Guide to Dental Coverage Under Non-Insured Health Benefits (NIHB)

The Non-Insured Health Benefits (NIHB) program provides eligible First Nations and Inuit individuals with coverage for a range of health benefits, including dental care.

To be eligible for 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 one of the four Inuit land claim organizations under their land claim agreement
A child under 2 years of age whose parent qualifies for NIHB

There is no application process for this program. All individuals meeting the criteria above can access dental care services under the NIHB program. The practitioner may request to see the client's documentation at each visit to confirm identity and ensure information is correct.

The dental services covered under the NIHB include, but are not limited to:

Category	Examples of Covered Services	Coverage Details	Notes
Diagnostic Services	Comprehensive, recall, and emergency examinations X-rays (bitewings, periapical, panoramic)	Exams: Typically covered at recommended frequencies (e.g., one comprehensive exam every 2 years, recall exams every 6 or 9 months depending on age, emergency exams as needed). Radiographs: Covered based on clinical necessity and standard NIHB frequency guidelines (e.g., bitewings every 6–12 months, panoramic X-ray within specified intervals).	Panoramic or full-mouth X-rays sometimes require justification (e.g., for impacted teeth or complex diagnoses). Check the NIHB schedule for age-based frequencies and intervals.
Preventive Services	Polishing, fluoride treatments Pit and fissure sealants Scaling (periodontal debridement)	Routine cleaning/polishing: Allowed at specified intervals (e.g., once or twice a year, depending on age and region). Fluoride: Covered based on age or caries risk (often up to 2 times per year for children/adolescents). Scaling: NIHB covers a set number of scaling units per year, but additional units may require approval or justification.	Frequency limits apply (e.g., the number of scaling units is capped annually). Additional scaling beyond the annual maximum requires pre-approval with supporting clinical notes (periodontal status, etc.).
Restorative Services	Amalgam or tooth-coloured fillings Prefabricated crowns (stainless steel) for primary teeth	Fillings: Typically covered for cavities or tooth fractures. Materials: Both amalgam and composite (tooth-coloured) often covered; some rules may limit composite use on posterior teeth, unless justified by clinical need. Primary teeth crowns: Covered when needed to save the tooth (e.g., stainless steel crowns for children).	Large or multiple restorations may need supporting clinical information (X-rays, reason for multiple fillings). In some cases, more extensive restorations (e.g., inlays, onlays) may not be covered or require specific pre-approval.
Endodontic Services	Pulpotomy, pulpectomy Standard (non-complicated) root canal Root canal retreatment	Pulpotomy/Pulpectomy: For primary teeth or emergency relief. Standard Root Canal Therapy: Usually covered for permanent teeth to retain a salvageable tooth, especially anterior or premolars. Retreatment: Possible coverage if the tooth can be saved and there is a reasonable prognosis for success.	No pre-approval for standard, uncomplicated root canals on certain teeth (especially anterior teeth). Pre-approval may be required for some posterior teeth (like molars) or complicated cases. Clinical documentation (X-rays, notes) is often needed for retreatments or certain molars to confirm necessity and prognosis.
Periodontal Services	Scaling (advanced periodontal debridement) Root planing Periodontal surgery (in limited circumstances)	Coverage typically extends to basic periodontal care such as root planing and scaling beyond routine prophylaxis if justified by periodontal charting and clinical notes. Major periodontal surgery (e.g., flap surgery) might be covered only if other conservative treatments have failed or if it’s the only way to save the tooth.	Pre-approval is often required for specialized periodontal surgeries. Documentation (periodontal charting, radiographs) is required to demonstrate necessity.
Prosthodontic Services	Dentures (complete or partial) Repairs, rebasing, relining	Dentures: Full or partial dentures are usually covered with certain frequency limits (e.g., once every 8 years for a complete set), and prior approval is often required. Repairs/relines: Covered if the existing denture can be salvaged and if clinically indicated. Tissue conditioning and soft liners may also be covered if needed.	Pre-approval is required for new or replacement dentures, along with supporting documentation (charts, X-rays if requested). Repairs, relines, and adjustments typically require justification within certain timeframes.
Oral Surgery	Extractions (simple and complex) Minor surgical procedures (e.g., impacted teeth)	Extractions: Covered when the tooth cannot be saved, including erupted or impacted teeth. Surgical procedures: Some complex procedures (e.g., impacted wisdom teeth) may require additional documentation or specialist referral.	Many oral surgery procedures need a predetermination or specialist referral (e.g., impacted wisdom teeth with sedation). Justification with X-rays, clinical notes is standard for major surgeries.
Orthodontic Services	Orthodontic assessments Braces (for severe malocclusion)	Limited Coverage: Orthodontics under NIHB is usually restricted to cases of severe malocclusion that affects function or poses health risks (e.g., speech impediments, risk to tissues). Comprehensive orthodontic coverage requires a special assessment and typically must meet strict clinical criteria.	Pre-approval is mandatory. A qualified orthodontist must provide treatment plans, study models, X-rays, photos, etc. Minor or cosmetic orthodontics (e.g., mild crowding) is typically not covered.
Adjunctive Services	Sedation or general anesthesia Consultations or specialist fees	Conscious sedation (nitrous oxide, oral sedation) may be covered in specific cases (e.g., young children, special needs patients). General anesthesia is covered when it’s deemed medically necessary (e.g., complex surgery, severe anxiety or special needs).	Usually requires pre-approval with justification (medical reasons, patient’s age, complexity). Specialist consultations (oral surgeons, pediatric specialists) are often covered if referred by a general dentist.

For the most accurate and up-to-date details (including procedure-specific frequency limits), refer to the official NIHB Dental Benefits page.

This program has been available since 2002. Services can be accessed through a licensed dental care provider.

Key NIHB (Non-Insured Health Benefits) Dental Coverage Details

Certain dental services may require prior approval/predetermination. This includes orthodontics, extractions and sedation.

Emergency dental services do not require predetermination. Emergency services can include examinations and radiographs, procedures for the immediate relief of pain and infection and preliminary care for trauma to the mouth.

In some cases, dental providers may be enrolled in the NIHB program and can submit claims directly. In other cases, the patient will need to pay for the services upfront and submit their own claim to Express Scripts, which handles reimbursement. If the patient is visiting a dentist who is not enrolled in the program, they should first contact the NIHB program to confirm coverage.

FAQs

What are the steps to submit a claim for dental services under the NIHB program if my dental provider is not enrolled?

The steps to submit a claim to Express Scripts are as follows:

Create an NIHB Express Scripts account.
Enter all relevant information under ‘Submit Claim’.
Attach relevant documents and submit.

Are there any dental services that are not covered under the NIHB program?

Some services will not be covered or considered for appeal under the NIHB program. This includes mouth guards, bone grafts, veneers and more.

References

*The content provided in this article, including text, graphics, and referenced material, is intended for informational purposes only and is not a substitute for professional dental advice, diagnosis, or treatment. Always consult with your dentist or another qualified oral health professional for questions regarding your dental condition. Never disregard professional dental advice or delay seeking it based on information from this article. If you believe you have a dental emergency, contact your dentist, or seek immediate assistance from an oral healthcare professional.

Guide to Dental Coverage Under Non-Insured Health Benefits (NIHB)

Key NIHB (Non-Insured Health Benefits) Dental Coverage Details

FAQs

References

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