Ministry of Social Development and Poverty Reduction

Appeal Number 2024-0138 Part C – Decision Under Appeal The decision under appeal is the reconsideration decision of the Ministry of Social Development and Poverty Reduction (“Ministry”) dated April 5, 2024, in which the Ministry denied coverage for dental services in excess of the rates set out in the Schedule of Fee Allowances – Dentist under Schedule C of the Employment and Assistance for Persons with Disabilities Regulation (“Regulation”). The Ministry approved coverage for dental services listed in the Schedule of Fee Allowances – Dentist up to the 2-year limit of $1,000.00 for basic dental services. The Ministry approved a further $1,253.77 as emergency dental services, at the rates set out in the Schedule of Fee Allowances – Emergency Services – Dentist and for complete upper and lower dentures up to the maximum rates set out in the Schedule of Fee Allowances – Denturist under Schedule C of the Regulation.

Part D – Relevant Legislation Employment and Assistance for Persons with Disabilities Regulation (“Regulation”), sections 57(1) and (3), 62, 63, 63.1, 64, 69 and Schedule C, sections 1 (definitions of “basic dental service”, “dentist”, “denture services”, “denturist”, and “emergency dental service”), 4, 4.1 and 5

Full text of the legislation is provided at the end of the decision.

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Appeal Number 2024-0138 Part E – Summary of Facts The hearing took place in person on May 7, 2024, with the Ministry and an interpreter attending by telephone.

Evidence Before the Ministry at Reconsideration:

The Appellant is a recipient of disability assistance and is eligible for coverage of basic dental services, emergency dental services and crown and bridgework under the Regulation.

The Appellant was in severe pain due to the condition of his teeth and he needed multiple extractions. His dentist submitted a treatment plan proposal for dental services with fees totalling $6,361.00.

The Ministry approved coverage of $1,235.77 for the following dental services in the treatment plan as emergency dental services, according to the services and Ministry rates set out in the Schedule of Fee Allowances – Dentist – Emergency Services:

Item Tooth No.

1

2 3

4

5 6

7

N/A

16 15

14

36 35

34

Fee Code

79331

71211 71209

71209

71211 71209

71209

Antral Surgery, Oro-

-

-

-

-

Fees

$475.00

$451.00 $255.00

$255.00

$451.00 $255.00

$255.00

Rate

$178.57

$201.55 $85.98

$85.98

$201.55 $85.98

$85.98

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8 9

10

11

33

32

31

41

71219 71109

71209

71209

tooth

Appeal Number 2024-0138 $383.00

-

-

-

$151.00

$255.00

$255.00

$133.03

$45.59

$85.98

$63.58

TOTAL:

The Ministry determined that the following dental services from the treatment proposal were included in the Schedule of Fee Allowances – Dentist and determined the Ministry fee rates for the dental services shown:

Item

1 2 3 4

5

6 7

8

9 10

Tooth No.

N/A N/A 16 15

14

36 35

34

33 32

Fee Code

79331 92445 71211 71209

71209

71211 71209

71209

71219 71109

Antral Surgery, Oro-

-

-

-

-

-

Fees

$475.00 $455.00 $451.00 $255.00

$255.00

$451.00 $255.00

$255.00

$383.00 $151.00

Rate

$178.57 $0.00 $201.55 $85.98

$85.98

$201.55 $85.98

$85.98

$133.03 $45.59

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11

12

13

14

15 16

17

18 19 20

31

41

42

43

44 N/A

48

N/A N/A N/A

71209

71209

71209

71209

71211 73152

72311

77801 73111 73111

Appeal Number 2024-0138 $255.00 -

-

-

-

-

TOTAL:

$255.00

$255.00

$255.00

$451.00 $596.00

$171.00

$389.00 $174.00 $174.00

$85.98

$85.98

$85.98

$85.98

$201.55 $224.44

$63.84

$146.29 $65.38 $65.38

The Ministry approved coverage up to $961.24 towards this amount, which the Ministry said was the unused balance of the Appellant’s 2-year, $1,000.00 coverage limit for basic dental services.

The Appellant also submitted a treatment plan from a denturist for complete upper and lower dentures, at a total cost of $4,750.00. The Ministry approved coverage for the dentures up to $1,162.50, which is the maximum fee set out in the Schedule of Fee Allowances – Denturist.

Additional Evidence:

Appellant:

In the Notice of Appeal, the Appellant stated that he lives in a small community with no access to transportation to travel elsewhere to find a denturist who charges less.

At the hearing the Appellant provided two additional documents:

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Appeal Number 2024-0138 Standard dental claim form signed by the dentist and the Appellant, listing some of the dental services in the first treatment plan proposal dated February 29, 2024. The list says “continued on next page”, but the next page was not provided to the Panel. Additional treatment plan proposal from the dentist, dated April 25, 2024, for two fee items #73111, alveoloplasty, in the total amount of $348.00.

At the hearing, the Appellant stated: He was in very bad pain with his teeth and needed to be put to sleep for the extraction of five teeth, which took two hours. The dentist did not charge him for the anaesthetic. The dentist had sent in a pre-authorization for $427 in January 2024, but the dentist’s office only did an x-ray to see if he needed the surgery. He maintains that the dentist should not have sent a pre-authorization request for that much, they should only have sent a pre-authorization for the extractions. He spoke to a Ministry Community Integration Specialist who told him the Ministry would cover the dental work and pay for his dentures. The Appellant showed the Panel the business card of the Community Integration Specialist. He now needs more dental work done, as shown on the treatment plan dated April 25, 2024, for dental services that will cost another $348.00. He has to pay $3,948.00 in addition to the amount the Ministry has agreed to pay, and while he is trying to save all the money he can, he needs more help from the Ministry to pay for the dental work he needs, so that he can eat.

In answer to questions from the Panel, the Appellant said: The Ministry told him to send the papers from the dentist, they did not tell him that the Ministry would only pay $1,000.00. He was in so much pain, he could not wait any longer to have the extractions done.

Admissibility of Additional Evidence:

The Ministry did not object to the additional documents and the additional oral evidence of the Appellant. The documents relate to the dental services that the Appellant needed, and therefore the Panel finds that the evidence is reasonably necessary to determine the issues in the appeal. The Panel finds that the additional evidence is admissible under section 22(4) of the Employment and Assistance Act.

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Appeal Number 2024-0138 Part F – Reasons for Panel Decision The issue on appeal is whether the Ministry was reasonable in denying a health supplement for dental services in excess of the rates set out in the Schedule of Fee Allowances – Dentist, the Schedule of Fee Allowances – Emergency Services - Dentist and Schedule of Fee Allowances – Denturist under Schedule C of the Regulation.

Appellant’s Position:

The Appellant says that the extractions were needed urgently, because he was in extreme pain, and he could not eat. He argues that the amounts the Ministry has agreed to pay are not enough to cover even minimal dental services, let alone the extensive dental services he needs. He says that there is no dentist in his community who would provide dental services for the fees on the Ministry’s schedule, and he does not have transit to go to another community to find a less expensive provider, if one exists. He says that he is doing everything he can to save money, but being on disability assistance, he does not have enough money to pay the dentist or the denturist.

Ministry Position:

The Ministry acknowledges that the Schedules of Fee Allowances for Dentists and Denturists have not kept up with current fees charged by dentists and denturists. However, the Ministry says that it is only allowed to authorize coverage as set out in the legislation, and under the legislation they cannot approve fees for more than the amounts set out in the Schedules. Further, there is a coverage limit of $1,000 for basic dental services in a two year period. The Ministry maintains that it has approved the maximum fees allowed under the legislation.

The Ministry also says it considered whether the dental services could be covered as a crisis supplement, but that, under section 57(3) of the Regulation, the Ministry may not provide a crisis supplement for dental services.

Panel Decision:

Under the Regulation, the Ministry is authorized to provide a recipient of disability assistance with health supplements for dental supplements, emergency dental supplements and crown and bridgework supplements. Under Schedule C of the Regulation, fees for dentists and denturists are limited to the amounts set out in the Schedule of Fee Allowances – Dentists, Schedule of Fee Allowances – Emergency Dental – Dentists, and Schedule of Fee Allowances – Denturists.

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Basic Dental Services:

Appeal Number 2024-0138

Under Schedule C of the Regulation, the dental supplement for basic dental services is also limited to $1,000.00 for a two year period. The current two-year period runs from January 1, 2023, to December 31, 2024under section 4(1) of Schedule C of the Regulation.

The Appellant was in pain and urgently needed extensive dental extractions. Following the extractions, he would need upper and lower dentures. His dentist provided a treatment plan proposal with fees totalling $6,381.00. The denturist provided a treatment plan for complete upper and lower dentures for a total of $4,750.

The Ministry reviewed the treatment plans and determined that not all of the fee items in the dentist’s treatment plan proposal were in the Schedule of Fee Allowances. For the fee items that were in the Schedule of Fee Allowances, the Ministry determined that the Ministry rates totalled $2,149.63. After reviewing the Schedules of Fee Allowances, the Panel finds that the Ministry correctly determined the fee items and fee rates for the dental services in the treatment plan proposals, under the various Schedules of Fee Allowances.

The Ministry had paid $38.76 on January 25, 2024, for a radiograph, leaving $961.24 out of the $1,000.00 coverage limit, so the Ministry approved coverage for basic dental services for $961.24. (The Appellant was quite concerned that the dentist had submitted a pre­authorization request for $427.60 before the appointment when the radiograph was taken; however, the Panel confirms that only the actual payment of $38.76 was deducted from his $1,000.00 coverage limit.) The Panel finds that the Ministry correctly determined the amount remaining in the two-year, $1,000.00 coverage limit for dental services under Schedule C, section 4 of the Regulation. The Panel also finds that the legislation does not permit the Ministry to provide more than $1,000.00 coverage for basic dental services in a two year period from January 1, 2023 to December 31, 2024.

Emergency Dental Services:

The Ministry determined that some of the dental services were emergency dental services, needed for immediate relief of pain. Under section 69 of the Regulation, the Ministry can provide coverage for eligible recipients for emergency dental services over the $1,000.00 coverage limit, as a health supplement for a person who faces a direct and imminent life threatening health need. The Ministry accepted that the Appellant met the eligibility requirements under section 69 of the Regulation, and his eligibility is not in issue in this

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Appeal Number 2024-0138 appeal. However, the Ministry may only provide a health supplement for emergency dental services at the rates set out in the Schedule of Fee Allowances – Emergency Dental – Dentist. After reviewing the Schedules of Fee Allowances , the Panel finds that the Ministry correctly determined the allowable fees for emergency dental services under the Regulation. The Panel also finds that the Ministry is not authorized under the legislation to provide a health supplement for emergency dental services at rates that are more than the rates set out in the Schedule of Fee Allowances – Emergency Dental – Dentist.

Dentures:

The Ministry approved the Appellant’s request for coverage for complete upper and lower dentures, at the maximum rate set out in the Schedule of Fee Allowances – Denturists. The Panel finds that the Ministry is not authorized under the legislation to provide a denture supplement for a fee that is more than the rate set out in the Schedule of Fee Allowances – Emergency Dental – Dentist.

Summary:

All the amounts approved by the Ministry are less than the fees actually charged by the dentist and the denturist. The Ministry acknowledges that the Schedules of Fee Allowances have not been updated for a number of years. The Panel notes that the Schedules for Dentists were published in 2017, and for denturists, 2010. The Ministry also acknowledges that the Schedules do not reflect the actual fees charged by dentists and denturists in 2024. However, the Ministry says that it has no discretion to provide dental supplements except as authorized in the legislation. The Ministry has determined that the Appellant was eligible to receive $961.24 for basic dental services, $1,253.77 for emergency dental services and $1,162.50 for upper and lower dentures and says those are the maximum amounts it can provide under the legislation.

The Panel agrees, and finds that the Ministry’s reconsideration decision, in which it denied coverage for fee items not listed in the Schedule of Fee Allowances – Dentist, denied coverage in excess of the rates listed in the Schedules of Fee Allowances for Dentists and Denturists, and denied coverage for basic dental services in excess of the two-year, $1,000.00 coverage limit, was a reasonable application of the legislation in the Appellant’s circumstances. The outcome leaves the Appellant with an unavoidable shortfall that he cannot afford to pay, but the legislation does not permit the Ministry to provide coverage for more than the amounts set out in the reconsideration decision: $961.24 for basic dental services, $1,253.77 for emergency dental services and $1162.50 for upper and lower dentures.

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Crisis Supplement for Dental Services:

Appeal Number 2024-0138

The Ministry also considered whether it could provide a crisis supplement for the dental services, but determined that, under section 57(3) of the Regulation, it cannot provide a crisis supplement for a supplement described in Schedule C. The Panel finds that the Ministry is not authorized under the legislation to provide a supplement for dental services, as dental services are a supplement described in Schedule C. Therefore, the Panel finds that the Ministry’s determination that it could not provide a crisis supplement for the dental services was a reasonable application of the legislation in the Appellant’s circumstances.

Conclusion:

The Panel finds that the Ministry’s reconsideration decision, in which the Ministry: denied coverage for fee items not listed in the Schedule of Fee Allowances – Dentist; denied coverage for dental services in excess of the rates set out in the Schedule of Fee Allowances – Dentist, the Schedule of Fee Allowances – Emergency Services – Dentist and the Schedule of Fee Allowances – Denturist under Schedule C of the Employment and Assistance for Persons with Disabilities Regulation (“Regulation”), and denied coverage for basic dental services in excess of the two-year, $1,000 coverage limit for dental services was a reasonable application of the legislation in the Appellant’s circumstances.

The Panel confirms the Ministry decision. The Appellant is not successful in the appeal.

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Appeal Number 2024-0138 Relevant Legislation

Employment and Assistance for Persons With Disabilities Regulation

Crisis supplement s. 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. (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. General health supplements s. 62 The minister may provide any health supplement set out in section 2 [general health supplements] or 3 [medical equipment and devices] 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.

Dental supplements s. 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,

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Appeal Number 2024-0138 (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 s. 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. Denture supplement s. 63.2 (1) Subject to subsection (2), the minister may provide any health supplement set out in section 4.2 [denture supplements] of Schedule C to or for a family unit in receipt of hardship assistance.

(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 63 [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.

Emergency dental and denture supplement s. 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

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Appeal Number 2024-0138

s. 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: (i) paragraph (a) or (f) of section (2) (1); (ii) sections 3 to 3.12, other than paragraph (a) of section 3 (1). (2) For the purposes of subsection (1) (c), (a) "adjusted net income" has the same meaning as in section 7.6 of the Medical and Health Care Services Regulation, and

(b) a reference in section 7.6 of the Medical and Health Care Services Regulation to an "eligible person" is to be read as a reference to a person in the family unit, other than a dependent child.

Definitions

Schedule C Health Supplements

s. 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,