I APPEAL# __ PART C Decision under Appeal In a reconsideration decision dated 13 June, 2012, the Ministry denied the Appellant full coverage of dental fees because they determined the submitted cost of the Appellant's treatment plan exceeded the rate and frequency limits as set out in the EAPWDR Schedule of Fee Allowances Dentist. PART D Relevant Legislation Employment and Assistance Persons with Disabilities Regulation, Section 63 Employment and Assistance Persons with Disabilities Regulation, Schedule C, Section 4 Employment and Assistance Persons with Disabilities Regulation, Schedule of Fee Allowances Dentist EAAT 003(10/06/01)
IA PPEAL# PART E Summary of Facts Preliminary Matter: The Ministry requested that a trainee sit in the hearing as an observer. The Appellant or his Advocate did not object, therefore the Panel proceeded with the hearing with the observer present. The evidence before the Ministry at the time of the reconsideration decision included: • Reasons for reconsideration from the Appellant dated June 5, 2012. • Two letters from the Appellant's dentist dated April 18, 2012 and February 8, 2012. • A statement of dental fees per appointment from the Appellant's dentist estimating $134.46 to be paid by the insurer and $59.34 to be paid by the Appellant. In the letter dated April 18, 2012, the dentist states the Appellant has severe gingivitis and moderate periodontitis due to a lack of motivation for thorough home care. He explains a treatment plan every 4 months could decrease the Appellant's likelihood of decay. In the letter dated February 8, 2012, the dentist states "As requested by A (the Appellant), I am writing a letter of exception to have his patient portion covered." He refers to his statement of costs that estimates the patient fees to be $59.34 every 4 months. In his reasons for reconsideration, the Appellant states his support staff helped him write his submission and historically additional funding has been approved for others and he wants the same consideration. He refers to a commitment by the minister of Social Development to improve supports for people with developmental disabilities. He states his monthly income is not sufficient to cover his regular bills and he is facing mounting debt every month and cannot cover the costs associated with his necessary dental care. He concludes without the financial support to cover the costs, he will be unable to maintain his dental health. In the reconsideration decision, the Ministry confirms the Appellant as a designated person with disabilities (PWD) and as such is eligible for dental supplements under Section 63 and Schedule C, Section 4 and the EAPWDR. The Ministry continues that basic dental services under the section are limited to a maximum of $1,000 each 2 year period and the Appellant's claim history indicates the Ministry has paid $110 of basic dental services for the current period. The Ministry states the amount remaining for the period is $890 and this may be applied to cover the planned dental treatment of the Appellant's dentist but within the financial and frequency limits as defined in the Schedule of Fee Allowances Dentist. The Ministry includes a chart, (Appendix C) based on the dentist's estimate of the 3 recommended treatment of 4 specific procedures and the Schedule of Fee Allowances. The Ministry determines that 3 of the procedures are allowed at the frequency suggested by the dentist but the fee the dentist estimates is in excess of the rates indicated in the Schedule. The Ministry determines the fourth procedure is also in excess of the rates indicated in the Schedule and is limited to one session per calendar year rather than the 3 times in the dentist's estimate. Based on these conclusions, the Ministry calculates the dentist's total fees to be $581 .40, the Ministry's coverage rates at $355.62 and the difference, or Appellant's portion to be $226.08. At the hearing the Aooellant stated he only earns approximately $300 per month in the summer and EAAT003(10/06/01)
IA PPEAL# he can't afford the additional dental expenses. At the hearing the Ministry submitted that although the Appellant has $890 available of his allowed $1000 for basic dental service over the current 2 year period, the Ministry cannot fund fees that exceed the legislated rates or frequency limits. From the information presented, the Panel finds: • The Appellant designated as a PWD and as such is eligible for dental supplements. • The Appellant has $890 for basic dental services available for the current period ending December 31, 2012. • The Appellant's dentist estimates a fee of $581.40 for an additional 3 treatments. EAAT003(10/06/01)
I APPEAL~ PART F Reasons for Panel Decision The issue in this case is the reasonableness of the Ministry's decision to deny the Appellant full coverage of dental fees because they determined the submitted cost of the Appellant's treatment plan exceeded the rate and frequency limits as set out in the EAPWDR Schedule of Fee Allowances Dentist. The relevant legislation in the EAPWDR is as follows: Schedule C "basic dental service" means a dental service that (a) if provided by a dentist, (i) is set out in the Schedule of Fee Allowances Dentist that is effective April 1, 2010 and is on file with the office of the deputy minister, and (B.C. Reg. 65/2010) (ii) is provided at the rate set out for the service in that Schedule, 4 (1) In this section, "period" means (b) in respect of a person not referred to in paragraph (a), a 2 year period beginning on January 1, 2003 and on each subsequent January 1 in an odd numbered year. (1.1) The health supplements that may be paid under section 63 [dental supplements] of this regulation are basic dental services to a maximum of (b) $1 000 each period, if provided to a person not referred to in paragraph The Ministry argues that it is not authorized to provide coverage for fees in excess of the financial and frequency limits for basic dental services other than at the rates and frequency provided by the Schedule of Fee Allowances Dentist. The Appellant argues that he cannot afford additional dental costs and without support he will be unable to maintain his dental health. The Panel acknowledges the Appellant will have remaining dental benefits as defined under EAPWDR Schedule C, Section 1 "basic dental service" with the suggested treatment plan from the Appellant's dentist. However, the definition specifies the rates and frequency of "basic dental service" as set out in the Schedule of Fee Allowances-Dentist. The Panel finds that the Ministry compared the dentist rates and frequency of the 4 procedures suggested from the treatment plan to that Schedule and indicated funding at the rate and frequency as set out for that service in that Schedule. The Panel finds the Ministry reasonably determined that it must provide funding at the rate and frequency as set out in the Schedule of Fee Allowances Dentist. The Panel finds the Ministry's decision was a reasonable application of the applicable lei:iislation and confirms the decision. EMT 003(10/06/01)
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