133	54	187	55	17	72	17	7	24	535	195	730
65+	108	58	166	54	11	65	451	201	652	959	384	1,343
Total	3,957	1,749	5,706	2,462	1,188	3,650	902	402	1,304	18,256	8,194	26,450
Average Age	34	34	34	32	29	31	50	46	49	33	31	32
Source: HICPS and SVS adapted by Business Support, Audit and Negotiations Division

NIHB mental health counselling expenditures by category: 2021 to 2022

In 2021 to 2022, individual counselling sessions accounted for $28.6 million or 63.1% of all HICPS mental health counselling expenditures. Telehealth counselling sessions were $15.5 million or 34.2%, followed by family counselling sessions at $499 thousand or 1.1%.

Table 9.3: NIHB mental health counselling claimants and expenditures ($ 000's) by category
Category	Claimants	Expenditures	% Change from previous
Individual Counselling Session	19,210	$28,614,042	37.6%
Telehealth Counselling Session	8,400	$15,530,770	34.8%
Family Counselling Session	395	$498,583	58.4%
Other	1,662	$378,027	39.6%
Group Counselling Session	429	$358,979	19.2%
Source: HICPS adapted by Business Support, Audit and Negotiations Division

Section 10: 10 year regional expenditure trends

Atlantic region

Annual expenditures in the Atlantic Region for 2021 to 2022 totalled $84.2 million, an increase of 13.8% over the $74.0 million spent in 2020 to 2021. Pharmacy expenditures in 2021 to 2022 increased by 8.9% to $40.7 million, medical transportation costs increased by 18.9% to $15.8 million and dental expenditures increased by 24.8% to $11.8 million. Mental health expenditures increased by 16.0%, MS&E expenditures increased by 8.9% and vision care expenditures increased by 21.0%.

Pharmacy expenditures accounted for almost half of NIHB expenditures in the Atlantic Region 48.3%. Medical transportation expenditures ranked second at 18.7%, followed by dental at 14.8%. MS&E, vision care and mental health counselling expenditures accounted for 5.4%, 8.3% and 4.9% of total expenditures respectively.

Over the ten year period from fiscal year 2012 to 2013 to fiscal year 2021 to 2022, NIHB expenditures in the Atlantic Region were impacted by changes to the NIHB eligible client population. The creation of the Qalipu Mi'kmaq First Nation band in 2011 resulted in a 2 year surge in expenditures in the Atlantic Region. As of March 31, 2022, a total of 24,484 Qalipu clients were eligible to receive benefits through the NIHB program. The decrease in expenditures in 2013 to 2014 can be attributed to the transfer of authority to the First Nations Health Authority for clients registered to First Nations in the Atlantic region but residing in British Columbia.

**Chart 10.1: Percentage change in Atlantic region NIHB expenditures ($ 000's)**

Atlantic region	2012 to 2013	2013 to 2014	2014 to 2015	2015 to 2016	2016 to 2017	2017 to 2018	2018 to 2019	2019 to 2020	2020 to 2021	2021 to 2022
Total expenditures ($M)	$49,995	$46,033	$46,912	$50,773	$55,079	$60,040	$63,342	$73,071	$73,984	$84,227
Total benefits annual % change	16.7%	-7.9%	1.9%	8.2%	8.5%	9.0%	5.5%	15.4%	1.2%	13.8%

Annual expenditures by benefit ($ 000's)

Table 10.1: Atlantic region annual expenditures by benefit ($ 000's)
Atlantic region	2012 to 2013	2013 to 2014	2014 to 2015	2015 to 2016	2016 to 2017	2017 to 2018	2018 to 2019	2019 to 2020	2020 to 2021	2021 to 2022
Transportation	$6,875	$6,916	$7,419	$8,380	$9,277	$11,147	$11,820	$13,910	$13,263	$15,776
Pharmacy	$29,979	$27,517	$28,398	$30,064	$31,899	$33,021	$34,348	$39,724	$37,323	$40,657
MS&E	$2,147	$2,064	$2,120	$2,449	$2,990	$3,279	$3,900	$4,359	$4,177	$4,508
Dental	$9,660	$8,609	$8,238	$8,846	$9,593	$10,610	$10,841	$11,545	$9,455	$11,801
Mental health	$512	$235	$169	$419	$601	$1,204	$1,932	$3,428	$6,037	$7,001
Vision care	$2,969	$2,757	$2,666	$3,021	$3,502	$3,632	$3,885	$4,150	$3,436	$4,158
Other	$0	$0	$21	$44	$207	$427	$516	$314	$293	$326
Total	$49,995	$46,033	$46,912	$50,773	$55,079	$60,040	$63,342	$73,071	$73,984	$84,227
Source: FST and FIRMS adapted by Business Support, Audit and Negotiations Division

Quebec

Annual expenditures in Quebec for 2021 to 2022 totalled $117.4 million, an increase of 13.1% from the $103.8 million spent in 2020 to 2021.

Medical transportation expenditures increased by 5.5% to $26.8 million in 2021 to 2022, pharmacy expenditures increased by 10.4% to $58.8 million and dental expenditures increased by 27.8% to $14.9 million. MS&E costs increased by 20.0%, mental health expenditures increased by 24.7% and vision care expenditures increased by 40.0%.

Pharmacy expenditures accounted for half of total NIHB expenditures in Quebec in 2021 to 2022 at 50.1%. Medical transportation expenditures ranked second at 22.8%, followed by dental at 16.3%. Mental health counselling, MS&E and vision care expenditures accounted for 4.8%, 3.4% and 2.4% of total expenditures respectively.

**Chart 10.2: Percentage change in Quebec NIHB expenditures ($ 000's)**

Quebec	2012 to 2013	2013 to 2014	2014 to 2015	2015 to 2016	2016 to 2017	2017 to 2018	2018 to 2019	2019 to 2020	2020 to 2021	2021 to 2022
Total expenditures ($M)	$80,915	$80,608	$84,666	$87,690	$91,831	$94,210	$96,120	$104,136	$103,773	$117,373
Total benefits annual % change	3.8%	-0.4%	5.0%	3.6%	4.7%	2.6%	2.0%	8.3%	-0.3%	13.1%

Annual Expenditures by Benefit ($ 000's)

Table 10.2: Quebec Annual Expenditures by Benefit ($ 000's)
Quebec	2012 to 2013	2013 to 2014	2014 to 2015	2015 to 2016	2016 to 2017	2017 to 2018	2018 to 2019	2019 to 2020	2020 to 2021	2021 to 2022
Transportation	$22,578	$21,945	$23,506	$23,687	$23,501	$23,918	$24,642	$25,729	$25,379	$26,775
Pharmacy	$40,393	$40,825	$42,581	$44,206	$47,444	$48,390	$48,967	$53,311	$53,282	$58,827
Dental	$15,239	$15,216	$15,799	$16,641	$17,569	$17,961	$17,882	$18,733	$2,379	$2,855
MS&E	$1,350	$1,501	$1,684	$1,752	$1,994	$2,163	$2,345	$2,564	$14,934	$19,092
Mental health	$1,135	$1,003	$1,148	$1,148	$1,292	$1,861	$2,382	$3,138	$4,493	$5,604
Vision care	$1,570	$1,619	$1,622	$1,749	$1,762	$1,819	$1,908	$2,736	$2,814	$3,938
Other	$0	$0	$10	$258	$263	$260	$339	$490	$493	$282
Total	$80,915	$80,608	$84,666	$87,690	$91,831	$94,210	$96,120	$104,136	$103,773	$117,373
Source: FST and FIRMS adapted by Business Support, Audit and Negotiations Division

Ontario

Annual expenditures in Ontario for 2021 to 2022 totalled $325.5 million, an increase of 18.8% from the $274.0 million spent in 2020 to 2021.

In 2021 to 2022, pharmacy expenditures in Ontario increased by 6.4% to $112.1 million, while medical transportation costs increased by 26.7% to $114.8 million. Dental expenditures increased by 25.6% to $59.3 million. Mental health counselling expenditures increased by 40.5%, while MS&E increased by 19.2% and vision care expenditures increased by 10.4%.

Medical transportation expenditures accounted for 35.3% of total expenditures for Ontario. Pharmacy costs ranked second at 34.4%, followed by dental at 18.2%. Mental health, MS&E and vision care expenditures accounted for 6.7%, 2.7% and 2.5% of total expenditures respectively.

**Chart 10.3: Percentage change in Ontario NIHB expenditures ($ 000's)**

Ontario	2012 to 2013	2013 to 2014	2014 to 2015	2015 to 2016	2016 to 2017	2017 to 2018	2018 to 2019	2019 to 2020	2020 to 2021	2021 to 2022
Total expenditures ($M)	$186,544	$193,929	$203,043	$215,738	$231,663	$250,947	$269,127	$287,643	$273,987	$325,494
Total benefits annual % change	3.2%	4.0%	4.7%	6.3%	7.4%	8.3%	7.2%	6.9%	-4.7%	18.8%

Annual expenditures by benefit ($ 000's)

Table 10.3: Ontario Annual Expenditures by Benefit ($ 000's)
Ontario	2012 to 2013	2013 to 2014	2014 to 2015	2015 to 2016	2016 to 2017	2017 to 2018	2018 to 2019	2019 to 2020	2020 to 2021	2021 to 2022
Transportation	$59,251	$62,865	$65,781	$67,772	$74,890	$86,091	$98,605	$106,638	$90,646	$114,814
Pharmacy	$77,131	$78,510	$81,982	$88,872	$94,101	$99,550	$100,558	$104,760	$105,300	$112,069
MS&E	$4,640	$4,505	$4,255	$4,811	$5,825	$5,915	$6,662	$7,322	$7,297	$8,700
Dental	$42,259	$43,972	$46,759	$49,903	$52,105	$52,055	$53,667	$55,386	$47,218	$59,326
Mental health	$2,490	$2,862	$2,803	$3,021	$4,091	$6,028	$9,053	$12,116	$15,491	$21,762
Vision care	$5,412	$5,721	$5,717	$6,160	$6,223	$6,848	$6,744	$7,860	$7,346	$8,113
Other	$0	$0	$2	$11	$254	$375	$500	$883	$688	$710
Total	$186,544	$193,929	$203,043	$215,738	$231,663	$250,947	$269,127	$287,643	$273,987	$325,494
Source: FST and FIRMS, adapted by Business Support, Audit and Negotiations Division

Manitoba

Annual expenditures in Manitoba for 2021 to 2022 totalled $391.2 million, an increase of 15.9% from the $337.5 million spent in 2020 to 2021. Medical transportation expenditures in 2021 to 2022 increased by 18.2% to $184.2 million, while pharmacy costs increased by 5.1% to $112.4 million. Dental expenditures increased by 30.0% to $57.4 million. Mental health counselling, MS&E and vision care expenditures increased by 18.3%, 19.6% and 32.6% respectively.

Due to the higher proportion of clients living in northern or remote communities in Manitoba, medical transportation expenditures comprised almost half of total expenditures in Manitoba at 47.1%. Pharmacy costs ranked second at 28.7%, followed by dental at 14.7%. Mental health couselling, MS&E and vision care expenditures accounted for 4.2%, 3.4% and 1.9% of total expenditures respectively.

**Chart 10.4: Percentage change in Manitoba NIHB expenditures ($ 000's)**

Annual expenditures by benefit ($ 000's)

Table 10.4: Manitoba Annual Expenditures by Benefit ($ 000's)
Manitoba	2012 to 2013	2013 to 2014	2014 to 2015	2015 to 2016	2016 to 2017	2017 to 2018	2018 to 2019	2019 to 2020	2020 to 2021	2021 to 2022
Transportation	$109,409	$111,016	$115,705	$125,308	$147,167	$155,370	$156,961	$168,686	$155,794	$184,200
Pharmacy	$80,676	$77,034	$81,059	$87,997	$94,757	$98,046	$101,250	$112,025	$106,851	$112,353
MS&E	$4,801	$4,908	$5,045	$5,300	$6,341	$6,985	$9,166	$11,966	$11,145	$13,330
Dental	$30,734	$33,649	$33,527	$36,764	$39,986	$41,949	$48,099	$52,622	$44,149	$57,381
Mental health	$3,429	$3,622	$4,099	$3,780	$5,635	$8,124	$9,705	$11,475	$13,803	$16,333
Vision care	$4,048	$4,348	$4,800	$4,212	$4,204	$4,479	$4,699	$6,935	$5,529	$7,334
Other	$0	$0	$0	$17	$240	$240	$240	$240	$245	$247
Total	$228,295	$229,670	$239,190	$258,077	$291,989	$308,208	$320,953	$351,983	$337,517	$391,177
Source: FST and FIRMS, adapted by Business Support, Audit and Negotiations Division

Saskatchewan

Annual expenditures in Saskatchewan for 2021 to 2022 totalled $335.6 million, an increase of 17.3% from the $286.0 million spent in 2020 to 2021.

NIHB pharmacy expenditures increased in Saskatchewan by 3.3% to $120.0 million, while medical transportation costs increased by 21.4% to $103.2 million. Dental cost increased by 33.5% to $63.4 million. Mental health counselling, MS&E and vision care costs increased by 48.4%, 12.1% and 24.6% respectively.

Pharmacy expenditures comprised the largest portion of total NIHB expenditures in Saskatchewan at 35.8%, medical transportation costs ranked second at 30.7%, followed by dental at 18.9%. Mental health, MS&E and vision care expenditures accounted for 7.4%, 4.0% and 3.2% of total expenditures respectively.

**Chart 10.5: Percentage change in Saskatchewan NIHB expenditures ($ 000's)**

Annual expenditures by benefit ($ 000's)

Table 10.5: Saskatchewan Annual Expenditures by Benefit ($ 000's)
Saskatchewan	2012 to 2013	2013 to 2014	2014 to 2015	2015 to 2016	2016 to 2017	2017 to 2018	2018 to 2019	2019 to 2020	2020 to 2021	2021 to 2022
Transportation	$45,793	$47,180	$51,543	$53,566	$58,902	$64,363	$75,330	$83,947	$84,951	$103,152
Pharmacy	$74,646	$78,546	$83,361	$91,170	$104,082	$119,326	$118,250	$126,963	$116,188	$120,000
MS&E	$5,891	$6,911	$6,542	$7,260	$8,382	$9,426	$10,762	$11,889	$11,908	$13,352
Dental	$36,219	$36,399	$37,679	$41,028	$47,321	$50,635	$55,603	$57,639	$47,507	$63,408
Mental health	$1,038	$1,017	$1,351	$1,631	$3,304	$6,559	$7,867	$11,783	$16,770	$24,881
Vision care	$5,676	$5,611	$6,066	$6,104	$6,533	$6,905	$7,822	$9,844	$8,493	$10,581
Other	$0	$0	$0	$4	$210	$210	$210	$210	$211	$211
Total	$163,372	$168,752	$180,000	$193,502	$220,352	$247,997	$265,082	$290,386	$286,028	$335,584
Source: FST and FIRMS, adapted by Business Support, Audit and Negotiations Division

Alberta

Annual expenditures in Alberta for 2021 to 2022 totalled $248.9 million, an increase of 11.6% from the $223.0 million spent in 2020 to 2021. Medical transportation expenditures increased by 13.0% to $67.2 million, while pharmacy costs increased by 2.1% to $86.6 million. Dental expenditures increased by 23.1% to $58.8 million. Mental health counselling, MS&E and vision care expenditures increased by 15.0%, 20.8% and 17.1% respectively

Pharmacy expenditures accounted for 34.8% of total NIHB expenditures in Alberta. Medical transportation costs ranked second at 27.0%, followed by dental at 23.6%. Mental health counselling, MS&E and vision care expenditures accounted for 5.9%, 4.7% and 3.8% of total expenditures respectively.

**Chart 10.6: Percentage change in Alberta NIHB expenditures ($ 000's)**

Annual expenditures by benefit ($ 000's)

Table 10.6: Alberta Annual Expenditures by Benefit ($ 000's)
Alberta	2012 to 2013	2013 to 2014	2014 to 2015	2015 to 2016	2016 to 2017	2017 to 2018	2018 to 2019	2019 to 2020	2020 to 2021	2021 to 2022
Transportation	$39,216	$41,451	$45,756	$46,252	$48,157	$51,187	$56,870	$61,669	$59,492	$67,206
Pharmacy	$60,584	$58,777	$64,087	$69,992	$77,265	$79,343	$83,103	$93,776	$84,920	$86,680
MS&E	$10,019	$6,136	$6,487	$5,938	$8,236	$8,260	$9,127	$10,250	$9,647	$11,658
Dental	$34,501	$34,928	$35,974	$39,753	$44,315	$47,637	$51,617	$54,993	$47,741	$58,790
Mental health	$4,791	$4,959	$6,010	$6,003	$6,444	$7,761	$9,545	$11,020	$12,843	$14,771
Vision care	$5,836	$5,936	$7,084	$6,207	$6,928	$6,764	$7,696	$10,514	$8,030	$9,405
Other	$0	$0	$0	$3	$0	$291	$291	$204	$280	$360
Total	$144,928	$146,051	$158,911	$168,211	$183,108	$192,983	$209,122	$232,177	$222,953	$248,869
Source: FST and FIRMS, adapted by Business Support, Audit and Negotiations Division

Northern region

Annual expenditures in the Northern region for 2021 to 2022 totalled $162.1 million, an increase of 2.8 % from the $157.7 million spent in 2020 to 2021.

Medical transportation expenditures decreased by 2.8% to $90.3 million in 2021 to 2022 while pharmacy costs increased by 6.9% to $31.5 million. Dental expenditures increased by 31.9% to $26.8 million. Mental health counselling expenditures decreased by 14.4%, while MS&E and vision care expenditures increased by 40.3% and 27.3% respectively.

Similar to Manitoba, medical transportation expenditures comprised the largest portion of total NIHB expenditures in the Northern region at 55.7%. Pharmacy costs ranked second at 19.4%, followed by dental at 16.6%. MS&E, vision care, and mental health counselling expenditures accounted for 3.5%, 2.5% and 2.1% of total expenditures respectively.

**Chart 10.7: Percentage change in Northern Region NIHB expenditures ($ 000's)**

Annual expenditures by benefit ($ 000's)

Table 10.7: Northern Region Annual Expenditures by Benefit ($ 000's)
Northern region	2012 to 2013	2013 to 2014	2014 to 2015	2015 to 2016	2016 to 2017	2017 to 2018	2018 to 2019	2019 to 2020	2020 to 2021	2021 to 2022
Transportation	$41,727	$44,703	$48,246	$50,940	$55,125	$67,413	$70,806	$76,601	$96,194	$90,286
Pharmacy	$23,682	$23,144	$23,941	$27,408	$28,488	$29,373	$31,571	$33,220	$29,479	$31,499
MS&E	$2,564	$2,949	$3,101	$3,146	$3,263	$4,018	$4,529	$4,884	$4,024	$5,647
Dental	$19,773	$20,415	$20,413	$20,936	$21,966	$25,141	$26,211	$26,546	$20,342	$26,830
Mental health	$4	$2	$0	$191	$362	$1,528	$2,172	$2,167	$3,895	$3,333
Vision care	$3,370	$3,763	$1,743	$2,564	$3,217	$3,131	$3,713	$3,929	$3,206	$4,081
Other	$0	$0	$1	$1	$0	$346	$1	$498	$524	$405
Total	$88,557	$92,027	$94,343	$102,040	$109,157	$126,933	$134,474	$142,961	$157,664	$162,080
Source: FST and FIRMS, adapted by Business Support, Audit and Negotiations Division

Section 11: NIHB program administration

Non-insured health benefits administration costs ($ 000's): 2021 to 2022

This table outlines program administration expenditures by region as well as NIHB headquarters (HQ) costs. In 2021 to 2022, total NIHB administration costs were $69.9 million representing a decrease of 4.8% over the previous fiscal year.

The roles of NIHB headquarters include:

program policy development and determination of eligible benefits
development and maintenance of the HICPS system and other national systems such as the Medical Transportation Reporting System (MTRS)
claims verification and provider negotiations
adjudicating benefit requests through the NIHB Drug Exception Centre and the Dental Predetermination Centre
providing expert advice through the MS&E Review Centre
producing national Program communications for NIHB clients and providers and
maintaining relationships with partner organizations at the national level as well as with other federal departments and agencies.

The roles of NIHB regional offices include:

adjudicating benefit requests for medical transportation, mental health counselling, vision care and medical supplies and equipment
maintaining relationships with partner organizations at the provincial/territorial level as well as with provincial/territorial officials
managing contribution agreements (CA)

Claims processing contract costs are related to the administration of pharmacy, medical supplies and equipment, dental benefits, mental health counselling and vision care benefits through the Health Information and Claims Processing Services (HICPS) system, and include:

claim processing and payment operations
claim adjudication and reporting systems development and maintenance
provider registration and communications
provider verification programs and recoveries and
standard and ad hoc reporting.

NIHB program administration expenditures by region ($ 000's)

Table 11.1: NIHB program administration expenditures by region ($ 000's)
Categories	Atlantic	Quebec	Ontario	Manitoba	Saskatchewan	Alberta	Northern region	HQ	Total
Salaries	$1,674	$2,312	$5,186	$3,556	$4,139	$4,167	$1,586	$19,137	$41,756
EBP	$452	$624	$1,390	$960	$1,117	$1,125	$428	$5,155	$11,252
Operating	$88	$18	$31	$49	$240	$16	$28	$2,313	$2,782
Subtotal	$2,214	$2,954	$6,607	$4,566	$5,496	$5,307	$2,043	$26,605	$55,791
Claims processing contract costs									$14,090
Total administration costs									$69,881
Source: FST adapted by by Business Support, Audit and Negotiations Division

Non-Insured Health Benefits administration costs as a proportion of benefit expenditures ($ Millions)

In 2021 to 2022, total NIHB benefit expenditures were $1,695.3 million, of which direct benefit expenditures totaled $1,625.4 million and expenditures for claims processing administration amounted to $14.1 million. An additional $55.8 million was spent on salaries and operating costs associated with program administration.

Total NIHB program administration costs ($69.9 million, including claims processing and other program administration) as a proportion of direct benefit expenditures ($1.7 billion), was 4.2% in 2021 to 2022. Over the past five fiscal years, the percentage of NIHB program administration costs as a proportion of total benefit expenditures has ranged from a high of 5.1% in 2019 to 2020 to a low of 4.2% in 2021 to 2022.

**Chart 11.1: Non-Insured Health Benefits administration costs as a proportion of benefit expenditures ($ Millions)**

Health Information and Claims Processing Services (HICPS): 2021 to 2022

Claims for NIHB pharmacy, dental, MS&E, as well as most mental health counselling and vision care benefits provided to eligible First Nations and Inuit clients are processed via the Health Information and Claims Processing Services (HICPS) system. HICPS includes administrative services and programs, technical support and automated information management systems used to process and pay claims in accordance with NIHB program client/benefit eligibility and pricing policies.

Since 1990, the NIHB program has retained the services of a private sector contractor to administer the following core claims processing services on its behalf:

claim processing and payment operations
claim adjudication and reporting systems development and maintenance
provider registration and communications
provider audit programs and audit recoveries and
standard and ad hoc reporting.

The current HICPS contract is with Express Scripts Canada. This contract came into force on June 28, 2020, following a competitive contracting process led by Public Services and Procurment Canada (PSPC). The NIHB program manages the HICPS contract as the project authority in conjunction with PSPC, the contract authority.

As of March 31, 2022, there were 35,829 active^{Footnote *} pharmacy, dental, MS&E, mental health counselling and vision care providers registered with the HICPS claims processor to deliver NIHB benefits. The number of active providers by region and by benefit is outlined in the table below.

Table 11.2: Number of NIHB providers by region and benefit April 2020 to March 2022
Region	Pharmacy	MS&E	Dental	Vision	Mental Health
Atlantic	831	235	1,134	469	399
Quebec	1,815	191	2,676	822	350
Ontario	4,065	697	6,628	1,987	1,115
Manitoba	461	90	1,033	165	202
Saskatchewan	450	145	775	244	299
Alberta	1,653	330	3,265	918	387
British Columbia	824	37	541	199	2
North	30	25	278	30	32
Total	10,129	1,750	16,330	4,834	2,786
Source: HICPS adapted by Business Support, Audit and Negotiations Division

Number of claim lines settled through the Health Information and Claims Processing Services (HICPS) system: 2021 to 2022

Table 10.3 sets out the total number of pharmacy, dental, MS&E, mental health counselling and vision care claims settled through the HICPS system in fiscal year 2021 to 2022. During this period, a total of 31,087,244 claim lines were processed through HICPS. Ontario had the highest volume of total claims processed at 8.4 million, followed by Manitoba at 5.7 million and Saskatchewan at 5.3 million.

Claim Lines vs. Prescriptions or Visits

It is important to note that the program reports annually on claim lines. This is an administrative unit of measure as opposed to a health care unit of measure. A claim line represents a transaction in the claims processing system and is not equivalent to a prescription or health practitioner visit. Prescriptions can contain a number of different drugs with each one represented by a separate claim line. Prescriptions for a number of drugs may be repeated and refilled many times throughout the year. In the case of repeating prescriptions, each time a prescription is refilled, the system will log another transaction (claim line). Therefore, it is possible for an individual who has a prescription that repeats multiple times in a year to have numerous related claim lines associated with the single prescription. Likewise, an appointment with a dental or MS&E practitioner may results in multiple claim lines as several procedures are performed at the same time.

Mental health counselling services for clients in Nunavut and the Northwest Territories are funded via contribution agreements, as such, claim lines are not captured in the HICPS system.

Table 11.3: Number of claim lines processed through HICPS by region and benefit
Region	Pharmacy	Dental	MS&E	Mental Health	Vision Care	Total
Atlantic	1,768,589	183,802	55,915	26,089	32,118	2,066,513
Quebec	3,278,569	231,067	47,187	15,414	21,524	3,593,761
Ontario	7,534,749	655,702	71,061	131,569	50,118	8,443,199
Manitoba	4,916,359	570,538	122,543	31,393	38,056	5,678,889
Saskatchewan	4,389,316	650,157	124,396	49,469	62,542	5,275,880
Alberta	3,674,960	612,998	81,248	49,591	64,627	4,483,424
British Columbia	192,846	35,811	2,928	80	278	231,943
North	1,004,455	254,395	43,818	3,310	7,657	1,313,635
Total Claim Lines	26,759,843	3,194,470	549,096	306,915	276,920	31,087,244
Source: HICPS adapted by Business Support, Audit and Negotiations Division

Section 12: NIHB policy and program initiatives

NIHB Drug benefit listing and review

The NIHB Drug Benefits List (DBL) is a listing of all of the drugs provided as benefits by the NIHB program. Drugs considered for, or currently listed on, the DBL must meet established criteria. For example, they must be legally available for sale in Canada with a Notice of Compliance (NOC) and Drug Identification Number (DIN) or Natural Product Number (NPN), and be dispensed in a pharmacy. The drugs must also demonstrate evidence of therapeutic efficacy, safety, and incremental benefit in proportion to incremental cost.

The review process for drug products that are considered for inclusion as a benefit under the NIHB program varies depending on the type of drug submitted. Submissions for new chemical entities, new combination drug products and existing chemical entities with new indications, must be sent to the Canadian Agency for Drugs and Technologies in Health (CADTH), an independent organization that provides research and information about the effectiveness of drugs and other medical treatments.

Through the Common Drug Review (CDR) and pan-Canadian Oncology Drug Review (pCODR) processes, CADTH conducts objective evaluations of the clinical, economic, and patient evidence on drugs and medical technologies. Based on this information, the CADTH expert committees provide coverage recommendations and advice to Canada's public drug plans, including the NIHB program. The CDR and pCODR were established by federal, provincial and territorial public drug plans to reduce duplication of effort in reviewing drug submissions, to maximize the use of resources and expertise, and to enhance the consistency and quality of drug reviews.

NIHB Drugs and Therapeutics Advisory Committee (DTAC)

The NIHB DTAC is an advisory body of highly qualified health professionals who bring impartial and practical expert medical and pharmaceutical advice to the NIHB program to promote improvement in the health outcomes of First Nations and Inuit clients through effective use of pharmaceuticals. The approach is evidence-based and the advice reflects medical and scientific knowledge, current utilization trends, current clinical practice, health care delivery and client healthcare needs.

More information on DTAC and its members can be found on the Government of Canada's website at
https://www.sac-isc.gc.ca/eng/1576436698232/1576436761446

NIHB Oral Health Advisory Committee (NOHAC)

The NIHB Oral Health Advisory Committee (NOHAC) is an independent advisory body of highly qualified oral health professionals and academic specialists. They bring impartial and practical expert views, advice, and recommendations to the NIHB program to support the improvement of oral health outcomes for First Nations and Inuit clients. The advice and recommendations provided by the Committee follow an evidence-based approach and reflect scientific knowledge, as well as clinical and oral health care delivery and disease prevention best practices.

More information on NOHAC and its members can be found on the Government of Canada's website at
https://www.sac-isc.gc.ca/eng/1634916354457/1634916416104

NIHB Medical Supplies and Equipment Advisory Committee (MSEAC)

The NIHB MSEAC is a multidisciplinary advisory committee of highly qualified health professionals and academic specialists who bring evidence-informed impartial and practical expert advice and recommendations to the NIHB program regarding both medical supplies and equipment and vision care benefits. The approach reflects medical and scientific knowledge, current utilization trends, current clinical practice, health care delivery and client healthcare needs and is intended to promote improvement in the health outcomes of First Nations and Inuit clients.

Drug Exception Centre (DEC)

The Drug Exception Centre is a call centre that provides efficient responses to all requests for drugs that are not on the NIHB Drug Benefit List or require prior approval, for extemporaneous mixtures containing exception or Limited Use (LU) drugs, for prescriptions on which prescribers have indicated "no substitution," and for claims that exceed $1,999.99. The table below shows the volume of requests made to the DEC in 2021 to 2022 by benefit listing type.

Table 12.1: Volume of requests and approvals made to the DEC by benefit listing type
Status	Open benefit (unrestricted)	Open benefit (restricted)	Exceptions	Limited use	Total
Total requested	7,394	12,223	15,192	54,821	89,630
Total approved	5,571	11,332	8,939	41,979	67,821
Source: HICPS adapted by Business Support, Audit and Negotiations Division

Benefit listing type refers to a drug product's status on the NIHB Drug Benefit List (DBL), and are defined as follows:

Open benefit (unrestricted): Drugs included on the DBL which do not have established criteria or prior approval requirements. The DEC reviews claims for open benefit drugs only where the total dollar value is more than the point of sale limit, a pre-determined frequency limit has been reached or more than a three-month supply is requested.
Open benefit (restricted): Drugs included on the DBL which have been restricted due to safety concerns. These drugs are part of the Problematic Substance Use Strategy, such as opioids, benzodiazepines, stimulants and gabapentin.
Exceptions: Exception drugs are drug products which are not listed in the Drug benefit list. These drug products may be approved in special circumstances upon receipt of a completed "Exception Drugs Request Form" from the licensed prescriber.
Limited use: Limited use benefits are drug products listed on the Drug benefit list that may not be appropriate for general listing, but have value in specific circumstances. These products will have specific criteria for provision as a benefit under the NIHB program.

The DEC also supports the implementation of the Problematic Substance Use Strategy to address and prevent potential misuse of prescription drugs. The program has set limits on medications of concern, and developed a structured approach towards client safety which includes the implementation of the Client Safety Program across the country.

Dental Predetermination Centre

The Dental Predetermination Centre (DPC) is a call centre that provides efficient adjudication of all dental and orthodontic predetermination requests, post-determination requests and appeals. In addition, the DPC is responsible for addressing client and provider inquiries, and for assisting clients and providers with the submission of the predetermination, post-determination, client reimbursement and appeal requests.

Medical Supplies and Equipment Review Centre

NIHB staff at the regional level manage prior approval of medical supplies and equipment benefit requests, with support from the MS&E Review Centre (MSERC) at the NIHB national office. The MSERC is staffed in-house by various health professionals, including registered nurses. In cases where advice is required by a particular specialist, such as an audiologist or an orthotist, information is forwarded to the appropriate specialist consultant for review. Consultants make their recommendations based upon the current standards of practice, best practices, current scientific evidence, program policy and recommended guidelines within their field of specialty.

Client and provider communications

NIHB is continually seeking ways to improve communications with clients, providers and partners regarding benefit coverage and administration.

The NIHB program regularly produces newsletters and updates to inform clients and providers about any changes to NIHB policy and benefit coverage. For example, NIHB enrolled providers for dental, pharmacy, MS&E, vision care and mental health counselling receive notification of policy updates and relevant information regarding benefits through regular provider newsletters, periodic bulletins and broadcast messages.

These communications are distributed to enrolled providers by Express Scripts Canada (ESC), Indigenous Services Canada's claims processing contractor, and are available via the ESC website at: nihb.express-scripts.ca.

The NIHB website is a key venue for disseminating program information to clients. NIHB program updates are produced quarterly and as needed to provide information for clients regarding changes to benefit coverage. They can be found on the Canada.ca website at: www.canada.ca/nihb-update. Clients can subscribe to receive email notifications when these updates are published, and those who have set up web accounts through Express Scripts Canada also receive notification of new updates. Client-focused communications are also promoted through social media on the Government of Canada's Healthy First Nations and Inuit Facebook Page and GCIndigenous Twitter account. Additional social media posts promote client awareness of benefit coverage, often in conjunction with broader public health promotion campaigns. For example, a post on diabetes awareness will include a reminder about NIHB coverage of diabetes medications and supplies, and a post on vision health may include a reminder about NIHB coverage of eye exams.

NIHB strives to be accessible and responsive to clients. Clients can contact NIHB directly by calling Indigenous Services Canada regional offices, the NIHB Dental Predetermination Centre, or the NIHB Drug Exception Centre. The "Contact Us" web page for the NIHB program also provides an email address for direct inquiries to the NIHB program.

NIHB Navigators

NIHB Navigators help eligible clients to navigate and access the NIHB program. They are a resource for communities, organizations or individuals who need support or information on NIHB-related issues. Navigators are employed by regional First Nations and Inuit organizations. Their roles and activities are adapted to meet regional needs, and generally include the following:

increase understanding of the NIHB program and share information on eligible benefits
help clients and communities to resolve NIHB-related issues
link with health departments and agencies to help improve client access to NIHB benefits and related health services.

Collaboration with First Nations and Inuit partners

Indigenous Services Canada (ISC) is engaged in a multi-year Joint Review of the NIHB program in partnership with the Assembly of First Nations (AFN). The overall objectives of the review are to identify and implement actions that enhance client access to benefits, identify gaps in benefits, streamline service delivery to be more responsive to client needs, and increase program efficiencies. The AFN conducted a robust program of client, provider and stakeholder engagement activities to gather broad input and perspectives that will inform recommendations for program improvements. The Joint Review is guided by a Steering Committee comprised of First Nations and ISC representatives.

As of March 31, 2022, joint reviews of the mental health counselling, dental, vision care, pharmacy and medical supplies and equipment benefits are complete, and the review of the medical transportation benefit is in progress. Meanwhile, the NIHB Program continues to implement many improvements to benefit coverage and administration. More information on the Joint Review, including highlights of changes and improvements made by NIHB throughout the process, can be found at https://www.sac-isc.gc.ca/eng/1664819343076/1664819370161.

Indigenous Services Canada continues to work with the Inuit Tapiriit Kanatami (ITK) to improve the quality, access, and delivery of NIHB benefits to Inuit clients. NIHB and ITK representatives meet regularly to discuss issues of concern, and identify opportunities for improvement. NIHB shares information and updates Inuit partners regularly on progress made to advance priorities identified by Inuit partners.

Section 13: Technical notes

Information contained in the 2021 to 2022 NIHB Annual Report has been extracted from several databases. All tables and charts are footnoted with the appropriate data sources. These data sources are considered to be of very high quality but, as in any administrative data set, some data may be subject to coding errors or other anomalies. For this reason, users of the data should always refer to the most current edition of the NIHB Annual Report. Please note that some table totals may not add due to rounding procedures.

To address reporting challenges related to NIHB clients registered to British Columbia bands but living elsewhere, and Inuit clients living in BC, select financial and utilization data relating to the British Columbia Region have been suppressed. National totals, however, include these values.

To address reporting challenges related to the small number of NIHB clients choosing a non-binary gender designation at this time and in respect of departmental privacy obligations, population and utilization data relating to these individuals at the provincial/territorial level have been suppressed. National totals, however, include these values. As such, the sum of the provincial/territorial totals will not match the national total.

Starting in 2020 to 2021, expenditures for the NIHB MS&E benefit are being reported separately from NIHB pharmacy benefit expenditures. As such, values reported for NIHB pharmacy will not match those reported in previous editions as those values included MS&E.

Population data

First Nations and Inuit population data are drawn from the Status Verification System (SVS) which is operated by NIHB. SVS data on First Nations clients are based on information provided by Indigenous Services Canada (ISC). SVS data on Inuit clients are based on information provided by the Governments of the Northwest Territories and Nunavut, and Inuit organizations including the Inuvialuit Regional Corporation, Nunavut Tunngavik Incorporated and the Makivik Corporation.

Pharmacy, MS&E, dental, mental health counselling and vision care data

Two Indigenous Services Canada data systems provide information on the expenditures and utilization of the NIHB pharmacy, MS&E, dental, meantal health counselling and vision care benefits. Financial Services and Training (FST) is the source of most of the expenditures data, while the Health Information and Claims Processing Services (HICPS) system provides detailed information on utilization. Expenditure data prior to fiscal year 2019 to 2020 were collected from the Framework for Integrated Resource Management System (FIRMS).

Medical transportation data

Medical transportation financial data are provided through FST. Medical transportation data are also collected regionally through other electronic systems. Operational data at the regional level are tracked through the Medical Transportation Reporting System (MTRS). Contribution agreement data are also collected, but in a limited manner. In some communities, MTRS is used to collect contribution agreement data, while other communities report data using spreadsheet templates, in-house data management systems, or through paper reports.

The Medical Transportation Data Store (MTDS) serves as a repository for selected operational data, as well as the data collected from medical transportation contribution agreements, and ambulance data systems. The objective of the MTDS is to enable aggregate reporting on medical transportation at a national level in order to further strengthen program management, provide enhanced data analysis and reporting and aid in decision making.

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Date modified:: 2023-05-02

Fiscal year	NIHB benefit expenditures ($M)	% Administrative costs
2017 to 2018	$1,309.2	4.7%
2018 to 2019	$1,390.2	4.7%
2019 to 2020	$1,519.5	5.1%
2020 to 2021	$1,490.6	5.0%
2021 to 2022	$1,695.3	4.2%