Medical Equipment - Breathing Devices

Overview

The least expensive, appropriate breathing devices may be provided to specific recipients to assist with a medically essential need. There must be no other resources available to the client to provide the breathing device requested.

The ministry provides breathing devices under the Employment and Assistance Regulation and the Employment and Assistance for Persons with Disabilities Regulation.

Policy

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Types of Breathing Devices

Effective: February 5, 2019

Breathing devices include only the following types of items:

positive airway pressure devices
apnea monitors
suction units
percussors
nebulizers
medical humidifiers
inhaler accessory devices

Eligibility Criteria

Effective: February 5, 2019

Breathing devices are available to clients who are eligible for general health supplements or meet the Life Threatening Health Need criteria. [For information on eligibility for general health supplements, see Related Links - Health Supplement Summary.]

A requested item must meet the following:

General Requirements for All Breathing Devices;

and

Specific Requirements for each Individual Type of Breathing Device.

General Requirements for All Breathing Devices

A client requesting a breathing device must meet general requirements that apply to all breathing devices:

there are no resources available to the family unit to pay the cost of or obtain the breathing device;
the item is the least expensive, appropriate breathing device;
must be prescribed by a medical practitioner or nurse practitioner; and
- if a Positive Airway Pressure Device, the medical need must be confirmed by the assessment of a respiratory therapist; or
- if another item, the medical need must be confirmed by the assessment of a relevant therapist (respiratory, occupational, or physical); and
the request must be pre-approved by the ministry prior to purchase.

Note: the ministry will not accept payment responsibility, except in cases of a life-threatening emergency, for breathing devices purchased without prior approval.

**Specific Requirements for each Individual Type of Breathing Device**
Type of Item	Specific Requirements
Positive Airway Pressure Devices	the ministry is satisfied that the positive airway pressure device or supply or accessory to operate the device is medically essential for the treatment of moderate to severe sleep apnea
Apnea Monitor	the ministry is satisfied that the apnea monitor, accessory, or supply is medically essential to monitor breathing
Suction Unit	the ministry is satisfied that the suction unit, accessory, or supply is medically essential for clearing respiratory airways
Percussor	the ministry is satisfied that the percussor, accessory, or supply is medically essential for clearing respiratory airways
Nebulizer	the ministry is satisfied that the nebulizer, accessory, or supply is medically essential to avoid an imminent and substantial danger to health medically essential to avoid an imminent and substantial danger to health refers an immediate need for a nebulizer where, without the nebulizer, the person is at risk for compromised health. For example: To avoid a significant health risk, a person has been provided with medication by Pharmacare that cannot be delivered without a nebulizer. A person with cystic fibrosis who requires hypertonic saline delivered by a nebulizer to avoid a significant health risk.
Medical Humidifier	the ministry is satisfied that the medical humidifier, accessory, or supply is medically essential to moisturize air in order to allow a tracheostomy patient to breathe
Inhaler Accessory Device (e.g. spacer)	the ministry is satisfied that the inhaler accessory device, accessory, or supply is medically essential to deliver medication

When clients no longer require the breathing device and it cannot be exchanged or traded to meet a current need, they should be encouraged to donate the item to an agency that would benefit from that item.

Non-Eligible Items

Effective: February 5, 2019

The ministry does not provide medical equipment and devices that do not meet the eligibility criteria above. For example:

ventilators

No Other Resources

Effective: February 5, 2019

By regulation, the ministry requires that all other available resources must first be considered before requesting funding. For income assistance and disability assistance clients, other resources include (but are not limited to) accessing breathing devices or funding through:

Other government programs or funding sources (e.g., Fair PharmaCare, Health Authorities, ICBC, WorkSafeBC, Veterans Affairs Canada)
Private insurance.

If there are other resources available, the individual is not eligible for breathing devices from the ministry.

Co-funding may be considered when other resources cannot pay the entire cost. For example, if an insurance company will pay $500 for an item that costs $1000, the ministry may consider funding the remaining $500 if all other eligibility criteria are met.

Note: When assessing breathing device eligibility for income or disability assistance clients, exempt assets are not considered. When assessing other resources for persons with a life-threatening health need, persons who are medical services only or transitional health services, see Related Links – Life-Threatening Health Need, Medical Services Only, or Transitional Health Services.

Guidelines for Determining Medically Essential for Treatment of Moderate to Severe Sleep Apnea

Effective: February 5, 2019

Sleep apnea occurs when a person regularly stops breathing for 10 seconds or longer during sleep. It can be mild, moderate, or severe, based on the number of times an hour that the person stops breathing (apnea) or that airflow to the lungs is reduced.

The ministry will consider funding positive airway pressure devices when medically essential for treatment of moderate to severe sleep apnea based on information provided by the Respiratory Therapist.

To determine whether sleep apnea is moderate to severe, ministry staff use guidelines determined by Ministry of Health [see Additional Resources – HealthLinkBC – Stages of Sleep Apnea].

Required Documentation

Effective: February 5, 2019

Recipients are responsible for providing required documentation. The ministry is not responsible for any fees associated with documentation.

Repairing or Replacing Breathing Devices

Effective: February 5, 2019

The ministry may consider repairing or replacing breathing devices due to the medical equipment being damaged, worn out, or not functioning.

Repairs may be considered if all of the following are met:

It is more economical to repair, rather than replace, the breathing device;
The breathing device has not been damaged by misuse;
If the device was not previously provided by the ministry, all other eligibility requirements must be met (e.g., prescription, assessment).

Note: Repairs are not considered for breathing devices that are under warranty. Upon the end of the warranty, the ministry may consider funding repairs.

Replacement may be considered if all of the following are met:

It is more economical to replace, rather than repair, the breathing device;
The breathing device has not been damaged by misuse;
The time period, if any, set out in the table below has passed.

Note: The replacement time period does not apply when an item is required due to changes in a person’s medical condition.

Breathing Device	Replacement Time Period
Positive Airway Pressure Devices	5 years
Accessories or supplies required to operate a positive airway pressure device	1 year
Apnea monitors, suction units, percussors, nebulizers, medical humidifiers	5 years
Inhaler Accessory Device (e.g. spacer)	1 year
Accessories or supplies required to operate an apnea monitor, suction unit, percussor, nebulizer, or medical humidifier	1 year

Procedures

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Assessing Eligibility

Effective: February 5, 2019

Persons who are income assistance or disability assistance recipients requesting breathing devices must first be determined to be eligible for general health supplements. If eligible, the following procedures must then be completed to assess eligibility for breathing devices.

Persons who are not income assistance or disability assistance recipients but require medical equipment for a direct and imminent life-threatening health need must meet the eligibility criteria for Life-Threatening Health Needs before being assessed eligibility for medical equipment and devices [see Related Link – Life Threatening Health Needs].

The ministry requires that all other available resources must first be considered before funding any requests. If there are other resources available, the individual is not eligible for breathing devices from the ministry. Co-funding may be considered when other resources cannot pay the entire cost [see Policy – No Other Resources].

Positive Airway Pressure Devices

Effective: February 5, 2019

All requests for positive airway pressure equipment must be assessed by Health Assistance (HA). To assess eligibility for positive airway pressure equipment, follow these steps:

POC	1.	Confirm that the recipient is eligible for general health supplements or are making an application under life-threatening health needs [see Policy].
	2.	Provide the client with a Breathing Device Request and Justification form (HR3727) and advise the client what information is required to complete the application. The assessment should include a current baseline overnight oximetry (completed within the past six months) or polysomnogram (completed without CPAP or BIPAP) to demonstrate severity of obstructive sleep apnea (OSA). The ministry only funds CPAP or BIPAP for moderate to severe OSA.
	3.	Forward the completed HR3727 including client signature (Section 1), medical practitioner or nurse practitioner prescription (Section 2), and assessment of respiratory therapist (Section 3), quote and other required documentation outlined above, to HA for adjudication.
HA	1.	Assess application and ensure that eligibility criteria are met.
	2.	If approved, a purchase authorization will be sent to the service provider and client. If denied, the client will be sent substantive reasons for the decision and be offered the right to reconsideration. The service provider will be also advised of the denial.
	3.	Make a note of all details. Details include substantive reasons explaining what is requested and why the eligibility criteria are met or not met. If the item is approved, include the cost of the item and the name of the service provider.

Purchase of Other Breathing Devices

Effective: February 5, 2019

Clients requesting breathing devices must first be determined to be eligible for general health supplements or approved under life-threatening health needs. All other resources must first be considered before the ministry funds any payment of breathing devices.

Health Assistance (HA) will assess a client’s eligibility for the purchase of breathing devices, follow these steps:

POC	1.	Confirm that the recipient is eligible for general health supplements or are making an application under life-threatening health needs [see Policy].
	2.	Verify that there are no other resources available [see Policy].
	3.	Provide client with the Breathing Device Request and Justification form (HR3727) and advise the client what information is required to complete the application.
	4.	For all eligible breathing devices except positive airway pressure devices (for positive airway pressure devices – see separate procedures above), advise the client to take the HR3727 to their medical practitioner or nurse practitioner for completion of Section 2 and to their respiratory therapist, occupational therapist or physical therapist for an assessment and quote which is completion of Section 3.
	5.	Forward the Service Request and all documentation to HA for adjudication.
HA	1.	Assess application and refer to policy to ensure eligibility criteria are met.
	2.	If application is approved, an approval letter will be issued to the client and a purchase authorization will be sent to the service provider. If denied, the client will be sent substantive reasons for the decision and be offered the right to reconsideration. The service provider will be also advised of the denial.
	3.	Make a note of all details. Details include substantive reasons explaining what is requested and why the eligibility criteria are met or not met. If the item is approved, include the cost of the item and the name of the service provider.

Note: If a diagnosis and prescription from a medical practitioner, or nurse practitioner and/or the assessment from the respiratory therapist are received before the HR3727 is completed, Section 1 must still be completed by the client and forwarded with the supplemental documentation to HA.

Repairs of Breathing Devices

Effective: February 5, 2019

Note: All requests for repairs for Breathing Devices must be assessed by Health Assistance (HA).

For repairs of breathing devices, follow these steps:

POC		Forward the Service Request and documentation outlining the repairs needed and the estimated cost to HA for review.
HA	1.	Assess the application and ensure that eligibility criteria are met.
	2.	If approved, a letter will be issued to the client and a purchase authorization will be sent to the service provider. If denied, the client will be sent substantive reasons for the decision and be offered the right to reconsideration. The service provider will be also advised of the denial.
	3.	Make a note of all details. Details include substantive reasons explaining what is requested and why the eligibility criteria are met or not met. If the item is approved, include the cost of the item and the name of the service provider.