P A R T C D E C I S I O N U N D E R A P P E A L T h e d e c i s i o n u n d e r a p p e a l i s t h e r e c o n s i d e r a t i o n d e c i s i o R e d u c t i o n ( t h e m i n i s t r y ) d a t e d M a y 6 , 2 0 1 9 , i n w h i c h t h o f S c h e d u l e C o f t h e E m p l o y m e n t a n d A s s i s t a n c e R e g u l a d e n t a l f e e s a b o v e t h e m i n i s t r y r a t e s f o r s e r v i c e s p r o v i d e P A R T D R E L E V A N T L E G I S L A T I O N E A R S c h e d u l e C , s e c t i o n s 1 , 4 , 4 . 1 , 5 a n d 6 S c h e d u l e o f F e e A l l o w a n c e s D e n t i s tI A P P E A L N U M B E R n o f t h e M i n i s t r y o f S o c i a l D e v e l o p m e n t a n d P o v e r t y e m i n i s t r y d e t e r m i n e d t h a t , i n a c c o r d a n c e w i t h s e c t i o n 1 t i o n ( E A R ) , t h e a p p e l l a n t w a s n o t e l i g i b l e f o r c o v e r a g e o f d .
I APPEAL NUMBER PART E -SUMMARY OF FACTS Information before the ministry ot reconsideration The appellant is a dependent child whose family is in receipt of income assistance. The appellant's parent ("the representative") requested dental supplements for the appellant. Pacific Blue Cross (PBC), to which the ministry has delegated its powers, duties and functions respecting dental supplements in accordance with section 34 of the Employment and Assistance Act, approved coverage as explained in the following Chart and Notes [excerpt from the reconsideration decision]. The panel notes that the PBC record of service provision is included in the appeal record and is consistent with the Chart. Tooth Fee Description Dentist PBC No. Code Fees Coverage Date: December 21, December 26, and December 27, 2018 1 36 23321 Tooth Coloured Restoration/ Permanent Tooth/ Bonded -$156.00 *$124.88 Molar/ One Surface 2 7 5 23512 Tooth Coloured Restoration/ Primary Tooth/ Bonded -$186.00 *$148.93 Molar I Two Surfaces 3 74 23512 Tooth Coloured Restoration I Primary Tooth I Bonded -$186.00 *$148.93 Molar / Two Surfaces 4 n/a 02122 Radiograph / lntraoral -Periapical / Twelve Films $88.60 *$70.49 5 85 23511 Tooth Coloured Restoration/ Primary Tooth I Bonded -$130.00 *$104.48 Molar / One Surfaces 6 53 23411 _Tooth Coloured Restoration/ Primary Tooth/ Bonded -$121.00 *$97.13 Anterior I One Surface 7 n/a 01103 Complete Exam and Diagnosis on Permanent Dentition $77.13 *$77.13 8 n/a 11112 Scaling -Two Units $64.00 *$64.00 9 n/a 11101 Polishing $27.23 $27.23 10 n/a 12101 Topical Fluoride Treatment $10.61 $10.61 11 n/a 11117 Scaling -1/2 Unit $15.58 $15.58 TOTAL: $1,062.15 $889.39 �= -• Certified specialists, including oral surgeons may receive an additional 10% on services billed from the Schedule of Fee Allowances -Dentist. As your dentist is a specialist, you are eligible for the additional 10% as outlined above (see line items 1 through 8). Regarding fee code 02122 (line item 4): As per a note in the Schedule of Fee Allowances -Dentist, radiographs are limited to $70.49 every 2 calendar years for children under 19 years of age. Therefore, although the ministry can exceed the rate specified in Schedule of Fee Allowances Dentist as your dentist is a specialist, coverage for fee code 02122 cannot exceed $70.49. Regarding fee code 11112 (line item 8): Your dentist has charged $64.00 for this treatment. Therefore, you have been provided coverage of $64.00 as opposed to a full 10% over the ministry rate set out in the Schedule of Fee Allowances -Dentist. Reconsideration of the decision to deny coverage at the dentist's rates for dental services #1 through #6 was requested. In support of this request, the representative provided a 7-page submission dated April 23, 2019, in which she questions both the correctness of PBC's determination of the "over-charges" by the dentist and the denial to pay any amount for some dental services. The representative also notes that in two provinces where she previously resided complete coverage was provided when she was receiving social assistance and that she did not have to wait for pre-approval because the coverage was complete. Additionally, the dentist was advised by PBC
t h a t c o v e r a g e w o u l d b e 1 0 0 % a n d t h e a p p e l l a n t c o n t a c t 1 0 0 % c o v e r e d . T h e r e p r e s e n t a t i v e d o e s n o t r e c a l l i f s h e b o t h s h e a n d t h e d e n t i s t h a d b e e n t o l d t h a t c o v e r a g e w T h e r e p r e s e n t a t i v e a l s o p r o v i d e d a 1 p a g e s u b m i s s i o n d d e n t a l s e r v i c e s [ f o r t h e a p p e l l a n t a n d s o m e o f t h e r e p r e D e c e m b e r [ 2 0 1 8 ] . I n e a r l y F e b r u a r y , w h e n t h e r e p r e s e n d e n t i s t d i d n o t m e n t i o n a n y t h i n g a b o u t a m o u n t s o w i n g F e b r u a r y t h a t t h e d e n t i s t w a s a d v i s e d t h a t h e w o u l d n o s h e w o u l d h a v e r e q u e s t e d p r e a p p r o v a l f o r s e r v i c e s . I n fo r m a t i o n p r o v i d e d a n a p p e a l T h e a p p e l l a n t ' s N o t i c e o f A p p e a l ( N O A ) d a t e d M a y 1 4 , 2 P r i o r t o t h e h e a r i n g , t h e r e p r e s e n t a t i v e e m a i l e d a 3 p a g a r g u m e n t a n d f u r t h e r e x p l a n a t i o n o f t h e t i m e f r a m e a n d h e r c h i l d r e n , w i t h t h e r e p r e s e n t a t i v e n o t i n g t h a t s h e w a b e f o r e t h e n e w y e a r , w h e n a n e w t w o y e a r c y c l e o f d e n T h e m i n i s t r y d i d n o t o b j e c t t o t h e a d m i s s i o n o f t h e a d d i a d d i t i o n a l i n f o r m a t i o n e i t h e r r e i t e r a t e d o r p r o v i d e d f u r r e c o n s i d e r a t i o n a n d t h e r e f o r e a d m i t t e d t h e a d d i t i o n a l i E m p l o y m e n t a n d A s s i s t a n c e A c t . N e i t h e r t h e a p p e l l a n t n o r t h e r e p r e s e n t a t i v e a t t e n d e d t H e a r i n g t o t h e a p p e l l a n t , t h e h e a r i n g p r o c e e d e d i n a c c o A t t h e h e a r i n g , t h e m i n i s t r y e x p l a i n e d t h e r e c o n s i d e r a t i T h e a r g u m e n t s o f b o t h p a r t i e s a r e s e t o u t i n P a r t F o f t h I A P P EA L N U M B E R e d a n a g e n t w h o a d v i s e d t h a t a l l b a s i c d e n t a l s e r v i c e s a r e w a s t o l d t o g e t p r e a p p r o v a l b u t w a s u n c o n c e r n e d a s o u l d b e 1 0 0 % . a t e d A p r i l 3 0 , 2 0 1 9 , i n w h i c h s h e n o t e s t h a t m o s t o f t h e s e n t a t i v e ' s o t h e r c h i l d r e n ] w e r e p r o v i d e d i n l a t e t a t i v e t o o k a n o t h e r o f h e r c h i l d r e n t o t h e d e n t i s t , t h e , o r u n p a i d . T h e a p p e l l a n t b e l i e v e s t h a t i t w a s n o t u n t i l l a t e t b e f u l l y p a i d b y P B C . I f t h e a p p e l l a n t h a d k n o w n e a r l i e r , 0 1 9 , w h i c h d i d n o t i n c l u d e n e w e v i d e n c e . e l e t t e r , d a t e d J u n e 7 , t o t h e T r i b u n a l . T h e l e t t e r i n c l u d e s c i r c u m s t a n c e s o f t h e p r o v i s i o n o f t h e d e n t a l s e r v i c e s t o s q u i t e d e s p e r a t e t o g e t t h e d e n t a l w o r k c o m p l e t e d t a l f u n d i n g w o u l d b e g i n . t i o n a l i n f o r m a t i o n . T h e p a n e l d e t e r m i n e d t h a t t h e t h e r d e t a i l i n s u p p o r t o f i n fo r m a t i o n b e f o r e t h e m i n i s t r y a t n f o r m a t i o n i n a c c o r d a n c e w i t h s e c t i o n 2 2 ( 4 ) o f t h e h e h e a r i n g . A f t e r c o n f i r m i n g d e l i v e r y o f t h e N o t i c e o f r d a n c e w i t h s e c t i o n 8 6 { b ) o f t h e E A R . o n d e c i s i o n b u t d i d n o t p r o v i d e a d d i t i o n a l e v i d e n c e . i s d e c i s i o n .
I APPEAL NUMBER PART F -REASONS FOR PANEL DECISION Issue on Appeal The issue on appeal is whether the ministry's decision to deny the appellant coverage for dental services above ministry rates was reasonably supported by the evidence or was a reasonable application of the applicable enactment in the circumstances of the appellant. Relevant Legislation EAR Dental supplements 68 The minister may provide any health supplement set out in section 4 {dental supplements] of Schedule C to or for (a) a family unit in receipt of income assistance, if (i)the family unit includes a person with persistent multiple barriers to employment, or (ii) the health supplement is provided to or for a person in the family unit who is under 19 years of age ... Schedule C -Health Supplements Definitions 1 In this Schedule .... "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 September 1, 2017 and is published on the website of the ministry of the minister, and (ii} is provided at the rate set out in that Schedule for the service and the category of person receiving the service ....
APPEAL NUMBER I Dental supplements 4 (1) In this section, "period" means ( a ) in respect of a person under 19 years of age, including a child in a home of a relative, a 2 year period beginning on January 1, 2017 and on each subsequent January 1 in an odd numbered year. ... (1 . 1) The health supplements that may be paid under section 68 [dental supplements] of this regulation are basic dental services to a maximum of (a) $2 000 each period, if provided to a person under 19 years of age .... Schedule of Fee Allowances -Dentist [rates for services provided for children are in the right-side column] Specialist Referrals Certified specialists, including oral surgeons may receive an additional 10% on services billed from the Schedule of Fee Allowances -Dentist. The Ministry contractor must have a record of the specialty on their billing system and the referring practitioner must be indicated on the claim form. If either of these is missing, the claim will be refused or reduced. If the referring practitioner is a Medical Doctor, please indicate this clearly on the claim form. As fee item 01601 -Examination and Diagnosis, Surgical by Oral Surgeon is restricted for use by Oral Surgeons only the additional 10% will not be applied to this fee item. RADIOGRAPHS Radiographs are limited to: $54.71 every 2 calendar years for adults, and $70.49 every 2 calendar years for children under 19 years of age. A complete series, fee items 02101 or 02102 or thirteen films, fee item 02123, will be paid only once every 3 years. Fee item 02601, panoramic radiograph is excluded from the two year radiograph limit for children. Complete Full Mouth Series (including bitewings) 02101 Minimum 12 films 50.52 65.74 02102 Minimum 16 films 54.71 70.49 lntraoral -Periapical 02111 Single Film 9.95 12.84 02112 Two Films 13.59 17.59 02113 Three Films 17.31 22.41 02114 Four Films 21.04 27.23
02115 Five Films 02116 Six Films 02117 Seven Films 02118 Eight Films 02119 Nine Films 02120 Ten Films 02121 Eleven Films 02122 Twelve Films 02123 Thirteen Films TOOTH COLOURED RESTORATIONS l::l.m;. Maximum fee allowance is five surfaces or the dollar equivalent per tooth in a two-year period. Tooth numbers are required. When billing for restorations, the total number of surfaces restored in that sitting on that tooth should be billed cumulatively. Where two different filling materials are used, these restorations may be billed separately. Tooth Coloured -Permanent Teeth Bonded -Anterior 23111 One surface 23112 Two surfaces 23113 Three surfaces 23114 Four surfaces 23115 Five surfaces (maximum) Bonded -Bicuspids 23311 One surface 23312 Two surfaces 23313 Three surfaces 23314 Four surfaces 23315 Five surfaces (maximum) Bonded -Molars 23321 One surface 23322 Two surfaces 23323 Three surfaces 23324 Four surfaces 23325 Five surfaces (maximum) Tooth Coloured -Primary Teeth Bonded -Anterior 23411 One surface 23412 Two surfaces 23413 Three surfaces 23414 Four surfaces 23415 Five surfaces (maximum) Bonded -Molars 23511 One surface 23512 Two surfaces 23513 Three surfaces l APPEAL NUMBER 24.76 32.13 28.44 36.95 32.12 41.63 35,88 46.52 39.52 51.35 43.31 56,10 47.11 60.92 50.90 65.74 54.71 70.49 7 5 . 4 7 90.52 90.56 109.07 114.46 137.27 141.99 171.40 171.65 202.57 87.91 104.62 122.65 144.69 144.04 176,60 177.11 216.66 203.58 239.67 94.21 113.53 144.04 173.63 174.08 209.24 209.19 250.80 243.18 297.54 Adult Child 69.63 88.30 88.21 113.53 98.30 126.14 112.33 144.69 127.50 164.72 78.43 94.98 111.12 135.39 128.95 158.05
2 3 5 1 4 F o u r s u rf a c e s 2 3 5 1 5 F i v e s u rf a c e s ( m a x i m u m ) P o s t s L i m i t e d t o o n c e p e r t o o t h i n a 5 y e a r p e r i o w i t h a r e s t o r a t i o n . P a n e l D e c i s i o n O n b e h a l f o f t h e a p p e l l a n t , t h e r e p r e s e n t a t i v e a r g u e s t h p r o v i d e d g i v e n t h a t t h e r e p r e s e n t a t i v e h a d r e c e i v e d c o n c o v e r a g e w o u l d b e 1 0 0 % . A d d i t i o n a l l y , i t s h o u l d b e t h e p r o v i d i n g s e rv i c e s a n d i t n o t t h e f a u l t o f t h e a p p e l l a n t o T h e m i n i s t ry ' s p o s i t i o n i s t h a t " b a s i c d e n t a l s e rv i c e " i s d A l l o w a n c e s D e n t i s t a t t h e r a t e s e t o u t i n t h a t S c h e d u l e a d d i t i o n a l 1 0 % . T h e r e fo r e , t h e m i n i s t r y c a n n o t p r o v i d e a m o u n t s s e t o u t i n t h e S c h e d u l e o f F e e A l l o w a n c e s D e M i n i s t r y p o l i c y p l a c e s t h e o n u s o n t h e d e n t i s t t o d e t e r m W h i l e t h e p a n e l a c k n o w l e d g e s t h a t t h e r e h a s b e e n m i s c w h i c h m i g h t h a v e b e e n d u e t o t h e s h o r t w i n d o w o f t i m e " b a s i c d e n t a l s e r v i c e " i s d e f i n e d i n s e c t i o n 1 o f S c h e d u l e a t t h e r a t e i n t h e S c h e d u l e o f F e e A l l o w a n c e s D e n t i s t , a s d e s c r i b e d i n t h a t S c h e d u l e . I n t h e a p p e l l a n t ' s c i r c u m s t a n c e s , t h e S c h e d u l e o f F e e A l r a d i o g r a p h s t o $ 7 0 . 4 9 i n a 2 c a l e n d a r y e a r p e r i o d . A s t h i n c l u d e d t h e 1 0 % s p e c i a l i s t i n c r e a s e u p t o $ 7 0 . 4 0 f r o m $ n o r e m a i n i n g c o v e r a g e f o r t h e r a d i o g r a p h s . R e s p e c t i n g 2 3 3 2 1 , 2 3 5 1 2 a n d 2 3 4 1 1 , t h e m i n i s t r y h a s a p p l i e d t h e 1 s p e c i a l i s t , b u t n o a d d i t i o n a l c o v e r a g e i s a l l o w e d . C o n cl u s i o n T h e p a n e l f i n d s t h a t t h e m i n i s t r y ' s r e c o n s i d e r a t i o n d e c i s f o r c o v e r a g e f o r d e n t a l s e r v i c e s b e y o n d t h e l i m i t s o f c o v D e n t i s t w a s a r e a s o n a b l e a p p l i c a t i o n o f t h e l e g i s l a t i o n i n c o n f i r m s t h e d e c i s i o n . T h e a p p e l l a n t i s n o t s u c c e s s f u l o n I A P P E A L N U M B E R 1 5 3 . 9 8 1 8 8 . 4 7 1 7 9 . 0 8 2 1 9 . 6 3 d a n d o n l y p a i d i n c o n j u n c t i o n a t i t i s u n f a i r t h a t f u l l c o v e r a g e o f t h e d e n t i s t ' s f e e s i s n o t f i r m a t i o n f r o m b o t h t h e d e n t i s t a n d t h e m i n i s t r y t h a t d e n t i s t w h o f i n d s o u t w h a t s e rv i c e s a r e c o v e r e d b e f o r e r r e p r e s e n t a t i v e . e f i n e d a s a s e r v i c e t h a t i s s e t o u t i n t h e S c h e d u l e o f F e e , n o t i n g t h a t a d e n t i s t w h o i s a s p e c i a l i s t m a y r e c e i v e a n c o v e r a g e f o r d e n t a l s e r v i c e s i n e x c e s s o f t h e l i m i t s a n d n t i s t . i n e t h e r a t e a t w h i c h e a c h d e n t a l s e rv i c e w i l l b e p a i d . o m m u n i c a t i o n a n d / o r l a c k o f c o m m u n i c a t i o n i n t h i s c a s e , w i t h i n w h i c h t h e d e n t a l s e r v i c e s w e r e r e q u i r e d , b e c a u s e C o f t h e E A R a s a s e r v i c e t h a t i s b o t h s e t o u t a n d p r o v i d e d t h e m i n i s t r y c a n o n l y p r o v i d e c o v e r a g e f o r d e n t a l s e r v i c e s l o w a n c e s D e n t i s t l i m i t s t h e a m o u n t t h a t m a y b e p a i d f o r e a p p e l l a n t w a s p r o v i d e d c o v e r a g e i n t h i s a m o u n t , w h i c h 6 5 . 7 4 , t h e m i n i s t r y r e a s o n a b l y d e t e r m i n e d t h a t t h e r e w a s t h e o t h e r d e n t a l s e r v i c e s a t i s s u e , r e s t o r a t i o n s w i t h c o d e s 0 % s p e c i a l i s t t o p u p b e c a u s e t h e s e rv i c e i s p r o v i d e d b y a i o n , w h i c h d e t e r m i n e d t h a t t h e a p p e l l a n t w a s n o t e l i g i b l e e r a g e p r o v i d e d i n t h e S c h e d u l e o f F e e A l l o w a n c e s t h e c i r c u m s t a n c e s o f t h e a p p e l l a n t , a n d t h e r e fo r e a p p e a l .
I APPEAL NUMBER PART G -ORDER THE PANEL DECISION IS: (Check one) [g]UNANIMOUS □BY MAJORITY THE PANEL [gjCONFIRMS THE MINISTRY DECISION □ RESCINDS THE MINISTRY DECISION If the ministry decision is rescinded, is the panel decision referred back to the Minister for a decision as to amount? □Yes □No LEGISLATIVE AUTHORITY FOR THE DECISION: Employment and Assistance Act Section 24{1)(a) D or Section 24{1)(b) [gj and Section 24{2)(a) [gj or Section 24(2)(b) D PART H -SIGNATURES PRINT NAME Jane Nielsen SIGNATURE OF CHAIR DATE (YEAR/MONTH/DAY) 2019/06/12 PRJNTNAME Wesley Nelson SIGNATURE OF MEMBER DATE (YEAR/MONTH/DAY) 2019/06/12 PRJNTNAME Joseph Rodgers SIGNATURE OF MEMBER DATE (YEAR/MONTH/DAY) 2019/06/12
You are being directed to the most recent version of the statute which may not be the version considered at the time of the judgment.