Ministry of Social Development and Poverty Reduction

APPEAL NUMBER 2021-0252

PART C – DECISION UNDER APPEAL The decision under appeal is the Ministry of Social Development and Poverty Reduction (Ministry) reconsideration decision dated December 20, 2021, in which the Ministry determined that the appellant

was not eligible for coverage of specific dental services.

PART D – RELEVANT LEGISLATION Employment and Assistance for Persons with Disabilities Regulation (EAPWDR), Sections 57, 62, 63, 63.1, 64, 65 and 69. Employment and Assistance for Persons with Disabilities Regulation, Schedule C Schedule of Fee Allowances – Dentist Schedule of Fee Allowances – Emergency Dental Services Schedule of Fee Allowances – Crown & Bridgework

Employment and Assistance Act (EAA) – Section 22

APPEAL NUMBER 2021-0252

PART E – SUMMARY OF FACTS The appellant is an adult recipient of disability assistance. Pacific Blue Cross (PBC), acting on behalf of the Ministry in accordance with delegated decision making powers, found the appellant ineligible for coverage for dental services in relation to a crown to repair a broken tooth. Coverage for the treatment was refused by PBC because the services requested were not covered benefits.

On December 2, 2021 the appellant attended a Ministry office seeking reconsideration of that decision. In a Request for Reconsideration, dated December 9, 2021 the appellant argued that the crown was necessary because the tooth could not be repaired with a filling. The appellant stated that they were in extreme discomfort for the past few months, since breaking the tooth, due to an exposed nerve. The

appellant further argued that they were unable to afford the cost of a crown, at $1400 to $1700, when their total monthly support is $1410. They stated that they had used their dental coverage only a few times since 2019 for cleaning and one filling.

On December 20, 2021 the Ministry issued its reconsideration decision. At reconsideration, the Ministry found it was not authorized to provide coverage for the services requested because they were not set out in the relevant Schedules of Fees for dental. This is the decision being appealed.

Notice of Appeal In the Notice of Appeal dated December 20, 2021 (received December 29, 2021), the appellant indicated that they understood how benefits work and was not requesting 100% coverage. The appellant argued that it was unacceptable that they be denied any coverage for essential dental services and stated they

should be able to access the unused portion of the 24-month $1000 maximum allocated for dental coverage towards the cost of the crown. The appellant argued that dental care is a part of healthcare and denial of dental coverage is abuse. The appellant argued that persons receiving provincial disability

benefits should have access to the same level of dental coverage as provincial employees. The appellant argued that the treatment of persons with disabilities is lacking in dignity and respect.

Appeal Submissions At the hearing, the appellant explained that they had broken their tooth while eating in October 2021 and less than 1/3 of the tooth remained. Their understanding, based on advice from their dentist, was that a crown was the only option to save the tooth. The appellant explained that they were hoping for partial coverage of the cost for the dental services to fit the crown, which has now been completed. The appellant reiterated that they had been in significant pain and put themselves into significant debt to have the work completed. The appellant expressed their opinion that these dental services should be covered, at least in part, by PBC because of the essential nature of the dental work. The appellant reiterated the

importance of appropriate dental care for health and dignity.

The Ministry relied on the reconsideration decision at the hearing. Admissibility The panel finds that there is no new information before us requiring an admissibility determination as set out in section 22(4) of the Employment and Assistance Act.

APPEAL NUMBER 2021-0252

PART F – REASONS FOR PANEL DECISION The issue on appeal is whether the Ministry's determination, that the appellant was not eligible for coverage of the dental services requested, is reasonably supported by the evidence or a reasonable

application of the legislation in the circumstances of the appellant.

Legislation The applicable legislation is provided in Appendix A

Analysis On appeal, the panel must, in accordance with section 24 of the EAA, determine whether the decision under appeal is reasonably supported by the evidence, or a reasonable application of the applicable enactment in the circumstances of the person appealing the decision. The applicable enactment in this appeal is the Employment and Assistance for Persons with Disabilities Regulation (EAPWDR).

The Ministry determined at reconsideration that the appellant, as a recipient of disability benefits, is eligible for basic and emergency dental services and crown/bridge work as set out in the legislation. However, the Ministry further found that the appellant was not eligible for coverage of the dental services

requested. The Ministry, as is their practice, considered several benefits, supplements and funding provisions at reconsideration prior to confirming that the appellant is not eligible for coverage.

Basic and Emergency Dental Services The Ministry first considered the appellant’s eligibility for funding of treatment associated with fee code 42341 by examining the dental fee codes associated with basic and emergency dental services, as set out in EAPWDR sections 63 and 64 and Schedule C sections 1, 4 and 5. The Ministry noted that it may only provide funding for dental services that are included in the Schedule of Fee Allowances – Dentist or

Schedule of Fee Allowances – Dental Emergency (“Schedules of Fee Allowances”) and that the treatment requested under this specific fee code is not included. The Ministry explained that it may only

provide coverage for basic dental services and emergency dental services, as set out at Section 63 and 64 respectively, as well as Schedule C, sections 1, 4 and 5 of the EAPWDR. The Ministry noted that the fee code submitted was not listed in the Schedules of Fee Allowances. The Ministry concluded that,

because the specific service requested by the appellant is not set out in the Schedules of Fee Allowances, the Ministry cannot cover that service. The Ministry went on to explain that it does not have

discretion to cover procedures that are not included in the Schedule of Fee Allowances.

Crown & Bridgework The Ministry next found that the appellant is not eligible for dental fees associated with fee code 27201. In this portion of the reconsideration decision, the Ministry explained that while the Schedule of Fee Allowances – Crown & Bridgework does cover some crowns, the specific crown requested is not set out

in that Schedule. The Ministry further noted that only full cast metal crowns can be contemplated for tooth numbers ending with 6, 7, 8. The appellant’s request for coverage was in relation to a tooth ending

with 6, 7, or 8 and the crown requested was not a full cast metal crown. The Ministry concluded that, because the specific service requested by the appellant is not set out in the Schedules of Fee Allowances, the Ministry cannot cover that service. The Ministry went on to explain that the appellant has

not met all of the legislative requirements set out in Schedule C, section 4.1(2). Specifically, the Ministry found that the appellant had not provided information establishing that one of the circumstances set out

in 4.1(2)(b) had been met.

The panel notes information from PBC shows an alternative service – “full cast metal crown”, associated with fee code 27301, which is included in the Schedule of Fee Allowances. At the hearing, the appellant stated they did not know the difference between the two types of crowns and stated they relied on their dentist’s expertise to determine the proper treatment.

APPEAL NUMBER 2021-0252

Life-Threatening Health Need The Ministry next found that the appellant is not eligible for dental fees as a life-threatening health need under section 69 of the EAPWDR. The Ministry noted section 69 contemplates coverage for medical transportation, equipment/devices and some medical supplies as described in EAPWDR Schedule C. The Ministry concluded that it it is not authorized to cover dental services as a life-threatening health

need because dental and denture supplements are not set out in the sections of Schedule C that apply to section 69.

Crisis supplement The Ministry went on to consider whether the appellant was eligible for coverage of the dental services as a crisis supplement under section 57(3) of the EAPWR and found that they were not. The Ministry explained that it may not provide a crisis supplement for items described in the EAPWDR Schedule C or for any health-care good or services. The Ministry found that a dental exam is both a health-care service and described in Schedule C and concluded that the appellant was not eligible to receive a crisis supplement for the cost of the dental service.

The appellant’s arguments and submissions do not specifically address the legislative requirements for the benefits discussed in the reconsideration decision. Rather the appellant argued that because the dental service provided was essential, due to pain associated with an exposed nerve, it should be covered by PBC, particularly because there was an unused portion of the appellant’s 24-month $1000

maximum. The appellant argued that they had not been informed of different crown options by their dentist and there had been no discussion as to the type of crown the appellant required.

The panel notes that the legislated benefits scheme allows funding for basic and emergency dental treatment only in certain circumstances and for certain services. The Ministry is only permitted to approve funding for the services specifically listed in the Schedules of Fee Allowances and only to the maximum amounts set out. The Ministry has no authority to approve funding for services that are not specifically listed or to approve funding above the maximum amounts in the Schedules of Fee Allowances.

Panel findings The panel finds, according to the evidence presented, the appellant required dental treatment relating to a broken tooth and exposed nerve. The appellant was advised by their dentist that a crown was the only option to save their tooth. Despite this advice from the appellant’s dentist, the panel finds that the Ministry is permitted to fund the provision of basic and emergency dental services only for portions of the

appellant’s dental treatment that are listed services in the Schedule of Fee Allowances and only to the accompanying maximum amounts. The panel further finds that the appellant has requested coverage for dental services associated with fee codes that are not included in the dental care scheme that the Ministry is permitted to approve.

In summary, the panel finds that the appellant has requested funding a dental service that the Ministry has no legal authority to approve as either basic or emergency dental services, a life-threatening health need, or a crisis supplement. As such, the panel finds the Ministry’s conclusions are both reasonably

supported by the evidence and a reasonable application of the legislation in the circumstances of the appellant.

Conclusion

APPEAL NUMBER 2021-0252

The panel finds that the Ministry’s reconsideration decision was reasonably supported by the evidence and a reasonable application of the legislation in the circumstances of the appellant. The panel confirms the Ministry’s reconsideration decision. The appellant is not successful on appeal.

Appendix A

57 (1) The minister may provide a crisis supplement to or for a family unit that is eligible for disability assistance or hardship assistance if (a) the family unit or a person in the family unit requires the supplement to meet an unexpected expense or obtain an item unexpectedly needed and is unable to meet the expense or obtain the item because there are no resources available to the family unit, and (b) the minister considers that failure to meet the expense or obtain the item will result in (i) imminent danger to the physical health of any person in the family unit, or (ii) removal of a child under the Child, Family and Community Service Act. (2) A crisis supplement may be provided only for the calendar month in which the application or request for the supplement is made. (3) A crisis supplement may not be provided f or the purpose of obtaining (a) a supplement described in Schedule C, or (b) any other health-care goods or services. (4) A crisis supplement provided for food, shelter or clothing is subject to the following limitations: (a) if for food, the maximum amount that may be provided in a calendar month is $40 for each person in the family unit; (b) if for shelter, the maximum amount that may be provided in a calendar month is the smaller of (i) the family unit's actual shelter cost, and (ii) the sum of (A) the maximum set out in section 2 of Schedule A and the maximum set out in section 4 of Schedule A, or (B) the maximum set out in Table 1 of Schedule D and the maximum set out in Table 2 of Schedule D, as applicable, for a family unit that matches the family unit; (c) if for clothing, the amount that may be provided must not exceed the smaller of (i) $100 for each person in the family unit in the 12 calendar month period preceding the date of application for the crisis supplement, and (ii) $400 for the family unit in the 12 calendar month period preceding the date of

APPEAL NUMBER 2021-0252

application for the crisis supplement. (5) Repealed. [B.C. Reg. 248/2018] (6) Repealed. [B.C. Reg. 248/2018] (7) Despite subsection (4) (b), a crisis supplement may be provided to or for a family unit for the following: (a) fuel for heating; (b) fuel for cooking meals; (c) water; (d) hydro. 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, 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; am. B.C. Reg. 161/2017, App. 2, s. 2.] 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.] Health supplement for persons facing direct and imminent life-threatening health need 69 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 eligib le for the health supplement under this regulation, and if the minister is satisf ied 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,

APPEAL NUMBER 2021-0252

(b) the health supplement is necessary to meet that need, (c) a person in the family unit is eligible to receive premium assistance under the Medicare Protection Act, and (B.C. Reg. 145/2015) (d) the requirements specif ied in the following provisions of Schedule C, as applicable, are met: (i) paragraph (a) or (f ) of section (2) (1); (ii) sections 3 to 3.12, other than paragraph (a) of section Schedule C 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 ef fective 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 categ ory of person receiving the service,

(b)if provided by a denturist, (i) is set out in the Schedule of Fee Allowances — Denturist that is ef fective 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

(c)if provided by a dental hygienist, (i) is set out in the Schedule of Fee Allowances — Dental Hygienist that is ef fective 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;

"dental hygienist" means a dental hygienist registered with the College of Dental Hygienists established under the Health Professions Act;

"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 (a)if provided by a dentist (i) are set out under fee numbers 51101 to 51302 in the Schedule of Fee Allowances — Dentist that is ef fective 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, and

(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 ef fective 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;

APPEAL NUMBER 2021-0252

"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 ef fective 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 ef fective 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 dependents 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 def inition "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 def inition "basic dental service" in section 1 of this Schedule.

APPEAL NUMBER 2021-0252

(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 def inition "basic dental service" in section 1 of this Schedule, or