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 7, 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 at 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.
ooth · Fee Description No. ode Date: February 1, 2019 1 14 71211 Extraction, Elevation Flap, Removal Bone/Sectionine, sinele tooth
2 24 71211 Extraction, Elevation Flap, Removal $369.00 $301.18 Bone/Sectionine, sinele tooth
3 S4 71211 Extraction, Elevation Flap, Removal $369.00 $301.18 Bone/Sectioning, single tooth 4 114 71201 Odontectomy, Extraction Erupted tooth, Surgical $236.00 $190.99 annroach
Notes: 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.
Reconsideration of the decision to deny coverage at the dentist's rates for dental services #1 through #4 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. 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 her other children were provided in late December [2018]. In early February, when taking the appellant to the dentist, the dentist did not mention anything about amounts owing, or unpaid respecting her other children. 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.
Dentist PBC Fees Coverage $369.00 $301.18
TOTAL: $1343.00 $1094.53
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. However, there was no time in December to do the appellant's extractions, so they were done in February. She finds this particularly troubling as there was plenty of time to seek pre-approval for these dental services.
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.
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 11 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) $2 000 each period, if provided to a person under 19 years of age ....
Schedule of Fee Allowances - Dentist Specialist Referrals Certified specialists, including oral surgeons may receive an additional 10% on services billed from the Schedule of Fee Allowances - Dentist. The Ministry contractor must have a record of the specialty on their billing system and the referring practitioner must be indicated on the claim form. If either of these is missing, the claim will be refused or reduced. If the referring practitioner is a Medical Doctor, please indicate this clearly on the claim form. As fee item 01601 - Examination and Diagnosis, Surgical by Oral Surgeon is restricted for use by Oral Surgeons only the additional 10% will not be applied to this fee item. FEE NO. FEE DESCRIPTION FEE AMOUNT ($) Adult Child ORAi SURGERY
When multiple surgical procedures are performed on one quadrant on the same date of service, the most expensive procedure will be paid at 100% and the lesser procedures will be paid at 50%, with the exception of multiple extractions in the same quadrant.
Surgical services include the necessary local anaesthetic, removal of excess gingival tissue, suturing and all routine post-operative care. Pre-operative radiograph(s) may be requested to support claims for the extraction of impacted teeth.
EXTRACTIONS (REMOVALS) Erupted teeth Uncomplicated 71101 Single tooth 71109 Each additional tooth in same quadrant Complicated (surgical approach) Extraction, erupted tooth, requiring surgical flap and/or sectioning of tooth 71201 Single tooth 71209 Each additional tooth in same quadrant Extraction, erupted tooth, requiring elevation of a flap, removal of bone AND section of tooth for removal of tooth 71211 Single Tooth 71219 Each additional tooth in same quadrant 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, the representative argued it should be the dentist who finds out what services are covered before providing services and it not the fault of the appellant and, in this case, there was plenty of time to seek pre-approval.
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, the Schedule of Fee Allowances - Dentist limits the amount that may be paid for the extractions to amounts less than the fees charged by the dentist, even after the 10% increase for specialist dentists is applied. As the appellant was provided coverage in the amounts set out in the Schedule of Fee Allowances - Dentist topped up by the extra 10% for specialist dentists, the ministry is not authorized to provide additional coverage.
I APPEAL NUMBER 69.02 89.04 45.59 58.77 130.27 173.63 85.98 130.59 201.55 273.80 133.03 205.53
l APPEAL NUMBER 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) [8]UNANIMOUS □BY MAJORITY THE PANEL [8]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) 18] and Section 24(2)(a) 18] or Section 24(2)(b) D PART H-SIGNATURES PRINT NAME Jane Nielsen
SIGNATURE OF CHAIR DATE (YEAR/MONTH/DAY) 2019/06/13
PRINT NAME Wesley Nelson
DATE(YEAR/MONTH/DAY) 2019/06/13
PRINT NAME Joseph Rodgers
SIGNATURE OF MEMBER DATE (YEAR/MONTH/DAY) 2019/06/13