Treatment Benefits Program of Choice (POC) 9 Oxygen Therapy and Respiratory Equipment Policy

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Issuing Authority

Director General, Policy and Research

Effective Date

March 31, 2025

Document ID

2097

Authority Policy Statement/Objective Policy Requirements Eligibility Criteria Exceptions / Exclusions Qualifying Conditions and Considerations Description of Benefit or Service Duration and Continuity Overpayments Redress/Appeals Appendix A – References and Related Policies References Related Policies

Authority

Veterans Health Care Regulations, section 4 under Part I, enacted under the authority of the Department of Veterans Affairs Act

Policy Statement/Objective

The payment or reimbursement of approved oxygen and respiratory equipment under Program of Choice (POC) 9 is to ensure eligible individuals receive financial support for appropriate and needed care for their identified health needs as intended under the Veterans Health Care Regulations (VHCR).

For the purposes of this policy, POC 9 items include but are not limited to oxygen concentrators, oxygen compressors, oxygen gas, continuous positive airway pressure machines (CPAP), automatic positive airway pressure machines (APAP), bilevel positive airway pressure machines (BiPAP), and ventilators.

Policy Requirements

Eligibility Criteria

Eligibility for treatment benefits is set out in section 3 of the VHCR.
Subsections 3(1) to 3(3) of the VHCR describe eligible clients with A-line coverage.
A former member or serving civilian member of the Royal Canadian Mounted Police (RCMP) with entitlement to a disability pension in respect of RCMP service is eligible for treatment benefits for their entitled condition, per a Memorandum of Understanding between the RCMP and Veterans Affairs Canada (VAC).
The Treatment for a Disability Benefits Entitled Condition policy sets out principles to be applied by the decision-maker when determining if a relationship exists between a treatment benefit and a client’s disability benefits entitled condition.
VHCR subsections 3(4) to 3(6) describe eligible clients with B-line coverage. See the Requirement to Access Provincial Programs policy for more information on determining B-line coverage, including where provincial or territorial programs are not sufficient to meet an eligible client’s needs, or are not provided in a timely manner. See the Costs Recoverable From Third Parties policy for information related to situations where the benefit cost is recoverable from a third party.
Where an eligible client has both A-line and B-line coverage, VAC’s funding for treatment benefits is considered in the following sequence:
1. treatment benefits related to a disability entitled condition.
2. treatment benefits for non-entitled conditions:
  1. payment or reimbursement of any residual amounts payable by the eligible client after accessing benefits provided under a provincial or territorial public health system; or,
  2. eligible benefits not provided by the provincial or territorial public health system.

Exceptions / Exclusions

Still-serving Regular Force members of the Canadian Armed Forces (CAF) and still-serving members of the RCMP are not eligible for treatment benefit coverage from VAC.
Class A or Class B (contracts of 180 days or less) CAF Reserve Force members who have disability benefit entitlement may be eligible to access financial support provided for approved treatment benefits.
The Rehabilitation Related Expenses – Other Than Training policy provides information on eligible expenses incurred by clients when accessing rehabilitation and vocational assistance services under the Veterans Well-being Act and Veterans Well-being Regulations.

Qualifying Conditions and Considerations

Approved prescribers may be found in the benefit grids and the Health Professionals policy. The Health Professionals policy provides direction on the criteria used by the Department to approve health professionals who deliver services to eligible clients.
Oxygen and respiratory equipment/supplies that may be approved are typically listed in the benefit grids. Items not listed may be considered by the Department when:
1. the equipment/supplies would qualify under POC 9 as oxygen and respiratory equipment; and,
2. there are no other acceptable equipment/supplies available in the particular case; or,
3. there is medical justification that the equipment/supplies are an appropriate intervention to address the client's eligible health needs.
Oxygen and respiratory equipment/supplies should not be authorized or replaced if there is a reasonable probability that:
1. the equipment may negatively affect the client’s health; or,
2. the equipment will be used in a manner or environment that creates a risk of injury to the client or others.

Description of Benefit or Service

The amount the Department is authorized to pay for services and benefits is established in accordance with section 5 of the VHCR. Paragraph 4(c) of the Rates Payable for Treatment Benefits policy explains that the cost of a benefit must reflect what is typically charged in the community in which it is provided.
If an eligible client chooses a provider who charges more than what VAC is permitted to pay for a particular benefit, the client can:
1. select another provider whose fees and costs are within the applicable rate for which VAC has the authority to pay, or,
2. pay the difference between what VAC is authorized to pay and what the provider charges.

Duration and Continuity

Unless otherwise supported within the VHCR, claims must be submitted by or on behalf of a client within 18 months of the day on which the expense was incurred for the eligible treatment benefit. See the Payment Time Limits for Benefits, Services or Care policy for information on when exceptions to this timeframe can be made.
The Renewal of Treatment Benefits policy provides guidance on the subsequent approval of benefits and services that have been approved previously under the authority of the VHCR.
For direction when clients are no longer eligible to receive benefits, services or care under the VHCR, see the Continuation of Benefits, Services or Care policy.

Overpayments

Overpayments will be addressed in accordance with the Overpayments – Health Care Programs policy. The policy provides direction on the recovery, remission, or write-off of treatment benefit overpayments.

Redress/Appeals

A client who is dissatisfied with a decision made under this policy may request to have the decision reviewed in accordance with the Review of Health Care Decisions policy.