Ministry of Social Development and Poverty Reduction

Appeal Number: 2023 - 0287 Part C – Decision Under Appeal The decision under appeal is the Reconsideration Decision of the Ministry of Social Development and Poverty Reduction (“Ministry”) dated September 12, 2023, in which the Ministry determined that the Appellant was not eligible for funding above ministry rates for dental fees between January 1, 2022, and June 20, 2023.

This was determined under Schedule C of the Employment and Assistance Regulation, and Schedule C of the Employment and Assistance for Persons with Disabilities (EAPWD) Regulation.

Part D – Relevant Legislation

Employment and Assistance Regulation • Sections 68, 68.1, 69, 70, 71, and 76 (prior to July 1, 2022)

Employment and Assistance Regulation • Schedule C, Sections 1, 4, 4.1, 5 and 6 (prior to July 1, 2022)

Employment and Assistance for Persons with Disabilities Regulation • Sections 57, 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, Emergency Dental – Dentist, Crown & Bridgework

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Part E – Summary of Facts

Appeal Number: 2023 - 0287

Evidence Before the Ministry at Reconsideration: The Appellant applied to the Ministry on June 22 nd , 2023, to request funding for dental fees paid for dental treatment in 2022 – 2023. The Ministry denied the request and informed the Appellant that Pacific Blue Cross, the Ministry’s designate for dental supplements, had covered the maximum amounts that are allowable. The Appellant submitted a request for reconsideration on August 1 st , and on September 12 th , the Ministry completed its review, and advised the Appellant that their request was denied. In their response, the Ministry noted that the Appellant had been designated as a Person with Disabilities on July 1st, 2022, and is receiving disability assistance.

The Ministry generated a chart showing the dental services received by the Appellant between January 2022 and June 2023. It shows the dates of service, the numbers of the teeth worked on for each service, the fee codes, descriptions of the services provided, and the related fees, both those charged by the dentist and the amounts approved by Pacific Blue Cross (PBC).

The Appellant provided a letter from their dentist, indicating the total amount the Appellant paid for dental services in 2022 – 2023. The Ministry advised the Appellant that PBC had provided coverage up to the maximum ministry rates.

The Appellant requested an extension, which was approved until August 31, 2023, in order to meet with an advocate, but no information from the advocate was provided to the Ministry.

The Ministry noted that the letter from the dentist indicates the amounts paid by the Appellant, but the amount cited does not match the claims history provided by PBC.

On September 7, 2023, the Ministry reviewed the Appellant’s claim history with PBC and noted that the Appellant reached their $1000 limit for basic dental services for January 2023 – December 2024 on January 27, 2023. The Ministry contacted the dental office that provided the dental services to clarify whether the services provided to the Appellant on January 27, 2023, were required for an emergency situation – needed for the immediate relief of pain, or to control infection or bleeding. The dental office did not respond to the inquiry.

As the Appellant receives disability assistance, they are eligible for coverage of basic dental services, emergency dental services, and crown/bridgework, as detailed in the legislation. This coverage became effective July 1, 2022, when the Appellant was approved

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Appeal Number: 2023 - 0287 for Persons with Disabilities designation (PWD). Prior to July 1, 2022, the Appellant received income assistance, and was not eligible for coverage of basic dental services. However, they may have been eligible for coverage of denture services and emergency dental services.

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Part F – Reasons for Panel Decision

Appeal Number: 2023 - 0287

None of the dental services provided to the Appellant qualify as emergency dental services, and none qualify for additional coverage for tooth restoration. The Ministry also stated that dental services cannot be provided as a life-threatening need health supplement or a crisis supplement.

In their decision summary, the Ministry said that they are not authorized, under the legislation, to provide coverage in excess of the rates set out in the Schedule of Fee Allowances – the applicable rate for basic dental services is $1000 in a 2-year period. The Appellant exceeded the $1000 coverage limit for the period January 1, 2023, to December 31, 2024, on January 27, 2023

Part F – Reasons for Panel Decision

The issue on appeal is whether the Ministry was reasonable in determining that the Appellant was not eligible for dental services in excess of the rates set out in the legislation.

Appellant’s Position: The Appellant, in their Notice of Appeal, stated that they disagree with the Ministry’s decision because they borrowed money from a friend to pay for the dental services, and they have to return it.

Ministry’s Position: The Ministry explained that the rates for coverage of dental services are detailed in the legislation, and they also explained the conditions under which an appellant would qualify for services beyond the basic dental services. There is no provision for providing payment for basic dental services in excess of the stipulated $1000 in a 2-year period, and there is no information to indicate that emergency dental services were provided. They also indicated that dental services do not qualify for a life-threatening need or crisis supplement.

Panel Decision: The issue under appeal is whether the Reconsideration Decision denying the Appellant additional dental coverage was reasonably supported by the evidence or a reasonable application of the legislation.

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Appeal Number: 2023 - 0287

The Regulations set out the criteria for providing dental services to applicants. Basic dental services are covered up to $1000 for a 2-year period. If the applicant requires emergency dental services, these costs can be covered above the $1000 2-year limit. The Ministry reached out to the dentist who provided the services to request clarification, and to identify whether any of the services constituted an emergency or a life-threatening situation but did not receive a response to their inquiry.

The Appellant did not provide reasons for the dental services exceeding the allowable amounts, other than that they had to repay their friend from whom they borrowed the funds to pay the dentist.

Conclusion:

The Panel finds that the Ministry’s reconsideration decision that the Appellant is not eligible for dental services above the amount already approved at ministry rates is a reasonable application of the legislation in the Appellant’s circumstances.

The Panel confirms the Ministry’s reconsideration decision. The Appellant is not successful in their appeal.

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Appeal Number: 2023 - 0287

Schedule of Legislation EMPLOYMENT AND ASSISTANCE FOR PERSONS WITH DISABILITIES ACT

Delegation of minister's powers and duties

25 (1) Subject to the regulations, the minister may delegate to any person or category of persons any or all of the minister's powers, duties or functions under this Act except

(a) the power to prescribe forms, and (b) the power to enter into an agreement under section 21 (2) or (2.1), unless section 21 (2.2) applies in relation to the agreement.

(2) A delegation of the powers, duties or functions of the minister must be in writing and may include any limits or conditions the minister considers advisable.

EMPLOYMENT AND ASSISTANCE FOR PERSONS WITH DISABILITIES REGULATIONS

Crisis supplement 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 for 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 (C)

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Appeal Number: 2023 - 0287 (D) 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 application for the crisis supplement.

(5) Repealed. [B.C. Reg. 248/2018] (6) 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.

61.01 In this Division: “continued person” means (a) a main continued person under section 61.1 (1) or (b) a dependent continued person under section 61.1 (2);

Eligibility for medical services only Access to medical services only 61.1 (1) Subject to subsection (4), a person is a main continued person if (a) the person was (i) part of a family unit identified in subsection (3) on the date the family unit ceased to be eligible for disability assistance, and (ii) a person with disabilities on that date, (b) the person has not, since that date, been part of a family unit in receipt of income assistance, hardship assistance or disability assistance. (c) In the case that the family unit referred to in paragraph (a) (I) was a family unit identified in subsection (3) (g), the agreement referred to in subsection (3) (g) is in force.

(2) Subject to subsection (6), a person is a dependent continued person if (a) the person was a dependant of a main continued person under subsection (1) on the main continued person's continuation date, and is currently a dependent of the main continued person, or (b) the person is a dependant of a person who is a main continued person under subsection (1) as a result of having been a part of a family unit identified in subsection (3) (b), (c), (d), (e), (f) or (g). (3) A family unit is identified for the purposes of subsection (1) (a) if the family unit, while in receipt of disability assistance, ceases to be eligible for disability assistance (a) on a date the family unit included a person aged 65 or older, (b) as a result of a person in the family unit receiving an award of compensation under the Criminal Injury Compensation Act or an award of benefits under the Crime Victim Assistance Act, (c) as a result of a person in the family unit receiving a payment under the settlement agreement approved by the Supreme Court in Action No. S50808, Kelowna Registry. (d) as a result of a person in the family unit receiving employment income,

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Appeal Number: 2023 - 0287 (e) as a result of a person in the family unit receiving a pension or other payment under the Canada Pension Plan(Canada), (f) as a result of a person in the family unit receiving money or value that is maintenance under a maintenance order or a maintenance agreement or other agreement, or (g) as a result of a person in the family unit receiving financial assistance provided through an agreement under section 12.3 of the Child, Family and Community Service Act.

(4) Subject to subsection (5), a person's status as a main continued person under subsection (1) is suspended for a calendar month if (a) the person fails to meet an applicable income test under subsection (7) in the calendar month and in each of the immediately preceding 12 calendar months, and (b) the person's continuation date is before those immediately preceding 12 calendar months.

(5) Subsection (4) does not apply to a person who is a main continued person under subsection (1) as a result of having been part of a family unit identified in subsection (3) (c) or (g).

(6) A person's status as a dependent continued person under subsection (2) of a main continued person under subsection (1) is suspended if the main continued person's status is suspended under subsection (4).

(7) For the purposes of subsection (4), (a) a person who is a main continued person under subsection (1) as a result of having been part of a family unit identified in subsection (3) (a), (b), (d) or (f) meets the income test for a calendar month if, (i) in the case that the main continued person is aged 65 or older or the main continued person's family unit includes a person aged 65 or older, the main continued person or another person in the family unit is in receipt of a qualifying federal benefit, and (ii) in the case that neither the main continued person nor another person in the main continued person's family unit is aged 65 or older, the main continued person or another person in the family unit is eligible to receive premium assistance under the Medicare Protection Act, and (b) a person who is a main continued person under subsection (1) as a result of having been part of a family unit identified in subsection (3) (e) meets the income test for a calendar month if, (i) in the case that the main continued person is aged 65 or older or the main continued person's family unit includes a person aged 65 or older, the main continued person or another person in the family unit is in receipt of a qualifying federal benefit, and (ii) in the case that neither the main continued person nor another person in the main continued person's family unit is aged 65 or older, the main continued person or another person in the family unit receives a pension or other payment under the Canada Pension Plan (Canada).

(8) Despite this Division, a person is not eligible, as a main continued person under subsection (1), to receive a health supplement under this Division for the calendar month in which the person's continuation date occurs.

(9) Despite this Division, a person is not eligible, as dependent continued person under subsection (2) of a main continued person under subsection (1), to receive a health supplement under this Division for the calendar month in which the main continued person's continuation date occurs.

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Appeal Number: 2023 - 0287 Dental supplement 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.

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.

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.

Orthodontic supplement 65 (1) Subject to subsection (2), the minister may provide orthodontic supplements to or for (a) a family unit in receipt of disability assistance, if the orthodontic supplements are provided to or for a person in the family unit who is (i) under 19 years of age, or [B.C. Reg. 161/2017] (ii) a person with disabilities, or (b) a family unit, if the orthodontic supplements are 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.C. Reg. 161/2017] (B) the person was, on the person's continuation date, a person with disabilities. (2) For a person referred to in subsection (1) to be eligible for orthodontic supplements, the person's family unit must have no resources available to cover the cost of the orthodontic supplements and the person must (a) have severe skeletal dysplasia with jaw misalignment by 2 or more standard deviations, and (b) obtain prior authorization from the minister for the orthodontic supplements.

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Schedule C - Health

Appeal Number: 2023 - 0287

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 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 (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 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; (B.C. Reg. 65/2010)

"dental technician" Repealed (B.C. Reg. 94/2005) "dentist" means a dentist registered with the College of Dental Surgeons of British Columbia continued under the Health Professions Act; (B.C. Reg. 421/2008)

"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 minster, 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;

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Appeal Number: 2023 - 0287

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, 2009, 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. (B.C. Reg. 65/2010) (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) $2000 each period, if provided to a person under 19 years of age, and (B.C. Reg. 161/2017) (b) $1 000 each period, if provided to a person not referred to in paragraph (a), (B.C. Reg. 163/2005) (c) Repealed (B.C. Reg. 163/2005) (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. (B.C. Reg. 94/2005) (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.C. Reg. 94/2005) (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. (B.C. Reg. 94/2005) (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 to 51102 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.C. Reg. 94/2005) (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. (B.C. Reg. 94/2005) (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.