I A P P EA L N U M B E R 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 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 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 8 , 2 0 1 9 , i n w h i c h t h 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 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 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 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 fo 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 t
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 Rate Date: December 21 and December 26, 2018 1 46 23321 Permanent Molars, Bonded, One surface $156.00 $124.88 2 36 23321 Permanent Molars, Bonded, One surface $156.00 $124.88 3 n/a 02118 Radiographs, Periapical, eight images $62.70 $51.17 4 n/a 0 1103 Examination and Diagnosis, complete, $77.13 $77.13 permanent dentition 5 n/a 11112 Scaling, Two units $62.32 $62.32 6 n/a 11101 Polishing, One unit of time $27.23 $27.23 7 n/a 12101 Fluoride Treatment, Topical Application $10.61 $10.61 TOTAL: $551.99 $478.22 Notes: 1. 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 received the additional 10% of coverage on line items 1-4. Reconsideration of the decision to deny coverage at the dentist's rates for dental services #1, #2 and #3 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 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 the representative took another of her children to the dentist, the dentist did not mention anything about amounts owing, or unpaid. The appellant believes that it was not until late February that the dentist was advised that he would not be fully paid by PBC. If the appellant had known earlier, she would have requested pre-approval for services.
I APPEAL NUMBER Information provided on appeal The appellant's Notice of Appeal (NOA) dated May 14, 2019, which did not include new evidence. Prior to the hearing, the representative emailed a 3-page letter, dated June 7, to the Tribunal. The letter includes argument and further explanation of the timeframe and circumstances of the provision of the dental services to her children, with the representative noting that she was quite desperate to get the dental work completed before the new year, when a new two-year cycle of dental funding would begin. The ministry did not object to the admission of the additional information. The panel determined that the additional information either reiterated or provided further detail in support of information before the ministry at reconsideration and therefore admitted the additional information in accordance with section 22(4) of the Employment and Assistance Act. Neither the appellant nor the representative attended the hearing. After confirming delivery of the Notice of Hearing to the appellant, the hearing proceeded in accordance with section 86(b) of the EAR. At the hearing, the ministry explained the reconsideration decision but did not provide additional evidence. The arguments of both parties are set out in Part F of this decision.
APPEAL NUMBER I 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 p rovide 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 item0 1601 -Examination and Diagnosis, Surgical by Oral Surgeon is restricted for use by Oral Surgeons only the additional1 0% will not be applied to this fee item. RADIOGRAPHS Radiographs are limited to: $54.7 1 every2 calendar years for adults, and $70.49 every2 calendar years for children under 19 years of age. A complete series, fee items0 2101 or02102 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 0211 Single Film 99. 5 12.84 02112 Two Films 13.59 17.59 02113 Three Films 173. 1 22.41 02114 Four Films 21.04 272. 3
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 23513 Three surfaces I 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 75.47 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
I APPEAL NUMBER 23514 Four surfaces 153.98 188.47 23515 Five surfaces (maximum) 179.08 219.63 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 was the representative's opinion that it should be the dentist who finds out what services are covered before providing services and it's 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, noting 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, coverage for the dental services at issue was provided at the rates set out in the Schedule of Fee Allowances- Dentist with the 10% top-up for services provided by a specialist. While the coverage amounts remain less than the dentist's fees, there is no ability for the ministry to provide additional coverage. 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) IZ]UNANIMOUS □ BY MAJORITY THE PANEL IZ]CONFIRMS 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) 1Z1 and Section 24(2)(a) iZ] or Section 24(2)(b) D PART H -SIGNATURES PRINT NAME Jane Nielsen SJGNATURE OF CHAIR DATE (YEAR/MONTH/DAY) 2019/06/12 PRINT NAME Wesley Nelson SIGNATURE OF MEMBER 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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