Amputee Prosthetic Funding Process
Please be advised that Pharmacare as impressed upon us that “Under NO Circumstances” are we to provide any service or products(s) prior to their approval. They are now performing random audits of all prosthetic facilities and if they have any reason to believe that we preceded their approval they will take back all the money they provided for the work or products in question. If we are penalized in this fashion we are left with no option but to send you a bill to collect payment for the service and products we provided to you.
In Canada there are 3 Major Primary Funding Agencies available for prosthetics:
- Provincial Funding – BC Pharmacare
- WorkSafe/Worker’s Compensation
- NIHB (ESI)
Virtually all Canadians should fall under at least one of these agencies for their primary funding coverage.
Provincial Funding – BC Pharmacare
All BC Residents have the right to funding coverage under BC Pharmacare. However, they must be registered for Fair Pharmacare. If you are unsure if you are registered or if you know you are not you can get registered at Fair Pharmacare Registration website. Alternatively, you can call Pharmacare: from the Lower Mainland, call 604 683-7151. From the rest of B.C., call toll-free 1 800 663-7100.
Once you are registered you will be given a registration number which will provide you with “temporary” coverage pending verification of your household (family) income for the previous tax year. You will receive a consent form in the mail from Pharmacare within the next 7 or so business days. It is imperative that you sign and return this to them immediately as failure to do so will result in them suspending your Fair Pharmacare coverage.
Do not confuse Fair Pharmacare with your Medical Services Plan (MSP) coverage as these are two different entities. MSP covers your doctor visits, hospital visits, etc., whereas Fair Pharmacare is funding assistance for your prescriptions. If you are not registered you will have an automatic annual deductible of $10,000 before they will provide any funding assistance whatsoever.
Once registered you will be given an annual deductible based upon your family income level. There will be 2 amounts to this deductible, for example:
This means that you have to contribute a certain amount defined by Pharmacare before they provide any assistance. Once that minimum has been met they will contribute partially or in full (depending on your income) of all approved expenses until you have paid out of pocket the amount of your maximum deductible, after which they will cover 100% of all approved expenses.
Unfortunately, this might still leave portions of the cost unpaid. There may be further funding assistance available for the deductible portions depending on the individual situations. See below for information on Secondary Funding & Alternative Funding Options.
These deductibles do not apply to anyone that is receiving financial assistance from the Ministry of Employment & Income Assistance (also known as welfare, or disability benefits). If you receive assistance from the Ministry then you would likely fall under PharmaCare Plan C which has 100% funding coverage for approved goods and services.
One thing to keep in mind is that BC Pharmacare will only cover approved expenses that fall within their “Basic Functionality” Guidelines. Therefore, depending upon your prosthetic needs there may be more than just the deductible portion left due after Pharmacare has paid their portion. That being said there are other sources of funding that may be available to you. You just need to discuss all your options with a funding expert within your prosthetist’s facility.
If your amputation was the result of a workplace incident and you have an active claim with any WorkSafe/WCB agency in Canada you will have 100% coverage for all approved prosthetic care. You need to be assessed by a prosthetist, who will then submit to the appropriate board on your behalf for the necessary work. Once approval has been provided all expenses for that work are covered by that agency. This funding has a larger scope of funding coverage available to to their recipients since it is often the only source of funding available to these clients.
The NIGH or Non Insured Health Benefits Program of Health Canada provides registered First Nations people and Inuit with a limited range of medically necessary health related goods & services when they are not otherwise insured by provincial, territorial or other third party health plans. This program is now being governed by ESI Canada, a leading health benefits management company. This agency has strict guidelines as to what they cover and how often. Funding approval must be obtained prior to starting on any prosthetic services.
That covers the primary funding agencies and from there any balances left then go on to any available secondary/third party agencies. For this group we will start with:
Secondary Insurance Agencies
Typically, these are your private agencies such as Pacific Blue Cross, Standard Life, Great West Life, etc.
These are private insurance policies that most people get from their employers but can be obtained privately by the individual as well. These agencies have different rules depending upon the agency in question, as well as dependant upon the policy the client is covered under. If in doubt, we recommend you contact your secondary insurance provider and inquire as to what they cover towards prosthetics both annually and for a lifetime ( some policies have a lifetime maximum which is important to be aware of if considering big ticket items such as computerized knees like the C-Leg or Plie Knee, for example).
Insurance companies prefer to have the funding request submitted upfront once the amount to be contributed by the primary agency is known, so that they can either accept of deny the claim upfront especially when considering the larger costs of replacement of new prostheses. However, in the case of smaller amounts (for repairs or supplies) it is often easier for the client to claim the amounts back from the funding agency following payment to the service provider. The reimbursement from these agencies varies as much as the different types of policies available but typically they pay between 70-80% of the approved costs on a reasonable priced “basic” prosthesis less the amount paid by your primary agency.
If you have become an amputee as a result of a motor vehicle accident in BC but did not receive a settlement, you might be covered under ICBC’s Part 7. This gives those accident survivors that do not receive a cash settlement a “funding account” of up to $150,000 to be used toward costs related to the amputated limb. Like all the above listed funding agencies, work cannot commence prior to receiving approval for the work to be done. In the case of ICBC any contravention to this rule will result in a denial of funding.
Last of all for funding options comes:
Charitable Organizations provide funding assistance for amputees. The largest of these is The War Amps of Canada. Within the War Amps there is the National Amputee Centre (NAC) which is located in Ottawa, Ontario. The War Amps NAC has various programs for funding. They are as follows:
Adult Amputee Prosthetic Program
This program is for amputees registered as adults and provides limited funding every 3 or more years towards a new prosthesis only. This program does not provide funding assistance for supplies or repairs.
The Champ Program
The Champ Program (Child Amputee) provides funding coverage for all child amputees registered under the age of 18 years. This program is fairly flexible and understands the needs of children; both in growth needs and recreation needs. They will provide funding for a variety of prosthetic requests with prior approval.
Champ Adult Program
This program provides funding for adult amputees that were registered with the War Amps prior to turning 18 years of age. This will continue to provide more flexible funding for these clients than they do for the adult registered amputees sub it is not flexible as the funding children. As well, all agencies pre-approval is necessary.
War Amps – Vancouver Branch
The War Amps has a local branch here in Vancouver that also provides funding assistance for amputees that are registered with the War Amps. Although we are unsure of the exact guidelines for funding, it seems so far as though they take each application on a case by case basis and are not restricted to funding of new prostheses only as they have assisted clients with costs for repairs and supplies as well in the past.
You should also consider approaching any of your local resource to ask funding if you need it. It is not unheard of for a Legion or Rotary Club to assist local people to obtain necessary prosthetic care if this is beyond their reach financially. Also consider local churches, fire fighters, etc. There are many groups within your local neighborhood that might be willing and able to assist you, in fact they may even be looking for a “project” to provide assistance with.
Last of all is the Medical Loaning Agencies. Another option is going to your bank as they might be able to offer you better terms if this is the option you are looking at.