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 rv 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 ry 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 .
APPEAL NUMBER I 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. . . Tooth Fee Description Dentist PBC No. · Code . •. Fees Coverage Date: Dec 21, 2018 and Dec 28 2018 1 n/a 02144 Radiograph / lntraoral -Bitewing / Four Films $27.23 $27.23 2 n/a 02123 Radiograph / lntraoral -Periapical /Thirteen Films $70.49 $43.26 3 n/a 01103 Complete Exam and Diagnosis on Permanent Dentition $77.13 *$77.13 4 n/a 11113 Scaling /Three Units $103.48 *$102.83 5 n/a 11101 Polishing $27.23 $27.23 6 n/a 12101 Topical Fluoride Treatment $10.61 $10.61 TOTAL: $316.17 $288.29 �= *Asper a note in the Schedule of FeeA llowances-Dentist, radiographs are limited to $70.49 every 2 calendar years for children under 19 years of age. [The appellant] has been provided the $70.49 maximum for radiographs {$27.23 for fee code 02144 and $43.26 for fee code 02123). See line items 1 and 2 above. *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 3 and 4). Reconsideration of the decision to deny coverage at the dentist's rates for dental services #2 and #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 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.
I A P P E A L N U M B E R P A R T F R E A S O N S F O R P A N E L D E C I S I O N I s s u e o n A p p e a l T h e i s s u e o n a p p e a l i s w h e t h e r t h e m i n i s t ry ' s d e c i s i o n t o d e n y t h e a p p e l l a n t c o v e r a g e f o r d e n t a l s e rv i c e s a b o v e m i n i s t ry r a t e s w a s r e a s o n a b l y s u p p o r t e d b y t h e e v i d e n c e o r 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 a p p l i c a b l e e n a c t m e n t i n 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 . R e l e v a n t L e g i s l a t i o n E A R D e n t a l s u p p l e m e n t s 6 8 T h e m i n i s t e r m a y p r o v i d e a n y h e a l t h s u p p l e m e n t s e t o u t i n s e c t i o n 4 [ d e n t a l s u p p l e m e n t s ] o f S c h e d u l e C t o o r f o r ( a ) a f a m i l y u n i t i n r e c e i p t o f i n c o m e a s s i s t a n c e , i f ( i ) t h e f a m i l y u n i t i n c l u d e s a p e r s o n w i t h p e r s i s t e n t m u l t i p l e b a r r i e r s t o e m p l o y m e n t , o r ( i i ) t h e h e a l t h s u p p l e m e n t i s p r o v i d e d t o o r f o r a p e r s o n i n t h e f a m i l y u n i t w h o i s u n d e r 1 9 y e a r s o f a g e . . . S c h e d u l e C H e a l t h S u p p l e m e n t s D e fi n i t i o n s 1 I n t h i s S c h e d u l e . . . . " b a s i c d e n t a l s e rv i c e 1 1 m e a n s a d e n t a l s e rv i c e t h a t ( a ) i f p r o v i d e d b y a d e n t i s t , ( i ) 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 A l l o w a n c e s D e n t i s t t h a t i s e f f e c t i v e S e p t e m b e r 1 , 2 0 1 7 a n d i s p u b l i s h e d o n t h e w e b s i t e o f t h e m i n i s t ry o f t h e m i n i s t e r , a n d ( i i ) i s p r o v i d e d 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 f o r t h e s e rv i c e a n d
I APPEAL NUMBER the category of person receiving the service .... 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
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I 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 A P P E A L N U M B E R P A R T G O R D E R T H E P A N E L D E C I S I O N I S : ( C h e c k o n e ) [gi U N A N I M O U S â–¡ B Y M A J O R I T Y T H E P A N E L [gi C O N F I R M S T H E M I N I S T R Y D E C I S I O N â–¡ R E S C I N D S T H E M I N I S T R Y D E C I S I O N I f t h e m i n i s t r y d e c i s i o n i s r e s c i n d e d , i s t h e p a n e l d e c i s i o n r e f e r r e d b a c k t o t h e M i n i s t e r f o r a d e c i s i o n a s t o a m o u n t ? â–¡ Y e s â–¡ N o L E G I S L A T I V E A U T H O R I TY F O R T H E D E C I S I O N : 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 S e c t i o n 2 4 ( 1 ) ( a ) D o r S e c t i o n 2 4 ( 1 ) ( b ) [gl a n d S e c t i o n 2 4 ( 2 ) ( a ) [gJ o r S e c t i o n 2 4 ( 2 ) ( b ) D P A R T H S I G N A T U R E S P R I N T N A M E J a n e N i e l s e n S I G N A T U R E O F C H A I R D A T E ( Y E A R / M O N T H / D A Y ) 2 0 1 9 / 0 6 / 1 3 P R I N T N A M E W e s l e y N e l s o n S I G N A T U R E O F M E M B E R D A T E { Y E A R / M O N T H / D A Y ) 2 0 1 9 / 0 6 / 1 3 P R I N T N A M E J o s e p h R o d g e r s S I G NA T U R E O F M E M B E R D A T E ( Y E A R I M O N T HI D A Y ) 2 0 1 9 / 0 6 / 1 3
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.