Ministry of Social Development and Poverty Reduction

I APPEAL NUMBER PART C - DECISION UNDER APPEAL The decision under appeal is the Ministry of Social Development and Poverty Reduction (the ministry) reconsideration decision dated May 28, 2019 which denied the appellant's request for full coverage of dental services provided on November 23, 2018 and December 13, 2018.

Specifically, the ministry is not authorized by legislation to provide coverage for services that are not set out in the Schedule of Fee Allowances-Dentist, Emergency Dental-Dentist or Crown and Bridgework. The ministry is also not authorized to provide coverage for fees above the rates set out in the schedules

PART D - RELEVANT LEGISLATION Employment and Assistance for Persons with Disabilities Regulation, sections 63,63.1 and 64 Employment and Assistance for Persons with Disabilities Regulation, Schedule C, sections 1, 4, 4.1 and 5

Schedule of Fee Allowances- Dentist, Emergency Dental-Dentist, Crown & Bridgework

I APPEAL NUMBER PART E - SUMMARY OF FACTS The appellant is a Person with Disabilities who has been transitioned to Medical Services Only due to receipt of federal pensions and is eligible for dental supplements under sections 63, 63.1, and 64, and Schedule C, sections 4, 4.1, and 5 of the Employment and Assistance for Persons With Disabilities Regulation.

Summary of Key Dates • March 20, 2019- the appellant contacted the ministry to enquire about dental coverage noting that she had paid $3000 for a root canal, the first part had been completed and the next was scheduled for March 21, 2019. The request for coverage had been processed by the dental office, who had submitted a claim to Pacific Blue Cross (PBC), which was denied. The appellant was instructed to provide a copy of the pre-determination from PBC and an invoice, showing what was covered and was not covered. • March 27/ 19- a district supervisor contacted the appellant to explain further documentation was required. Specifically, an invoice that outlined the dental services provided, amounts paid,s ervices rendered and the amount covered by PBC. • March 28/19- the appellant submitted the following documents: o Pre-determination from PBC dated December 12, 2018- tooth 36 • Fee Code 23321-Tooth Colored Restoration-Dentist fee $156- Ministry Rate 103.63 • Fee Code 33145-Root Canal-Dentist fee $1,950-Ministry Rate 00.00 • Fee Code 39212-Opening through artificial crown-Dentist Fee$100-Ministry Rate 00.00 • Dentist Fee Total-$2,206.00 • Ministry Rate Total $103.63 o Standard Dental Claim Form dated March 27,2019-tooth 36 • Date of service-2018/12/13-Fee Code 32314-Pulpectomy-four canals or more-Dentist's Fee-$975 • Date of service-2018/12/13-Fee Code 39212-opening through crown­ Dentist's Fee-$100 • Date of service-2019/03/21-Fee Code 33145-root canal, retreatment­ Dentist's Fee-$975 • Date of service-2019/03/21-Fee Code23321-tooth color-Dentist's Fee-$156 • Total Dentist's Fee 2,206.00 o Standard Dental Claim Form dated March 27,2019- tooth 36 • Date ofservice-2018/11/23-Fee Code 01801-Exam and diagnosis-Dentist's Fee-$120 • Total Dentist's Fee- $120 o Patient Receipt dated March 27, 2019 • December 13, 2018- Previous balance $370, Pulpectomy- Dentist's Fee$975, Open Crown- Dentist's Fee$100. Total $1,075 • March 21, 2019-Root canal- Dentist's Fee$975, Molar Bonded-Dentist's Fee $156. Total $1,131 • April 29/19- The ministry received the appellant's Request for Reconsideration • Mav 28/19-Additional information was submitted by the aooellant to suooort her Request

I APPEAL NUMBER for Reconsideration. The ministry denied the appellant's request. The information before the ministry at the time of reconsideration included the following: • A letter from the appellant's advocate dated May 24, 2019 requesting the appellant be afforded additional coverage under emergency dental supplements if the $1000 limit had been exhausted. As well, if there were any remaining amounts from the applicable 2-year time period in which the procedure was performed, that it be applied in addition to emergency dental supplements. • Patient Receipt dated March 27, 2019. Date- November 23, 2018, Complete Endodontic Exam-$120. • Standard dental claim form dated March 27, 2019, November 23, 2018 code 01801, $120 fee. • Patient Receipt dated March 27, 2019. Date December 13/18- $1075, March 21/19-$1,131. • Standard dental claim form no date, fees for December 13/18 and March 21/19 totalling $2,206 • A Letter from PBC dated December 12/18- Dental Predetermination Summary- Total amount submitted-$2,206.00, approved by plan-$103.63 • A PBC predetermination breakdown of coverage dated December 12, 2018 which notes coverage for: o First Page • Procedure 23321- $103.63 • Procedure 33145-$0.00 • Procedure 39212-$0.00 o Second Page • Procedure 23321-$77.34 • Procedure 32314-$0.00 • Procedure 33145-$573.95 • Procedure39212-$0.00 • Twelve page printout from PBC noting claim details of the appellant from July, 2017-May 08,2019 In the Notice of Appeal the appellant stated: • A number of mistakes have been made by the Reconsideration Officer which are important enough to have determined the outcome (decision made).

In the appellant's Request for Reconsideration , section 3- reason for request, the appellant stated: • A total of $2,326 was paid by the appellant. • Pre-authorization for all procedures was sought from PBC. • Funds that paid for the procedure came from funds saved to pay property taxes and Strata-Insurance. • As a senior with Continued Person Status/Medical only she is now receiving considerably less. • She has absolutely no discretionary income. • Her health is severely challenged with surgeries, working to supplement income is not oossible.

I APPEAL NUMBER • The root canal procedure to deal with persistent infection was absolutely necessary. • The procedure was medically necessary. • Due diligence was practised(pre-authorizations sought). • Payment of taxes and strata insurance are due by June. • Her dental plan allows $1000 over 2 years, much of that amount remained unused at the end of the 2017-2018 cycle. January 2019 marked the start of a new cycle with $1000 available for 2019/2010. Appendix A- Appellant Submission in which the appellant stated: • She has tried to point out to several reconsideration members the mistakes that have been made. • The procedure she went through to address the problems with tooth 36. • Important dates: o November 23/18- consult- paid $120 o December 13/18-first part of procedure- paid $1075.00 o March 21/19- second part of procedure- paid $1131.00 • Blue Cross reimbursed the appellant $651.29 • Monies paid for these procedures were savings for tax and strata insurance. Appendix A- Ministry Submission contained: • A letter noting a mistake of payment that was corrected from $77.34 to $103.63. • Record of claims from the specialist's office in terms of her reconsideration request. Appendix B Appellant Submission which contained Patient receipts from the appellant's dental office without notation from the appellant.

Appendix C Appellant Submission which contains Patient receipts from the appellant's dental office and a blue cross statement with notations by the appellant. • Patient receipts from the appellant's dental office note: o As of May 08, 2019 PBC, has paid $85. 77 therefore the appellant's remaining benefit should be $914.23 o For the 2017-2018 time period the appellant spent $277.67 • Blue Cross web account of the appellant notes, benefit period of Jan 1, 2019-Dec 31, 2020, amount used $763.35

At the hearing, the appellant stated: • Her dental work had to be completed by a specialist. • The dental work was an emergency due to pain and infection which have impacted her future surgeries. • She had requested the specialist seek pre-authorization of all procedures but did not determine herself if the procedures would be covered by PBC. • There are issues with her and the reconsideration officer which are being addressed but that do not necessarily have a direct impact on the panel's role in this appeal. • She feels her 2017-2018 benefits of $1000 paid for the $651.29 which put her account at zero then the reconsideration officer contacted PBC in a vindictive manner to have the funds taken from her 2019-2020 benefit oackaae thus reducina her current dental

I APPEAL NUMBER benefits to $236.65. At the hearing, the appellant's advocate: • Asked if the dental schedule could be flexible to allow payment for the appellant in terms of code 32314. The ministry responded by saying no, they were bound by legislation and the fee schedule must be adhered to. • Asked if code 23321 which was increased from $77.34 to $103 could be raised to the Dentist's fee of $156 the ministry responded that the $77 .34 had been a mistake in calculations which was corrected to $103 which is the ministry rate with an additional 10% for use of a specialist. No additional funding is applicable. • Asked if under emergency procedures, the appellant could obtain additional funding. The ministry explained emergency funding uses the same fees and schedule and is not an extra source of monies for the appellant. • Stated the most important issue in this appeal is the protocol followed by the ministry. There has been miscommunication and a break from appropriate procedures from the Reconsideration Officer involved. The break from appropriate protocol has confused and stressed the appellant and he felt the panel should be aware of this issue.

At the hearing the ministry: • Answered the above questions asked by the appellant's advocate. • Stated benefit funds from one two year term cannot be carried over to the next term. • Stated the Schedule and Fees for dental benefits are legislative and cannot be altered by the ministry.

Admissibility of Additional Information The panel considered the information provided in the three submissions made by the appellant and the one by the ministry. • Submission A from the appellant contains a letter from the appellant explaining why she felt the reconsideration decision was unfair. The panel admitted this additional information as being in support of information and records that were before the ministry at the time of the reconsideration, in accordance with Section 22(4)(b) of the Employment and Assistance Act. • Submission A from the ministry contained a letter explaining a mistake in payment by PBC and PBC claim records of the appellant in terms of the appellant's claim. The panel admitted this additional information as being in support of information and records that were before the ministry at the time of the reconsideration, in accordance with Section 22(4)(b) of the Employment and Assistance Act. • Submission 8 and C from the appellant were to be one submission. The content of the submission contains patient receipts from the appellant's dental office and a blue cross statement with notations by the appellant which notes ·payments and the balances of benefit accounts. The panel admitted this additional information as being in support of information and records that were before the ministry at the time of the reconsideration,

in accordance with Section 22(4)(b) of the Employment and Assistance Act.

I APPEAL NUMBER PART F -REASONS FOR PANEL DECISION The issue under appeal is the ministry's reconsideration decision, dated May 28, 2019 which held that the appellant was not eligible for full coverage of dental services provided on November 23, 2018 and December 13, 2018. The ministry held that it is not authorized by legislation to provide coverage for services that are not set out in the Schedule of Fee Allowances-Dentist, Emergency Dental-Dentist or Crown and Bridgework. The ministry is also not authorized to provide coverage for fees above the rates set out in the schedules.

Relevant Legislation Employment and Assistance for Persons with Disabilities Regulation Dental supplements 63 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 disability assistance,

(b) a family unit in receipt of hardship assistance, if the health supplement is provided to or for a person in the family unit who is under 19 years of age, or (c) a family unit, ift he health supplement is provided to or for a person in the family unit who is a continued person. [en. B.C. Reg. 145/2015, Sch. 2, s. 4; am. B.C. Reg. 161/2017, App. 2, s. 2.J Crown and bridgework supplement 63.1 The minister may provide a crown and bridgework supplement under section 4.1 of Schedule C to or for

(a) a family unit in receipt of disability assistance, if the supplement is provided to or for a person in the family unit who is a person with disabilities, or (b) a family unit, if the supplement is provided to or for a person in the family unit who (i) is a continued person, and (ii) was, on the person's continuation date, a person with disabilities. [en. B.C. Reg. 145/2015, Sch. 2, s. 4.] Emergency dental and denture supplement 64 The minister may provide any health supplement set out in section 5 [emergency dental supplements] of Schedule C to or for (a) a family unit in receipt of disability assistance, (b) a family unit in receipt of hardship assistance, or (c) a family unit, if the health supplement is provided to or for a person in the family unit who is a continued person. [en. B.C. Reg. 145/2015, Sch. 2, s. 4.J

Employment and Assistance for Persons with Disabilities Regulation, Schedule C 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 I, 2017 and is published on the website of the ministrv of the minister, and

I APPEAL NUMBER (ii) is provided at the rate set out in that Schedule for the service and the category of person receiving the service, (b) if provided by a denturist, (i) is set out in the Schedule of Fee Allowances -Denturist that is effective September I, 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,

and (c ) if provided by a dental hygienist, (i) is set out in the Schedule of Fee Allowances -Dental Hygienist that is effective September 1, 2017 and is published on the website ofth e ministry ofth e minister, and "dentist" means a dentist registered with the College of Dental Surgeons ofB ritish Columbia continued under the Health Professions Act; "emergency dental service" means a dental service necessary for the immediate relief of pain that, (a) if provided by a dentist, (i) is set out in the Schedule of Fee Allowances -Emergency Dental-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 the person receiving the

service, and (b) if provided by a denturist, (i) is set out in the Schedule of Fee Allowances -Emergency Dental- Denturist, 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 the person receiving the service; "specialist" means a medical practitioner recognized as a specialist in a field of medicine or surgery in accordance

with the bylaws made by the board for the College of Physicians and Surgeons of British Columbia under section 19 (I) (k.3) and (k.4) of the Health Professions Act.

Dental supplements 4 (1) In this section, "period" means (a) in respect of a person under 19 years of age, a2 year period beginning on January 1, 2017, and on each subsequent January 1 in an odd numbered year, and (b) in respect of a person not referred to in paragraph (a), a2 year period beginning on January 1,2 003 and on each subsequent January 1 in an odd numbered year. (1.1) The health supplements that may be paid under section 63 [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, and (b) $1 000 each period, if provided to a person not referred to in paragraph (a). (c ) Repealed. [B.C. Reg. 163/2005, s. (b) .] (2) Dentures may be provided as a basic dental service only to a person (a) who has never worn dentures, or (b) whose dentures are more than 5 years old. (3) The limits under subsection (1.1) may be exceeded by an amount necessary to provide dentures, taking into

account the amount remaining to the person under those limits at the time the dentures are to be provided, if (a) a person requires a full upper denture, a full lower denture or both because of extractions made in the previous 6 months to relieve pain, (b) a person requires a partial denture to replace at least 3 contiguous missing teeth on the same arch, at least one of which was extracted in the previous 6 months to relieve pain, or (c ) a person who has been a recipient of disability assistance or income assistance for at least 2 years or a dependant of that person requires replacement dentures. (4) Subsection (2) (b) does not apply with respect to a person described in subsection (3) (a)who has previously had a partial denture. (5) The dental suoolements that may be provided to a person described in subsection (3) (b), or to a person

I APPEAL NUMBER described in subsection (3) (c ) who requires a partial denture, are limited to services under (a) fee numbers 52101 to52402 in the Schedule of Fee Allowances -Dentist referred to in paragraph (a) of the defmition "basic dental service" in section 1 oft his Schedule, or (b) fee numbers 41610, 41612, 41620 and 41622 in the Schedule ofFeeA!lowances-Denturist referred to in paragraph (b) of the defmition "basic dental service" in section 1 of this Schedule.

(6) The dental supplements that may be provided to a person described in subsection (3) (c) who requires the replacement of a full upper, a full lower denture or both are limited to services under (a) fee numbers 51101 and 51102 in the Schedule of Fee Allowances-Dentist referred to in paragraph (a) of the defmition "basic dental service" in section I of this Schedule, or (b) fee numbers 31310, 31320 or 31330 in the Schedule of Fee Allowances-Denturistreferred to in paragraph (b) of the definition "basic dental service" in section 1 of this Schedule. (7) A reline or a rebase of dentures may be provided as a basic dental service only to a person who has not had a reline or rebase of dentures for at least 2 years. Crown and bridgework supplement 4.1 (1) ln this section, "crown and bridgework" means a dental service (a) that is provided by a dentist, (b)that is set out in the Schedule of Fee Allowances-Crown and Bridgework, that is effective April I, 2010 and is published on the website of the ministry of the minister, ( c) that is provided at the rate set out for the service in that Schedule, and (d ) for which a person has received the pre-authorization of the minister. (2) A health supplement may be paid under section 63.l of this regulation for crown and bridgework but only if the minister is of the opinion that the person has a dental condition that carmot be corrected through the provision of basic dental services because (a) the dental condition precludes the provision of the restorative services set outu nder the Restorative Services

section of the Schedule of Fee Allowances -Dentist, and (b) one of the following circumstances exists: (i) the dental condition precludes the use of a removable prosthetic; (ii) the person has a physical impairment that makes it impossible for him or her to place a removable prosthetic; (iii) the person has an allergic reaction or other intolerance to the composition or materials used in a removable prosthetic; (iv) the person has a mental condition that makes it impossible for him or her to assume responsibility for a removable prosthetic. (3) The minister must also be satisfied that a health supplement for crown and bridgework will be adequate to correct the dental condition. (4 ) A health supplement for crown and bridgework may not be provided in respect of the same tooth more than once in any period of 60 calendar months. Emergency dental supplements 5 The health supplements that may be paid for under section 64 [emergency dental and denture supplements] of this regulation are emergency dental services. Schedule of Fee Allowances- Dentist, Emergency Dental-Dentist, Crown & Bridgework­ (related to appeal) Part A - Preamble - Dental Supplements - Dentist

The overall intent of the Ministry of Social Development and Poverty Reduction (Ministry)Dental Supplements is to provide coverage for basic and emergency dental services to eligible individuals who receive assistance through the BC Employment and Assistance(BCEA) Program and children in low­ income families. The attached Part 8 - Schedule of Fee Allowances - Dentist outlines the eligible services and fees associated with the Ministry's Dental Supplements and the provision of basic dental services. It contains the rules, freauencv and financial limits associated with each service. All frequency

I APPEAL NUMBER limitations include services performed by dentists, denturists and hygienists. The following information provides details on the Ministry's Dental Supplements, how to confirm eligibility and obtain payment for services rendered.

Eligibility for Dental Supplements It is important to note that the Ministry provides varying levels of benefits and some individuals may have coverage for basic dental services with a 2-year limit while others are limited to coverage of emergency dental services only. To ensure active coverage is in place and to confirm the type and amount of coverage available, eligibility must be confirmed for all patients prior to proceeding with any treatment. Procedures for confirming eligibility for your patients are outlined on page (v) under the Eligibility Information section.

BCEAAdults Adults who are eligible for basic dental services under Ministry Dental Supplements are eligible for a $1,000 limit every 2- year period beginning on January 1st of every odd numbered year. The applicable fees for services provided to adult patients are listed in the Schedule of Fee Allowances - Dentist under the column marked "Adult"

Emergency Dental Supplements For Ministry clients who are not eligible for the previously noted 2-year limit or those who have exhausted their limit, some short-term assistance may be available through Emergency Dental Supplements. Children covered under the Healthy Kids program are also eligible for Emergency Dental Supplements. Emergency Dental allows for treatment of an eligible person who needs immediate attention to relieve pain, or to control infection or bleeding or if a person's health or welfare is otherwise immediately jeopardized.

Specific and comprehensive information regarding allowable emergency services along with their associated fees, rules and restrictions and billing information can be found under Part C - Preamble -Emergency Dental Supplements and Part D - Schedule of Fee Allowances - Emergency Dental - Dentist. Emergency services must be billed on a separate claim form and clearly marked as "Emergency".

Crown and Bridge Supplement Specific and comprehensive information regarding allowable services along with their associated fees, rules and restrictions and billing information can be found under Part E - Preamble - Crown and Bridgework Supplement and Part F - Schedule of Fee Allowances - Crown and Bridgework.