Background
On October 13, 2011, First Nations in BC through the First Nations Health Society, the Government of Canada, and the Province of BC signed the British Columbia Tripartite Framework Agreement on First Nations Health Governance. The Agreement paved the way for the federal government to transfer the planning, design, management, and delivery of Indigenous Services Canada's First Nations Inuit Health Pacific Region to the First Nations Health Authority (FNHA). Included in the transfer was the Non-Insured Health Benefits (NIHB) program that the FNHA delivers as First Nations Health Benefits.
Transition and Service Continuity
On July 2, 2013 the FNHA began receiving transfer payments from
Indigenous Services Canada for the NIHB program. The FNHA purchased the
administration of some benefits from Indigenous Services Canada through an
arrangement called “buy-back”. The FNHA assumed responsibility for the benefit
programs, and the buy-back arrangement ensured continuity of services for
providers and First Nations in BC.
Health Benefits Plan Overview
Health Benefits covers specific health-related items and services that fall under six health benefit areas:
• Dental;
• Vision Care;
• Medical Supplies and Equipment;
• Pharmacy;
• Medical Transportation; and
• Mental Health
The mental health benefit provides coverage through three programs:
• Mental Wellness and Counselling;
• Indian Residential School Resolution Health Support; and
• Missing and Murdered Indigenous Women and Girls Health Support Services.
Plan Coverage
The Health Benefits program offers a comprehensive, principle-based, and community-driven plan. Items and services that are core benefits under the plan are fully covered.
Flexibility in Coverage
In order to offer clients more choice and flexibility, the plan also enables clients to access additional, alternative items and services that were previously unavailable. If, in consultation with a medical professional, clients choose an alternative to the core benefits, the plan will pay up to the amount covered for the equivalent core benefit. Clients will be responsible for any difference in cost. This way, clients can choose the item or service that best meets their needs.
For example, the plan fully covers white dental fillings as a core benefit. Rather than exclude gold fillings completely, the plan offers coverage for gold fillings up to the amount covered for white fillings. This gives clients greater flexibility when discussing treatment options with a dental professional.
Coordination of Benefits
When clients have access to another third-party health insurance, they should submit claims to that plan first and to Health Benefits second. One exception is the pharmacy benefit, where clients should submit claims to PharmaCare first.
Opting Out of Third-Party Insurance
Clients can choose to opt out of private, employer-sponsored, or other public health care coverage once enrolled with Health Benefits. However, it is important to note that private insurance may offer additional benefits not available through Health Benefits. For example, Health Benefits does not include coverage for physiotherapy, chiropractic treatment, massage therapy, naturopathy, or other paramedical or supplementary services. If clients opt out of their private insurance they will lose coverage for those services.
Partnerships
Health Benefits provides these benefits through partnerships with First Nations organizations and other provincial health organizations. Health Benefits has partnered with Pacific Blue Cross (PBC), BC PharmaCare, and First Nations organizations to offer clients a convenient way to access their benefits.
Partnership with Pacific Blue Cross
Health Benefits has partnered with PBC to administer the following benefits:
• Dental;
• Vision Care;
• Medical Supplies and Equipment (MS&E); and
• Some pharmacy items and services.
Clients can find detailed information about what items and services are covered under these benefits areas through the online PBC Member Profile.
The PBC Member Profile is an online service that offers convenient and secure access to benefit information 24 hours a day. Once logged in, clients can:
• Make and track online claims;
• View benefit coverage details;
• Track benefit usage; and
• Download claim forms.
Clients can often receive reimbursements for online claims within two business days if they enter direct deposit information into their Member Profile account. Note that many providers can bill PBC directly for services, which mostly eliminates the need to pay out-of-pocket and then submit a claim for reimbursement.
The PBC Member Profile displays benefit areas in three categories: Health, Dental, and Drug.
• The Health category contains the vision care and the MS&E benefits;
• The Dental category contains the dental benefit; and
• The Drug category contains some pharmacy items and services not covered by PharmaCare Plan W.
Clients can explore these categories to learn about specific coverage details, including which items and services are fully covered core benefits and which are alternative options. Items that show as “Paid As" are alternative options, where the plan will pay up to the amount covered for the equivalent core benefit. For example, gold dental fillings are shown as “paid as white dental fillings" to indicate that gold fillings are covered up to the same coverage amount as white fillings.
Some pharmacy items and services are covered by PBC. Clients can search the Drug category on the Member Profile for details about which items and services are covered. Items that show as “Not a Benefit" on the Member Profile might be covered by PharmaCare Plan W. Clients with questions about pharmacy coverage should call Health Benefits at 1-855-550-5454.
Partnership with PharmaCare
The vast majority of pharmacy items and services are covered through PharmaCare. Clients receive coverage for their eligible prescription and over-the-counter items through PharmaCare Plan W. Clients can search the PharmaCare Plan W formulary for details about which items and services are covered. Providers can bill PharmaCare directly through PharmaNet. Clients can submit out-of-province pharmacy reimbursement requests directly to PharmaCare.
Partnerships with First Nations Organizations
Health Benefits has partnered with First Nations Bands and organizations to administer the following benefits:
• Medical Transportation; and
• Mental Health.
Health Benefits has funding agreements with many First Nations Bands and organizations to enable communities to run the medical transportation and mental health programs with support from FHNB. Clients who need to access these benefits can call Health Benefits at 1-855-550-5454 to check if their community runs their medical transportation or mental health programs.
