2023-0195 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 July 7, 2023 (the “Reconsideration Decision”), in which the Ministry determined that, while the Appellant was eligible for coverage of complete maxillary and mandibular dentures (fee codes 51101 and 51102) up to $1538.25, which is the rate set out in the Schedule of Fee Allowances – Dentist, he was not eligible for coverage of fees charged in excess of this amount.
Part D – Relevant Legislation • Employment and Assistance Regulation (the “Regulation”) – sections 68, 69, and 70 • Schedule C of the Regulation (“Schedule C”) – sections 1, 4, 5, and 6 • Schedule of Fee Allowances – Dentist (the “Fee Schedule”)
Note: The full text is available after the Decision.
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2023-0195 Part E – Summary of Facts (a) The Reconsideration Decision The evidence before the Ministry at the Reconsideration Decision consisted of: • The Appellant is a recipient of income assistance and has been designated as a “Person with Persistent Multiple Barriers” (“PPMB”).
• Pursuant to section 25 of the Employment and Assistance for Persons with Disabilities Act, the Ministry delegated its powers and duties as set out in the legislation to Pacific Blue Cross (“PBC”) for determining whether any coverage for specific dental services applies to the Appellant based on information found in the Fee Schedule and, if it does, the amount of coverage available to him. The Ministry is also able to delegate its powers and duties pursuant to section 34 of the Employment and Assistance Act.
• In March 2023, the Appellant received the following coverage for basic dental services:
• On March 17, 2023, the Appellant’s spouse (the “Spouse”) contacted the Ministry to discuss the Appellant’s need for dentures. The Ministry advised the Spouse to contact the Appellant’s dentist (the “Dentist”) so that they could request a decision directly from PBC.
• On March 31 st , May 15 th , and June 5 th , 2023, the Dentist submitted requests for coverage for the Appellant’s maxillary and mandibular dentures which respectively cost $1,550.00 and $1,636.00. PBC approved coverage in the amount of $678.95, which was the maximum permitted by the Fee Schedule given the $1,000.00 limit for basic dental services applicable to every two year period (the “Decision”).
• On June 22, 2023, the Appellant submitted a Request for Reconsideration (the “Request”) wherein he explained his need for dentures and his inability to pay for them. More specifically, the Appellant explained:
o he has a disability;
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2023-0195 o he is 64 years old and unable to wor k due to illness which requires the daily use of medication;
o his dental condition makes it difficult for him to eat and, as a result, he had (then) been unable to eat solid food for four (4) months;
o his Dentist prescribed for him to get dentures; o he does not have the financial means or any sources of income which would help him cover the costs for the prescribed dentures; and
o he is mentally and emotionally affected by his ordeal. • On July 7, 2023, the Ministry issued the Reconsideration Decision wherein it determined that the Appellant was eligible for coverage of complete maxillary and mandibular dentures (fee codes 51101 and 51102) up to $1538.25, which is the rate set out in the Fee Schedule; however, he was not eligible for coverage for fees charged in excess of this amount. More specifically, the Ministry found that:
o as a person with a PPMB designation, the Appellant is eligible for dental supplements under section 68 of the Regulations and section 4 of Schedule C within the limits of those dental supplements as set out in the Fee Schedule;
o pursuant to section 4(3)(a) of Schedule C, the Appellant was able to receive funding exceeding the $1,000.00 limit for basic dental services for full upper and/or lower dentures because of extractions made in the past 6 months to his relieve pain, but only up to the maximum rates listed in that Fee Schedule for complete maxillary and mandibular dentures (fee codes 51101 and 51102); and
o the Appellant did not qualify for coverage of complete maxillary and mandibular dentures (fee codes 51101 and 51102) as an emergency dental service as the Fee Schedule did not provide for coverage of dentures themselves in the section for emergency dental services.
(b) The Appeal On July 12, 2023, the Appellant filed a Notice of Appeal (the “Appeal Notice”). In the Appeal Notice, the Appellant wrote, “… We are a senior couple and due to our age and physical condition we are unable to work. Currently, we are receiving support and assistance from Ministry which only covers our rent and we don’t have any other source of income…”
The Appellant’s Appeal hearing was held on August 2, 2023 via teleconference. Prior to the Appeal hearing, the Appellant submitted a note from his general practitioner in which they wrote, “… This letter certifies that above patient has multiple chronic condition which are listed below. This has been affecting his general health and well being and he is not able to
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2023-0195 work. Unfortunately, as a result he is struggl ing financially and not able to afford dental procedure. [He] has not able to eat solid foods due to dental issues and requires surgery. I would appreciate of you could please help him with funding for his dental procedure…” On review of the general practitioner’s note, the Appellant suffers from many health ailments which, on their face, appear unrelated to his need for dentures.
Oral Submissions At the Appeal hearing, the Appellant was assisted by his Spouse who also acted as a witness, and an interpreter who helped overcome any language barriers experienced by the Appellant and/or the Spouse.
Before oral submissions were provided by either party, the Panel asked the Appellant if he would like to request an adjournment so that he could find an advocate to assist with his Appeal. The Appellant did not request an adjournment despite being given multiple opportunities to do so.
During oral submissions, the Appellant and the Spouse restated much of the information that was found in the Request. For clarity, the Appellant and Spouse explained:
• the Appellant’s current dental situation is taking a great toll on him; • the Appellant only eats mushed foods as he cannot chew solid food; • he is unable to pay for the prescribed dentures; • he requires an additional $1,500.00 to pay for the prescribed dentures over and above what the Ministry has already agreed to pay; and
• the Spouse’s physical health has been adversely affected due to the burdens imposed upon her from assisting the Appellant.
The Ministry referred to and relied upon the Appeal Record which largely consisted of the Reconsideration Decision. In response to questions from the Panel, the Ministry clarified that, while the Appellant’s circumstances did not give rise to an emergency as contemplated by section 70 of the Regulation, he nonetheless was eligible to receive funding exceeding the $1,000.00 limit for basic dental services for full upper and lower dentures because of extractions made in the past 6 months to his relieve pain, but only up to the maximum rates listed in that Fee Schedule for complete maxillary and mandibular dentures
The Ministry had no objection to the Appellant’s oral submissions or additional evidence. The Panel determined that the Appellant’s submissions and evidence were admissible as additional evidence pursuant to section 22(4) of the Employment and Assistance Act as it was reasonably required for a full and fair disclosure of all matters related to the decision under Appeal. More specifically, the additional evidence contributed to the Panel’s understanding of the circumstances surrounding the Appeal.
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2023-0195 Part F – Reasons for Panel Decision The issue under appeal is the reasonableness of the Reconsideration Decision in which the Ministry determined that the Appellant was not eligible for coverage of dental fees in excess of the rates set out in the Fee Schedule.
Appellant’s Position The Appellant argues that he should be eligible for additional funding above the Regulation’s monetary limits.
Ministry’s Position The Ministry maintains that the Appellant is ineligible for the funding of dentures in excess of the amounts listed in the Fee Schedule.
Panel Decision
Section 68 of the Regulation permits the Ministry to provide a dental supplement as set out in section 4 of Schedule C to a family unit in receipt of income assistance if the family includes a person with a PPMB designation.
Section 69(1) of the Regulation permits the Ministry to provide a denture supplement as set out in section 5 of Schedule C to a family unit in receipt of income assistance. A person is ineligible for a denture supplement under subsection (1) unless the person: • is not eligible for a supplement under section 68 of the Regulation; and • has had tooth extractions that were performed in the last 6 months because of pain and • resulted in the person requiring a full upper denture, a full lower denture or both.
Section 70 of the Regulation permits the Ministry to provide an emergency dental supplement as set out in section 6 of Schedule C to a family unit in receipt of income assistance.
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2023-0195 The Fee Schedule indicates that the maximum amount of coverage that an individual can receive for maxillary and mandibular dentures (fee codes 51101 and 51102) is up to $1538.25:
(a) Sections 68 and 69 Eligibility It is undisputed that the Appellant is a recipient of income assistance and designated as a PPMB; as a result, the Appellant could receive a dental supplement as provided for by section 68 of the Regulation.
On review of section 4 of Schedule C, the Panel notes that section 1 of Schedule C clarifies that a "basic dental service" is defined as dental services set out in the Fee Schedule. The Panel finds that, in the case of the Appellant, the health supplements that may be paid for under section 68 of the Regulation are basic dental services up to a maximum of $1,000.00 for every two (2) year period as provided for by section 4(1.1) of Schedule C. However, section 4(3)(a) of Schedule C permits the Ministry to exceed the limitation imposed by section 4(1.1) to provide dentures if the Appellant requires dentures because of extractions made in the previous 6 months to relieve pain, but only up to the rates set out in the Fee Schedule.
Given the circumstances, the Panel finds that the Ministry reasonably applied the applicable legislation when it determined that the Appellant was eligible to receive funding exceeding the $1,000.00 limit for basic dental services for full upper and/or lower dentures because of extractions made in the past 6 months to his relieve pain, but only up to the maximum rates listed in that Fee Schedule for complete maxillary and mandibular dentures. As a result, the Ministry reasonably determined that the Appellant is able to receive $1538.25 for maxillary and mandibular dentures (fee codes 51101 and 51102).
The Panel also finds that the Ministry reasonably determined that the Appellant was ineligible for a health supplement under section 69 of the Regulation given his eligibly for a health supplement under section 68 of the Regulation.
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(b) Section 70 Eligibility It is undisputed that the Appellant is in receipt of income assistance; as a result, the Appellant could receive an emergency dental supplement as provided for by section 70 of the Regulation.
The Panel notes that section 1 of Schedule C defines an emergency dental supplement as a dental service necessary for the immediate relief of pain that, if provided by a dentist (i) is set out in the Schedule of Fee Allowances — Emergency Dental — Dentist, that is effective September 1, 2017 (updated on February 18, 2020) 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.
On review of the noted Fee Schedule, the Panel finds that emergency denture services are provided for denture repair, additions, and relining; not brand-new dentures as requested by the Appellant.
As a result of the foregoing, the Panel finds that the Ministry’s decision to deny the Appellant an emergency dental supplement was a reasonable application of section 70 of the Regulation.
Conclusion The Panel finds that the Ministry’s decision to deny the Appellant’s request for a complete dental treatment funding pursuant to sections 68, 69, and 70 of the Regulation was a reasonable application of the legislation in the circumstance.
The Appellant is not successful on appeal.
Legislation
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Employment and Assistance Regulation, BC Reg 263/2002
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
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2023-0195 (ii)the health supplement is provided to or for a person in the family unit who is under 19 years of age, (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 (i)is a continued person, and (ii)meets any of the following criteria: (A)the person is under 19 years of age; (B)the person was, on the person's continuation date, a person with persistent multiple barriers to employment or part of a family unit that then included a person with persistent multiple barriers to employment.
[en. B.C. Reg. 145/2015, Sch. 1, s. 9; am. B.C. Reg. 161/2017, App. 1, s. 2.]
Denture supplement 69 (1)Subject to subsection (2), the minister may provide any health supplement set out in section 5 [denture supplements] of Schedule C to or for (a)a family unit in receipt of income assistance or hardship assistance, or (b)a family unit, if the health supplement is provided to or for a person in the family unit who is a continued person. (2)A person is not eligible for a health supplement under subsection (1) unless (a)the person is not eligible for a supplement under section 68 [dental supplements], and (b)the person has had tooth extractions that were performed in the last 6 months because of pain and resulted in the person requiring a full upper denture, a full lower denture or both.
[en. B.C. Reg. 145/2015, Sch. 1, s. 9; am. B.C. Reg. 270/2019, App. 1, s. 16.]
Emergency dental and denture supplements 70 The minister may provide any health supplement set out in section 6 [emergency dental supplements] of Schedule C to or for (a)a family unit in receipt of income 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.
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[en. B.C. Reg. 145/2015, Sch. 1, s. 9.]
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Schedule C
Definitions 1 In this Schedule:
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"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,
"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
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, 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 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, and (b)$1 000 each period, if provided to a person not referred to in paragraph (a).
Denture supplements
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2023-0195 5 The health supplements that may be provided under section 69 [denture supplements] of this regulation are denture services.
Emergency dental supplements 6 The health supplements that may be paid for under section 70 [emergency dental and denture supplements] of this regulation are emergency dental services.
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Part G – Order The panel decision is: (Check one)
2023-0195
☒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) ☒ Section 24(2)(a)☒ or Section 24(2)(b) ☐
Part H – Signatures Print Name Anil Aggarwal Signature of Chair
Date (Year/Month/Day) 2023/08/02
Print Name Shannon Campbell
Signature of Member
Date (Year/Month/Day) 2023/08/02
Print Name John Pickford
Signature of Member
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Date (Year/Month/Day) 2023/08/15
Signature Page