PART C – Decision under Appeal The decision under appeal is the reconsideration decision of the Ministry of Social Development and Social Innovation (the ministry) dated March 11, 2016 which denied the appellant’s request for payment for dentures in excess of the rates allowed for a “basic dental service” in accordance with sections 1 and 4 of Schedule C of the Employment and Assistance for Persons with Disabilities Regulation (EAPWDR). PART D – Relevant Legislation EAPWDR, sections 1 and 4 of Schedule C Schedule of Fee Allowances - Denturist
PART E – Summary of Facts The appellant was not in attendance at the hearing. After confirming that the appellant was notified of the hearing, the hearing proceeded in accordance with section 86(b) of the Employment and Assistance Regulation. Information before the ministry at reconsideration The appellant is a recipient of disability assistance who received ministry approval for coverage for complete upper (maxillary) and lower (mandibular) dentures, identified respectively by fee codes 31310 and 31320 in the ministry’s Schedule of Fee Allowances – Denturist, with a fee amount of $581.25 for each service. On January 14, 2016, the denturist received payment of $1162.50 from Pacific Blue Cross on behalf of the ministry. The amount claimed by the appellant’s denturist was $1400 per service for a total of $2800.00. The ministry notes that as the appellant had paid the denturist $2155.74 towards the total charges of $2800 prior to the ministry issuing the $1162.50 payment, the denturist should reimburse the appellant the amount of $542.24. Information provided on appeal No additional evidence was provided at the hearing, with the ministry relying on the reconsideration decision.
PART F – Reasons for Panel Decision Issue under appeal The issue under appeal is whether the ministry decision, which held that the appellant is not eligible for coverage for dentures in excess of the rates allowed for a “basic dental service” in accordance with sections 1 and 4 of Schedule C of the EAPWDR, is reasonably supported by the evidence or a reasonable application of the legislation in the circumstances of the appellant. Relevant Legislation – EAPWDR and Schedule of Fee Allowances - Denturist Schedule C Definitions 1 In this Schedule……. "basic dental service" means a dental service that………. (b) if provided by a denturist, (i) is set out in the Schedule of Fee Allowances — Denturist that is effective April 1, 2010 and is on file with the office of the deputy minister, and (ii) is provided at the rate set out for the service in that Schedule, and Dental supplements 4 (1) In this section, "period" means (a) in respect of a dependent child, a 2 year period beginning on January 1, 2009, and on each subsequent January 1 in an odd numbered year, and (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 (a) $1 400 each period, if provided to a dependent child, and (b) $1 000 each period, if provided to a person not referred to in paragraph (a). (c) Repealed. [B.C. Reg. 163/2005, s. (b).]
(2) Dentures may be provided as a basic dental service only to a person (a) who has never worn dentures, or (b) whose dentures are more than 5 years old. (3) The limits under subsection (1.1) may be exceeded by an amount necessary to provide dentures, taking into account the amount remaining to the person under those limits at the time the dentures are to be provided, if (a) a person requires a full upper denture, a full lower denture or both because of extractions made in the previous 6 months to relieve pain, (b) a person requires a partial denture to replace at least 3 contiguous missing teeth on the same arch, at least one of which was extracted in the previous 6 months to relieve pain, or (c) a person who has been a recipient of disability assistance or income assistance for at least 2 years or a dependant of that person requires replacement dentures. Schedule of Fee Allowances – Denturist, Effective April 1 , 2010 FEE NO. FEE DESCRIPTION FEE AMOUNT ($) 31310 Complete Maxillary Denture 581.25 31320 Complete Mandibular Denture 581.25 Appellant’s position Based on his reconsideration submission and Notice of Appeal, the appellant’s position appears to be that the ministry has not provided full funding even though section 4(3) of Schedule C allows the $1000 limit to “be exceeded by an amount necessary to provide dentures…” Ministry’s position The ministry’s position is that the appellant has received the maximum amount of coverage allowed under the EAPWDR. Dentures are described as a “basic dental service” under section 4 of Schedule C and, in accordance with the definition of “basic dental service” set out in section 1 of Schedule C, the coverage for that service is provided at the rate set out in the Schedule of Fee Allowances – Denturist, which is $581.25 per denture for a total of $1162.50. In accordance with section 4(3) of Schedule C, the appellant received coverage for the dentures exceeding the 2-year period limit of $1000 set out under subsection (1.1), but the ministry has no authority to provide additional coverage to cover the difference between what the denturist charged and the allowable rate.
Panel Decision Section 4(1.1) of Schedule C sets out that the health supplements which may be provided under this section are “basic dental services” to a maximum of $1000 over a 2 year period. Subsection (2) sets out additional requirements specific to the provision of “dentures” as a basic dental service and subsection (3) allows for the $1000 limit set out in subsection (1.1) to be exceeded by an amount necessary to provide dentures if certain conditions are met. In this case, the ministry determined that the requirements for the provision of dentures for the appellant in excess of the $1000 limit were met. However, the provision of dentures is also governed by the definition of “basic dental service” in section 1 of Schedule C - a service set out the Schedule of Fee Allowances – Denturist “which is provided at the rate set out for the service in that Schedule.” It is not disputed that the services provided are identified by codes 31310 and 31320 and that the rate set out in the Schedule of Fee Allowances is $581.25 per denture for a total of $1162.50. The ministry has provided $1162.50 for the dentures as “basic dental services” in accordance with sections 1 and 4 of Schedule C, and while that amount is permitted to exceed the $1000 2-year period limit in accordance with subsection (3), there is no authority for the ministry to provide coverage at a rate in excess of the rate set out in the Schedule of Fee Allowances – Denturist. Conclusion Accordingly, the panel finds that in determining that the appellant is not eligible for coverage for his dentures at rates in excess of those set out in the Schedule of Fee Allowances – Denturist, the ministry has reasonably applied sections 1 and 4 of Schedule C of the EAPWDR in the appellant’s circumstances. The ministry’s reconsideration decision is confirmed.
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