I APPEAL NUMBER PART C -DECISION UNDER APPEAL The decision under appeal is the reconsideration decision of the Ministry of Social Development and Poverty Reduction (the ministry) dated May 13, 2019, in which the ministry determined that, in accordance with section 1 of Schedule C of the Employment and Assistance Regulation (EAR), the appellant was not eligible for coverage of dental fees above the ministry rates for services provided. PART D -RELEVANT LEGISLATION EAR -Schedule C, sections 1, 4, 4.1, 5 and 6 Schedule of Fee Allowances -Dentist
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 [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 Rate Date: December 21, 2018, December 26, 2018 and December 27, 2018 1 36 23321 Permanent Molars, Bonded, One Surface $156.00 $124.88 Restorations, Posterior, Bonded, Two 2 75 23512 surfaces (continuous) $186.00 $148.93 Restorations, Posterior, Bonded, Two 3 74 23512 surfaces (continuous) $186.00 $148.93 4 N/A 02122 Radiographs, Periapical, Twelve images $88.60 $70.49 5 85 23511 Restorations, Posterior, Bonded, one surface $130.00 $104.48 6 53 23411 Restorations, Anterior, Bonded, one surface $121.00 $97.13 Examination and Diagnosis, complete, N/A 01103 Permanent dentition $77.13 $77.13 8 NIA 11112 Scaling, Two units $64.00 $64.00 9 N/A 11101 Polishing, One unit of time $27.23 $27.23 10 N/A 12101 Fluoride Treatment, Topical Application $10.61 $10.61 11 N/A 11117 Scaling, one half unit $15.58 $15.58 TOTAL: $1062.15 $889.39 The ministry notes that the PCB rates for the dental services reflect the additional 10% coverage provided to dentists who are specialists, though the full 10% was not provided for the radiographs which are limited to a maximum of $70.49 every two years. 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 25, 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 that coverage would be 100% and the appellant contacted an agent who advised that all basic dental services are 100% covered. The representative does not recall if she was told to get pre-approval but was unconcerned as both she and the dentist had been told that coverage would be 100%. The representative also provided a 1-page submission dated April 30, 2019, in which she notes that most of the dental services [for the appellant and some of the representative's other children] were provided in late December [2018]. In early February, when taking another child to the dentist, the dentist did not mention
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 , o r u n p a i d . T h e a p p e l l a n 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 t b e f u l l y p a i d b y P 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 rv i c e s . I n fo r m a t i o n p r o v i d e d o 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 2 0 , 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 h e a r i n g o n b e h a l f o f t h e a p p e l l a n t a n d r e i t e r a t e d t h e i 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 . 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 E A L N U M B E R 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 F e b r u a r y t h a t t h e 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 , s h e w o u l d h a v e 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 rv 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 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 f o r m a t i o n i n t h i s 3 p a g e l e t t e r . 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 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 .
r 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 ....
I APPEAL NUMBER 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 the provision of services to a child are in the right-hand 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 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 � 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 I APPEAL NUMBER 21.04 27.23 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
I APPEAL NUMBER 23513 Three surfaces 128.95 158.05 23514 Four surfaces 153.98 188.47 23515 Five surfaces (maximum) 179.08 219.6 3 Posts Limited to once per tooth in a 5 year period and only paid in conjunction with a restoration. Panel Decision On behalf of the appellant, the representative argues that it is unfair that full coverage of the dentist's fees is not provided given that the representative had received confirmation from both the dentist and the ministry that coverage would be 100%. Additionally, it should be the dentist who finds out what services are covered before providing services and it not the fault of the appellant or representative. The ministry's position is that "basic dental service" is defined as a service that is set out in the Schedule of Fee Allowances -Dentist at the rate set out in that Schedule which provides that a dentist who is a specialist may receive an additional 10%. Therefore, the ministry cannot provide coverage for dental services in excess of the limits and amounts set out in the Schedule of Fee Allowances -Dentist. Ministry policy places the onus on the dentist to determine the rate at which each dental service will be paid. While the panel acknowledges that there has been miscommunication and/or lack of communication in this case, which might have been due to the short window of time within which the dental services were required, because "basic dental service" is defined in section 1 of Schedule C of the EAR as a service that is both set out and provided at the rate in the Schedule of Fee Allowances -Dentist, the ministry can only provide coverage for dental services as described in that Schedule. In the appellant's circumstances, the Schedule of Fee Allowances-Dentist limits the amount that may be paid for radiographs to $70.49 in a 2-calendaryear period. As the appellant was provided top-up coverage of the $65.74 set out in the Schedule for radiograph service 02122 to the maximum of $70.49, the ministry has reasonably concluded that the full 10% top-up could not be provided. For the remaining dental services, the ministry has applied the full 10% top-up for specialists, and while the coverage remains less than the amount charged by the dentist, no additional coverage is allowed. Conclusion The panel finds that the ministry's reconsideration decision, which determined that the appellant was not eligible for coverage for dental services beyond the limits of coverage provided in the Schedule of Fee Allowances Dentist was a reasonable application of the legislation in the circumstances of the appellant, and therefore confirms the decision. The appellant is not successful on appeal.
I APPEAL NUMBER PART G -ORDER THE PANEL DECISION IS: (Check one) iXIUNANIMOUS □BY MAJORITY THE PANEL iXICONFIRMS 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) IXI and Section 24(2)(a) IXI or Section 24(2)(b) D PART H -SIGNATURES PRINT NAME Jane Nielsen SIGNATURE OF CHAIR DATE (YEAR/MONTH/DAY) 2019/06/12 PRINT NAME Wesley Nelson DATE (YEAR/MONTH/DAY) 2019/06/12 PRINT NAME Joseph Rodgers SIGNATURE OF MEMBER DATE {YEAR/MONTH/DAY) 2019/06/12
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