Akwesasne Non-Insured Health Benefits; located in Kanonkwatsheri:io Health
Facility The Akwesasne Non-Insured Health Benefits Program is broken down into seven branches of coverage, which include: OHIP/QHIP Differential, Vision, Pharmacy, Medical Supplies, Medical Equipment, Dental and Medical Transportation. 1.0 MEMBERSHIP REQUIREMENT The primary area of concern in administering the Non Insured programs is that the client MUST be enrolled and assigned a Membership number. Akwesasne invoices are submitted to our office for processing of payment. Without an enrollment number, payment cannot be processed. Infants are listed under the parent's Membership number for a one-year period which is ample time for the parents to obtain necessary documents for enrollment purposes. After the one-year period and the child is not registered with the Membership office, the parents will be responsible for payments where required. Should you be required to pay for any services while your child's registration is being processed, keep your receipts for submission to the Akwesasne Non-Insured Health Services Offices for reimbursement. The Non-Insured programs all require a Membership number in order to process invoices. The information required to register your child can be obtained from the Office of Vital Statistics, Administration Building #1, St. Regis, Quebec. Please keep in mind, when obtaining the official birth certificate, the registrar's office only accepts the LONG FORM document and not the wallet size document. The official form may be completed and taken to MP John Cleary's office at 404 Montreal Road, Cornwall, Ontario. 1.1 Health Cards: The other area of concern in administering the Non Insured program is that the client MUST keep their health cards up to date. Our office is finding that the providers are submitting their invoices for the full amount as the patient has failed to comply with the health card renewal process. The Non-Insured Health Services Program only pays for the balance of account on services rendered and not covered by the Health Insurance Card. The renewal process can only be done by you. It is very important to keep your health cards updated. Quebec Health Card renewals can be done at the Community Health Nurses office at the Kanonhkwa'tsheri:io Medical Facility. The QHIP application mailed to you from the Registrar must be completed and brought in. Should you not receive an application form THREE MONTHS PRIOR TO YOUR BIRTHDATE, please call the following number to obtain your application: 1-800-561-9749. Along with a $6 cover charge for the picture that is required to be attached to the application. A residency letter may be required if your residency is questioned. An appointment must be made with the Mohawk Council Chiefs of your respective District to obtain this document. Ontario Health Card renewals can be done at the Hotel Dieu Hospital, Kiosk center at the emergency entrance. 1.1 Who can apply for a new Health Card? former residents returning to live in Ontario 1.2 Who can apply for a replacement Health Card? people whose Health Card has been lost, stolen, or damaged NOTE: If you already have a photo health card, you may not have to visit a Ministry of Health Office. Please call your local office for information. 1.3 How to Apply for a new photo Health Card Before you visit the Kiosk Center at the Hotel Dieu make sure you have all the documents you need. Whether applying for a new or replacement Health Card, you must take three (3) original documents, one each from lists 1, 2, and 3. If you are applying for a new Health Card, you must also fill in a Registration for Ontario Health Coverage form. If you need to replace your Health Card, you must also fill in a Change of Information form. If you have a Health Card you must take that as well.
1.4 Documents Required when Applying for a Health Card The original documents you must take with you include: 1.4.1 Proof of Canadian Citizenship To show your Canadian citizenship or immigration status, bring the original of one of these documents: * Birth certificate from a Canadian province, territory or the Department
of National Defense. 1.4.2 Proof of Being a Resident of Ontario To show you live in Ontario, bring a current original document with your name and address on it. it can be one of these: * Valid Ontario Driver's License or Temporary Driver's License. 1.4.3 ID Verification To show you are the person you say you are, bring the original of document with your name and signature. It can be one of these: * Social Insurance Number card Note: You cannot use the same document twice. For example if you use your driver's license for section 2, you can't use it again for section 3. You may be asked for additional documents. For example, if your name has changed, you may need to provide a marriage certificate or a change of name certificate. 1.5 Applying for Your Child's Health Card If your children are 15 ½ years or younger, apply for their health coverage at the same time you apply for your own. The children don't have to go with you because they won't have a photo on their card. All you need is a document from list 1 for each child. Children older than 15 ½ years must register in person because they will have a photo and signature on their card. They will need three original documents in their name, one from sections 1.4.1, 1.4.2 , and 1.4.3. The OHIP/QHIP Differential plays a crucial role for the physicians in the Cornwall area. RAMQ, which is the payer of medical bills in the province of Quebec and is at a lower rate than the payments made by OHIP. The Cornwall physicians bill QHIP and the balance of account is submitted to the Non-Insured Health Services office for payment. The OHIP or QHIP health card number along with the Membership number is required to process a balance of account. Reminder: The OHIP and QHIP card is to be updated and the recipient is responsible for the renewal. The recipient is responsible to be registered with the Akwesasne membership in order to qualify for the differential payment to be made. The patient is also responsible to provide the HOSPITALS, DOCTORS and LABS with the proper OHIP or QHIP number along with the proper Membership number each time they require services. You may be required to sign an OUT-OF-PROVINCE claim for services rendered. The Akwesasne Non-Insured Health Services took over the management of the Ontario portion of the Vision Program on March 1, 1998. The management entails the approval of eye exams, eyeglass wear, and processing of payment of invoices submitted by the optometrist. The eligibility criteria set forth for the Ontario portion are listed below: 3.1 Insured Vision Benefits covered and paid by OHIP * Under 20 years of age and over 65, one eye exam per person, per year. 3.2 Eye glass coverage for Ontario Residents * Under age 18 years, once every 12 months 3.3 Insured Services Covered and Paid by QHIP * Under 18 years of age and over 65, one eye exam per person per year. 3.4 Eye Glass Coverage for Quebec Residents * Under age 18 years, once every 12 months The Pharmacy, Medical Supplies and Medical Equipment are grouped into one program. All payments, verification and prior approvals for benefit exceptions are done in our office. The health cards and Membership number are required to receive the benefits. There are instances where the parents have not registered their child within the one-year period and in these instances, the parents are responsible to purchase the medication required. In the event that you are required to pay for prescriptions that are on our formulary, you will be required to submit the original receipt to the Akwesasne Non-insured Health Services Office for reimbursement. The Cornwall area dentists utilize our office to determine eligibility and frequency foy dental care. There are times when the clients become impatient with the process as their prior approval for exceptions to be made is sent to the dental consultant along with the supporting documents and x-rays. This process may take approximately 4-6 weeks. Upon receipt of the returned information, the dentist is then informed of the decision and the information submitted is returned. This process can be a lengthy and your patience is required. Patient history verification, eligibility verification, prior approvals and payments are done in the Akwesasne Non Insured Health Services office. Patients in the Cornwall area and across Canada are to note that there are dentists who use our dental system rather than to have the patient pay for the services rendered and then be reimbursed. The reimbursement is calculated at what the payment would have been if the dentist were to bill our program. The patients Membership number must be correct in order for the payment to be processed. The staff routinely try their best in finding the missing Membership number prior to rejecting the claim for payment. The rejected claim is sent back to the provider who in turn bills the patient for payment. The Akwesasne patient must have a valid Membership number prior to obtaining dental treatment. 5.1 Frequency Limitations Some examples of frequency limitations are: 5.1.1 Root Canal Therapy - reduced to one permanent tooth per three years, from two every five years (prior approval is required if there is a need to have a second root canal within the five year period). 5.1.2 Crowns - reduced to one permanent tooth every three years, from two teeth every five years (prior approval is required if there is a need to have a second crown within the three-year period). 5.1.3 Fillings - reduced to one filling every five years for the same surface on the same tooth, which before was never counted or limited (prior approval is required if there is a need to have the filling redone within the five year period). 5.1.4 Dentures - one per arch every eight years when it used to be one every five years (prior approval is required if there is a need to have dentures redone within the eight-year period). The transportation program is solely for the purpose of providing transportation assistance to individuals who have no other means. The individual is required to complete an application for assistance along with supporting documents from the physicians prior to the appointment. The driver is also required to complete a driver waiver form along with providing a copy of the license, registration and insurance for their vehicle. |
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