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 6, 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 ond 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 20 and December 28, 2018 1 n/a 02123 Radiograph / lntraoral -Periapical I Thirteen Films $70.49 $70.49 2 n/a 02144 Radiograph I lntraoral -Bitewing / Four Films $27.23 $0.00 3 n/a 11113 Scaling / Three Units $103.48 *$102.83 4 n/a 11101 Polishing $27.23 $27.23 5 n/a 12101 Topical Fluoride Treatment $10.61 $10.61 6 n/a 11117 Scaling -112 Unit $17,00 "$17.00 7 n/a 011 03 Complete Exam and Diagnosis on Permanent Dentition $77.13 "$77.13 TOTAL: $333.17 $305,29 t:12!l:l;: •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, 6, and 7). Regarding fee codes 02123 and 02144 (line items 1 and 2): 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. [The appellant] has been provided the $70.49 maximum for radiographs under fee code 02123. Therefore, there is no remaining coverage for radiographs under fee code 02144. Regarding fee code 11117 (line item 6): Your dentist has charged $17.00 for this treatment. Therefore, you have been provided coverage of $17 .DO 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 #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 w here 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
I APPEAL NUMBER 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. 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 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
I AP�EAL NUMBER the category of person receiving the service .... Dental supplements 4 ( 1 ) In this section, "period" means (a) in respect of a person under 1 9 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 02112 Two Films 02113 Three Films 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 lntraoral -Bitewing 02144 Four Films Scaling 11113 Scaling-three units 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 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, the Schedule of Fee Allowances -Dentist limits the amount that may be paid for radiographs to $70.49 in a 2-calendar year period. As the appellant was provided coverage in this amount for the radiographs with fee code 02123, the ministry reasonably determined that there was no remaining coverage for the radiographs with fee code 02144. Respecting the other dental service at issue, scaling fee code 11113, the I APPEAL NUMBER 9.95 12.84 13.59 17.59 17.31 22.41 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 21.04 27.23 66.51 93.48
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