APPEAL NUMBER 2020-00251 PART C – DECISION UNDER APPEAL The decision under appeal is the Ministry of Social Development and Poverty Reduction (the ministry) reconsideration decision dated October 30, 2020, which denied the appellant’s request for full coverage of an upper denture and extractions. Specifically, the ministry determined that the appellant is a continuing person under section 61.1 of the Employment and Assistance for Persons with Disabilities Regulation (EAPWDR) and therefore eligible for emergency dental and denture supplement under section 64 of the EAPWDR and Schedule C, sections 1, 4, 4.1 and 5. As a result the ministry found that the appellant was eligible for the extractions and denture up to the maximum set out in the Schedule of Fee Allowances – Dentist and the Schedule of Fee Allowances – Denturist. The ministry held that the appellant was not eligible for coverage in excess of the rates set out in the two Schedule of Fee Allowances. PART D – RELEVANT LEGISLATION Employment and Assistance for Persons with Disabilities Regulation , sections 62, 63, 63.1, 64, 65, and 69 Employment and Assistance for Persons with Disabilities Regulation, Schedule C, sections 1, 4, 4.1, and 5 Schedule of Fee Allowances – Dentist / Denturist, Emergency Dental – Dentist / Denturist, Crown & Bridgework
APPEAL NUMBER 2020-00251 PART E – SUMMARY OF FACTS The ministry requested an observer be present, the appellant’s advocate consented to this request. The appellant was not in attendance at the appeal hearing. Summary of key dates: September 24, 2020- the appellant contacted the ministry to advise the appellant was having 5 teeth extracted to have dentures. The appellant stated both the dental and denturist offices explained to the appellant they did not have full coverage. October 23, 2020- the appellant submitted receipts dated September 24, 2020 for five tooth extractions and an upper denture. The ministry had denied the appellant coverage as the appellant’s income assistance file had been closed April 18, 2015 and therefore was not eligible for a dental supplement. October 23, 2020- the ministry reopened the appellant’s file after review determining that the appellant was considered a “continued person” and therefore eligible for dental supplements. On October 30, 2020- the ministry completed its review of the appellant’s Request for Reconsideration. Evidence before the ministry at the time of reconsideration: In the Request For Reconsideration, under Reasons for request, the appellant writes: o They are a senior and unemployed. o Due to COVID, all daily expenses had increased. o The current denture is broken and very painful to have in the mouth. o Was looking for a one time supplement to have a new denture. o They had already paid for the teeth to be extracted. o They are in desperate need of a new denture. A dentist invoice dated September 24, 2020 with a total of $811.00. A denturist treatment plan dated September 24, 2020 with a total of $2302.00. Additional information: In the Notice of Appeal dated November 7, 2020 the following information was given: o The appellant requested coverage for fees related to denture replacement and extractions for immediate relief of pain. o The appellant felt coverage should be considered under emergency dental service. Basic Eligibility o As the appellant’s spouse was a recipient of disability assistance at the time the appellant was switched to MSO (Medical Services Only), the appellant is considered a continued person, and may be eligible for coverage of basic dental services, emergency dental services, and crown/bridgework as per the EAPWD Regulation, Sections 63, 63.1, and 64, and Schedule C, Sections 1, 4, 4.1, and 5. At the hearing the appellant’s advocate noted: o The appellant would like full coverage of dental costs through section 64, Emergency dental and denture supplement.
APPEAL NUMBER 2020-00251 o The appellant was a new patient to the denturist. At the hearing the ministry representative noted: o Maximum amounts for dental and denturist fees were given to the appellant as per the legislation, the ministry is not authorized to exceed the amounts as outlined in Schedule C. o When asked if the fee schedule of 2017 was the most up to date schedule; the ministry stated that the 2017 schedule was the current schedule and that changes of the schedule is through legislation. o When asked if a clerical error was made by the ministry or denturist office in terms of the exam fee code being 10010 instead of 11010, the ministry stated that since the treatment plan submitted by the denturist did not contain any fee numbers, the ministry telephoned the denturist’s office and was told the fee number for the examination was 11010. The ministry stated that the appellant may reapply for the coverage of this code if a clerical error had occurred.
APPEAL NUMBER 2020-00251 PART F – REASONS FOR PANEL DECISION Appeal Issue The issue in this appeal is whether the ministry was reasonable in denying the appellant’s request for the ministry to cover the full cost of 5 tooth extractions and a denturist examination and an upper denture. More specifically, the issue is whether the following ministry determinations are reasonably supported by the evidence or a reasonable application of the legislation in the circumstances of the appellant: the appellant is eligible for the extractions and denture up to the maximum set out in the Schedule of Fee Allowances – Dentist and the Schedule of Fee Allowances – Denturist, but is not eligible for coverage in excess of the rates set out in the two Schedule of Fee Allowances. the appellant is not eligible for coverage of the denturist examination fee under the fee code provided by the denturist’s office. the appellant is not eligible for the requested coverage as a crisis supplement (section 57 of the EAPWDR) or for a life-threatening health need (section 69 of the EAPWDR). ANALYSIS Appellant’s Position As the appellant was in severe pain due to a broken denture it was recommended all teeth in the upper jaw be extracted and a new denture be installed. The appellant feels full coverage should occur through emergency dental coverage. Ministry’s Position The ministry is bound by the legislation in terms of fee payment allocation for both basic and emergency dental services. The appellant was given the maximum allowable coverage. Panel Finding UPPER COMPLETE DENTURE Fee Code 11010 o The ministry is only authorized to provide coverage for dental services set out in the Schedule of Fee Allowances – Dentist or Schedule of Fee Allowances – Denturist. As the fee code 11010 is not set out in the Schedules of Fee Allowances – Dentist or Schedule of Fee Allowances – Denturist, the panel finds the ministry was reasonable in denying the appellant’s request for coverage of payment for fee code 11010. If the code 11010 was incorrect due to a clerical error and was supposed to be 10010, the panel recommends the appellant seek clarification from the denturist and if there has been a mistake, resubmit their claim to the ministry. Fee Code 31311 o The ministry determined that the appellant was eligible for funding for this fee code 31311 up to the maximum rate listed in the Schedule of Fee Allowances – Denturist, which is $675.00 for an adult.
APPEAL NUMBER 2020-00251 o The appellant was charged $2185.00 for the fee code31311 and has requested coverage of the total payment. Although the appellant is eligible for $675 as set out in the Schedule of Fee Allowances – Dentist or Schedule of Fee Allowances – Denturist, the panel finds the ministry was reasonable in denying the appellant’s request for full coverage of payment for fee code 31311as the appellant is not eligible for coverage in excess of the ministry rates set out in the Schedule of Fee Allowances – Denturist. Tooth Extractions The ministry may provide coverage for basic dental services as set out in EAPWD Regulation, Section 63 and Schedule C, Sections 1 and 4. The ministry may provide coverage for emergency dental services as set out in EAPWD Regulation, Section 64 and Schedule C, Sections 1 and 5. Both basic dental services and emergency dental services may be provided by a Dentist, Denturist, or Dental Hygienist The ministry determined the appellant was eligible for funding for tooth extractions up to the maximum rates as set out in Schedule of Fee Allowances – Dentist. The panel finds the ministry was reasonable in denying the appellant’s request for coverage in excess of the ministry rates set out in the Schedule of Fee Allowances - Dentist. Eligibility for Coverage of dental fees as a Life-Threatening Health Need Section 69 of the EAPWD Regulation states that the ministry may provide medical transportation, medical equipment / devices, and some types of medical supplies, to or for a person who is otherwise not eligible for the health supplement under this regulation. As Section 69 only applies to medical transportation, medical equipment / devices, and some types of medical supplies (as described in EAPWD Regulation, Schedule C, subsections 2(1)(a), 2(1)(a)(f), and Section 3) and not dental treatments and dentures the panel finds the ministry was reasonable in denying coverage of dental fees as a life-threatening health need. Eligibility for Coverage of Dental Fees as a Crisis Supplement Section 57(3) of the EAPWD Regulation states the ministry may not provide a crisis supplement to obtain a supplement described in Schedule C or for any other health care goods or services. As dental treatments are health care services as described in Schedule C, the panel finds the ministry was reasonable in denying coverage of dental fees as a crisis supplement. Conclusion Based on the foregoing analysis, the panel finds that the ministry’s reconsideration decision denying the appellant’s request for full funding of the dental services received is a reasonable application of the legislation in the circumstances of the appellant. The panel therefore confirms the ministry’s decision. The appellant’s appeal is thus not successful.
APPEAL NUMBER 2020-00251 Applicable Legislation Note: The applicable legislation and Schedules of Fee Allowances are fully reproduced in the Appeal Record. The Appendix to this Decision sets out the relevant text and fee number limits from the legislation and Fee Allowance Schedules. EMPLOYMENT AND ASSISTANCE FOR PERSONS WITH DISABILITIES REGULATIONS Dental supplements 63 The minister may provide any health supplement set out in section 4 [dental supplements] of Schedule C to or for (c) a family unit, if the health supplement is provided to or for a person in the family unit who is a continued person. 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. Health supplement for persons facing direct and imminent life threatening health need 69 (1) The minister may provide to a family unit any health supplement set out in sections 2 (1) (a) and (f) [general health supplements] and 3 [medical equipment and devices] of Schedule C, if the health supplement is provided to or for a person in the family unit who is otherwise not eligible for the health supplement under this regulation, and if the minister is satisfied that (a) the person faces a direct and imminent life threatening need and there are no resources available to the person's family unit with which to meet that need, (b) the health supplement is necessary to meet that need, (c) the adjusted net income of any person in the family unit, other than a dependent child, does not exceed the amount set out in section 11 (3) of the Medical and Health Care Services Regulation, and (d) the requirements specified in the following provisions of Schedule C, as applicable, are met:… 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 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, (b) if provided by a denturist, (i) is set out in the Schedule of Fee Allowances — 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 person receiving the service, and… "dentist" means a dentist registered with the College of Dental Surgeons of British Columbia continued under the Health Professions Act; "denture services" means services and items that
APPEAL NUMBER 2020-00251 (b) if provided by a denturist (i) are set out under fee numbers 31310 to 31321 in the Schedule of Fee Allowances — Denturist that is effective September 1, 2017 and is published on the website of the ministry of the minister, and (ii) are provided at the rate set out in that Schedule for the service or item and the category of person receiving the service or item; "denturist" means a denturist registered with the College of Denturists of British Columbia established 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; Dental supplements 4 (1) In this section, "period" means (a) in respect of a person under 19 years of age, a 2 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), a 2 year period beginning on January 1, 2003 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 supplements that may be provided to a person described in subsection (3) (b), or to a person described in subsection (3) (c) who requires a partial denture, are limited to services under (a) fee numbers 52101 to 52402 in the Schedule of Fee Allowances — Dentist referred to in paragraph (a) of the definition "basic dental service" in section 1 of this Schedule, or (b) fee numbers 41610, 41612, 41620 and 41622 in the Schedule of Fee Allowances — Denturist referred to in paragraph (b) of the definition "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
APPEAL NUMBER 2020-00251 definition "basic dental service" in section 1 of this Schedule, or (b) fee numbers 31310, 31320 or 31330 in the Schedule of Fee Allowances — Denturist referred 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. 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 Dental Supplement- Dentist 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. BCEA Adults 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”. ORAL SURGERY Note: 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 69.02 71109 Each additional tooth in same quadrant 45.59 71201 Single tooth 130.27 71209 Each additional tooth in same quadrant 85.98 Part C -Preamble - Emergency Dental Supplements – Dentist Emergency Dental Supplements is available for all eligible Ministry of Social Development and Poverty Reduction (Ministry) clients, including those who do not have a 2-year limit under the Ministry’s Dental Supplements or those who have exhausted their limit. 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. Payment Process Claims for any treatment completed under the Emergency Dental Supplements must be submitted on a separate claim form and you must clearly indicate that the services were provided for the immediate relief of pain or as an emergency. Claims under the Ministry’s Dental Supplements will be paid in accordance with the Schedule of Fee Allowances – Emergency Dental - Dentist and these fees represent the maximum amount the Ministry can pay for
APPEAL NUMBER 2020-00251 the services billed. EXTRACTIONS (REMOVALS) Erupted teeth Uncomplicated 71101 Single tooth 69.02 71109 Each additional tooth in same quadrant 45.59 71201 Single tooth 130.27 71209 Each additional tooth in same quadrant 85.98 Dental Supplement- Denturist 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 (iv) under the Eligibility Information section. BCEA Adults Adults who are eligible for basic dental services under Ministry Dental Supplements are eligible for a $1,000 limit every 2-year period beginning on January 1st of every odd numbered year. The applicable fees for services provided to adult patients are listed in the Schedule of Fee Allowances – Dentist under the column marked “Adult”. Schedule of Fee Allowances – Denturist Effective September 1, 2017 FEE NO. FEE DESCRIPTION FEE AMOUNT ($) Adult 31311 Immediate Complete Maxillary Denture 675.00
PART G – ORDER THE PANEL DECISION IS: (Check one) UNANIMOUS BY MAJORITY THE PANEL 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) or Section 24(1)(b) and Section 24(2)(a) or Section 24(2)(b) PART H – SIGNATURES PRINT NAME Charles Schellinck SIGNATURE OF CHAIR DATE (YEAR/MONTH/DAY) 2020l12/01 PRINT NAME Chris McEwan SIGNATURE OF MEMBER DATE (YEAR/MONTH/DAY) 2020l12/01 PRINT NAME Richard Roberts SIGNATURE OF MEMBER DATE (YEAR/MONTH/DAY) 2020l12/01
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.