Ministry of Social Development and Poverty Reduction

Part C – Decision Under Appeal

Appeal Number 2024-0314

The decision under appeal is the Ministry of Social Development and Poverty Reduction (ministry) Reconsideration Decision dated July 18, 2024, which determined the appellant is not eligible for complete coverage of upper and lower dentures.

Specifically, the ministry determined:  The requested amount was above the allowable rates.  The cost cannot be covered as a crisis supplement.  The cost cannot be covered as an emergency denture supplement.  The cost cannot be covered as a life-threatening need.

Part D – Relevant Legislation

Employment and Assistance for Persons with Disabilities Regulation (Regulation), sections 57, 63, 64 and 69, and Schedule C, sections 1, 2, 3, 4 and 5

Relevant sections of the legislation can be found in the Schedule of Legislation at the end of this decision, along with the Dental Supplement – Denturist, Schedule of Fee Allowances (Fee Schedule)

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Part E – Summary of Facts

Appeal Number 2024-0314

The hearing was held as a teleconference hearing on September 12, 2024. The appellant’s outreach worker was also her advocate at the hearing.

Evidence Before the Minister at Reconsideration

Ministry Records show:  On December 18, 2023, the appellant submitted claims for an examination and extractions for five teeth, which was approved up to the ministry rates.  On June 3, 2024, the appellant submitted claims for radiographs and examination, which were approved up to the ministry rates.  On June 24, 2024, the outreach worker submitted an estimate for complete upper and lower dentures on the appellant’s behalf.

Coverage for Requested Services and Ministry Rate Fee Code Description Dentist Fees 31310 Complete maxillary denture $1582.50 31320 Complete mandibular denture $1582.50 Total $3165.00

Ministry Rate $581.25 $581.25 $1162.50

 On June 25, 2024, the ministry denied the appellant’s request as the cost of the treatment is more than ministry rates, based on the Fee Schedule.

Letter to the Ministry from the Appellant’s Outreach Worker (June 27, 2024) On behalf of the appellant, the worker is requesting a reconsideration of the decision based on the following grounds. 1. Emotional well-being The appellant has been experiencing significant emotional distress due to the visible loss of teeth, impacting her self-esteem and confidence. This has led to social withdrawal and feelings of embarrassment, adversely affecting her health and overall well-being. 2. Physical Health The absence of proper dental care and the inability to chew food effectively has resulted in nutritional deficiencies and subsequent malnutrition posing a direct threat to the appellant’s physical health. 3. Mental Health The appellant has reported feelings of depression and anxiety related to the inability to properly interact socially and professionally due to her dental condition.

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This has had a profound impact on her mental health, affecting her ability to engage in daily activities and maintain interpersonal relationships. 4. Malnutrition The inability to chew food properly has led to an inability to consume a balanced diet, resulting in nutritional deficiencies that worsen her existing health issues. The appellant used to dance professionally and has a deep love for dancing. Her malnutrition has affected her ability to do what she loves. 5. Homelessness The appellant is experiencing homelessness, which exacerbates her ability to maintain good oral health and access necessary dental interventions. Homelessness increases the risk of dental issues due to limited access to regular hygiene practices and healthcare services. 6. Treatment for Substance Use The appellant has expressed a strong desire to seek treatment for substance use, once she regains confidence and stability from restoring her dental health. Addressing her dental needs is a critical first step in her journey towards recovery and rehabilitation. 7. Family Reunification After years of separation from her family, the appellant is hopeful that addressing her dental health will pave the way for family reunification. She is full of joy and love. She has been unable to see her children for many years, and lack of confidence due to her appearance, makes her anxious to see them again. The restoration of her dental health will contribute to her ability to establish stable relationships and a support system.

Under the BC Medical Services Plan and associated regulations, there is acknowledgment of the importance of providing healthcare services to vulnerable populations, including those experiencing homelessness. Access to necessary dental care is crucial for maintaining overall health and well-being, aligning with the principles of equity and compassion that underpin the Medical Services Plan.

Given the severe impact of dental health on the appellant’s overall well-being, compounded by her homeless status and aspirations for recovery and family reunification, the writer urges the ministry to reconsider the appellant’s case for coverage of a full set of dentures. Addressing this issue promptly is not only a matter of compassionate care but also essential for improving the appellant’s quality of life and supporting her path towards stability and recovery.

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Appeal Number 2024-0314

Email to the Ministry from the Appellant’s Community Liaison Worker (June 19, 2024) With the email, the worker attached the Pacific Blue Cross pre-assessment form from a denturist. They indicate that the denturist would not do a payment plan, so they will try this route first and if it does not succeed, perhaps see if another denturist would honour a payment plan.

Statement of Account – from a Denture Clinic (June 17, 2024) Estimate for upper and lower complete dentures: Denturist Association of BC Fee Guide - $3,165.00 BC Ministry Fee Schedule -$1,162.50 Patient’s portion - $2002.50

Additional Information Received after Reconsideration

Notice of Appeal (August 19, 2024) The appellant states this situation is severely affecting her health. She is not getting proper nutrition, it is causing depression and anxiety, and she is at risk of infection.

Testimony at the Hearing Appellant The following information was provided by the appellant’s outreach worker and the appellant. The information provided in the letter to the ministry dated June 27, 2024 was reiterated. In addition, the appellant can only consume liquids and so has had significant weight loss and has had quite a few infections.

The appellant received a partial denture many years ago. It is now chipped and cutting her gums. She had the last of her teeth pulled in December 2023 and now has no teeth at all. Her teeth needed to be pulled because they were rotten. They kept getting re-built but were weak. The appellant has been on disability benefits for more than twenty years.

Ministry At the hearing, the ministry stated the appellant is eligible for dentures, just not the full cost. The ministry stated the six-month timeframe was not an issue. The issue is that the ministry cannot cover the $2002.50 as this amount is above the allowable rates in the Fee Schedule. The ministry also stated that dentures are not covered under life-threatening needs as other options, such as antibiotics, are available to remedy the situation. As well, the ministry stated that the appellant is not eligible for additional funds under basic dental services. Although dentures can be covered under this section of the legislation, it is

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Appeal Number 2024-0314

intended as a basic supplement and not for an additional amount. The main driver for the ministry is that it cannot exceed the allowable amounts in the Fee Schedule.

Admissibility The panel determined the additional information above, from the appellant, her advocate and the ministry is reasonably required for a full and fair disclosure of all matters related to the decision under appeal and therefore is admissible under section 22(4) of the Employment and Assistance Act.

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Part F – Reasons for Panel Decision

Appeal Number 2024-0314

The issue on appeal is whether the ministry’s Reconsideration Decision was reasonably supported by the evidence or was a reasonable application of the legislation in the circumstances of the appellant.

Specifically, did the ministry reasonably determine the appellant was not eligible for complete coverage of upper and lower dentures for the following reasons:  The requested amount was above the allowable rates.  The cost cannot be covered as a crisis supplement.  The cost cannot be covered as an emergency denture supplement.  The cost cannot be covered as a life-threatening need.

Appellant Position The appellant’s advocate submits that the appellant has been experiencing significant emotional distress due to the loss of teeth. As well, the inability to chew food effectively has resulted in malnutrition, a direct threat to her physical health. In addition, she is homeless, which exacerbates her ability to maintain good oral health and access necessary dental interventions. Addressing the appellant’s dental needs is a critical first step in her journey toward recovery and rehabilitation from substance use, and family reunification.

Access to necessary dental care is crucial for maintaining overall health and well-being, aligning with the principles of equity and compassion that underpin the Medical Services Plan.

Ministry Position Basic Eligibility The ministry states that as the appellant is a recipient of disability assistance, she may be eligible for coverage of basic dental services and emergency dental services. Dentures are covered under basic dental services. The ministry refers to the Regulation, sections 63, 64, and Schedule C, Sections 1, 4, and 5.

Eligibility for Coverage of Dentures as a Basic Dental Service The ministry submits the appellant is not eligible for coverage of complete upper and lower dentures as a basic dental service. The ministry may only provide coverage for basic dental services (provided by denturists) as outlined in the ministry Fee Schedule and only up to the maximum rates listed in that Schedule As per the Fee Schedule,

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Appeal Number 2024-0314

clients are eligible for initial placement of a single complete denture (upper or lower), or complete dentures if the dentures are required as a result of extractions for the relief of pain resulting in full clearance of the arch/arches. This clearance must have taken place in the preceding six months. The ministry notes from the appellant’s online claims history with Pacific Blue Cross that she has not undergone any tooth extractions in the last six months, which resulted in complete clearance of the arch/arches. Therefore, the appellant is currently ineligible for coverage of complete upper and lower dentures as a basic dental service.

Based on the estimate provided, the appellant’s denturist intends to charge denture fees in excess of the rates set out in the Fee Schedule. The ministry is not authorized to provide coverage for fees in excess of the rates set out in the Fee Schedule. The appellant would be responsible for paying the difference.

Eligibility for Coverage of Denture fees as an Emergency Dental Service The ministry also submits that the appellant is not eligible for coverage of dentures as an emergency dental service (section 64 of the Regulation). The ministry may only provide coverage for emergency dental services (provided by denturists) when necessary for the immediate relief of pain, as outlined in the Fee Schedule and only up to the maximum rates listed in that Schedule.

It is noted that the Fee Schedule lists denture repairs and adjustments in the section for emergency dental services. However, it does not provide for coverage of dentures themselves.

Eligibility for Coverage as a Life-Threatening Health Need As well, the ministry submits the appellant is not eligible for coverage of complete upper and lower dentures as a life-threatening health need.

Section 69 of the Regulation states that the ministry may provide medical transportation, medical equipment/devices, and some types of medical supplies, for a person who is otherwise not eligible for the health supplement under this Regulation. However, section 69 only applies to medical transportation, medical equipment/devices, and some types of medical supplies. Unfortunately, denture supplements are not included in these sections.

Eligibility for Coverage as a Crisis Supplement Section 57(3) of the Regulation states that the ministry may not provide a crisis supplement to obtain a supplement described in Schedule C or for any other health

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Appeal Number 2024-0314

care goods or services. The minister notes dental treatments are health care services as described in Schedule C. As a result, the appellant is not eligible to receive a crisis supplement to cover dental fees.

Panel Analysis Schedule C, section 1, Regulation - basic dental service definition The panel notes, under section 1 of Schedule C of the Regulation, "basic dental service" means a dental service that if provided by a denturist, is set out in the Fee Schedule and is provided at the rate set out in that Schedule for the service and the category of person receiving the service.

Section 63 Regulation – dental supplements Section 63 of the Regulation states the minister may provide any health supplement set out in section 4 [dental supplements] of Schedule C for a family unit in receipt of disability assistance. The panel notes, ministry records state the appellant is a recipient of disability assistance.

Schedule C Section 4(1.1) states the health supplements that may be paid under section 63 are basic dental services to a maximum of $1,000 each period to people over 19 years of age.

Section 4(2) of Schedule C states 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 five years old.

Section 4(3) states the limits may be exceeded, if (a) a person requires a full upper and lower dentures because of extractions made in the previous six months to relieve pain, or because (c) a person who has been a recipient of disability assistance for at least two years requires replacement dentures.

At the hearing, the appellant stated she has a partial upper denture. She had the last of her teeth pulled in December 2023. Her teeth needed to be pulled because they were rotten. At the hearing, the ministry stated the appellant is not eligible for additional funds under basic dental services, as this section of the legislation it is intended as a basic supplement and not as an additional amount above the Fee Schedule.

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Appeal Number 2024-0314

The panel finds, considering the above evidence and legislation, the appellant is not eligible for the $2,002.50 difference in coverage for upper and lower dentures under Schedule C, section 4 of the Regulation.

Although dentures may be provided as a basic dental service, the panel notes they can only be provided to a person who has never worn dentures (section 4(2)(a) of section C of the Regulation). The appellant advised she has a partial upper denture. As well, the panel finds there is insufficient evidence to conclude that the extractions were made to relieve pain (section 4(3)(a) of section C of the Regulation). Also, the appellant is requesting a new full set of dentures not replacement dentures (section 4(3)(c) of section C of the Regulation).

In addition, the panel notes the ministry’s position that the $1,000.00, referred to in section 4(1.1) of Schedule C of the Regulation is intended as a basic supplement and not to top up the difference between the allowable amount in the Fee Schedule. As section 4(1.1) refers to this section as “basic dental services”, the panel finds this a reasonable application of the legislation.

Therefore, the panel finds the ministry decision that the appellant is not eligible for coverage of complete upper and lower dentures as a basic dental service, reasonable.

Section 57, Regulation – crisis supplement Section 57(1) of the Regulation states the minister may provide a crisis supplement to a family that is eligible for disability assistance if a person in the family requires the supplement to obtain an item unexpectedly and the minister considers that failure to meet the expense or obtain the item will result in imminent danger to the physical health of any person in the family.

The advocate argues that the appellant has been experiencing significant emotional distress, and depression and anxiety have had a profound impact on her mental health. Addressing her dental needs is a critical first step in her journey towards recovery and rehabilitation for substance use.

The panel acknowledges the appellant’s difficult situation. However, section 57(3) of the Regulation states a crisis supplement may not be provided for the purpose of obtaining a supplement described in Schedule C, or any other health care goods or services. The panel finds that as the appellant is requesting a supplement that is included in Schedule C of the Regulation, the ministry reasonably determined the

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Appeal Number 2024-0314

appellant was not eligible for coverage of dentures as a crisis supplement under section 57 of the Regulation.

Section 64, Regulation – emergency denture supplement Section 64 of the Regulation states the minister may provide any health supplement set out in section 5 [emergency dental supplements] of Schedule C of the Regulation to or for a family unit in receipt of disability assistance and section 5 states the health supplements that may be paid for under section 64 [emergency dental and denture supplements] of this regulation are emergency dental services.

In the Notice of Appeal, the appellant states this situation is severely affecting her health. She is not getting proper nutrition, it is causing depression and anxiety, and she is at risk of infection.

The panel notes, under section 1 of Schedule C of the Regulation, “emergency dental service" means a dental service necessary for the immediate relief of pain that, if provided by a denturist, is set out in the Fee Schedule and is provided at the rate set out in that schedule for the service and the category of the person receiving the service. The information under Emergency Dental supplements in the Fee Schedule, states, “Services outside this schedule (i.e., dentures… etc.) will not be covered and any work beyond the immediate relief of pain will not be considered.”

The panel notes dentures will not be covered under Emergency Dental supplements and there is insufficient evidence to conclude that the dentures are needed for the immediate relief of pain. Therefore, the panel finds the ministry reasonably determined the full cost of the dentures cannot be covered under this section of the legislation.

Section 69, Regulation – life-threatening health need Section 69 states the minister may provide 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 the person faces a direct and imminent life-threatening need, there are no resources available to the person's family unit with which to meet that need and the health supplement is necessary to meet that need.

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Appeal Number 2024-0314

The advocate argues that the absence of proper dental care and the inability to chew food effectively has resulted in nutritional deficiencies and subsequent malnutrition posing a direct threat to the appellant’s physical health.

The panel empathizes with the appellant’s situation. However, as the appellant is otherwise eligible (as she is a recipient of disability assistance), she is not eligible for coverage of dentures under this portion of the legislation. In addition, the panel notes dentures are not included under either general health supplements or medical equipment and devices under sections 2(1)(a) and (f) and 3 of Schedule C of the Regulation. Section (2)(1)(a) deals with medical or surgical supplies and section 2(1)(f) deals with transportation. Section 3 deals with medical equipment and devices such as canes, wheelchairs and hearing instruments.

Therefore, the panel finds the ministry decision that the appellant is not eligible for coverage of dentures under section 69 of the Regulation, reasonable.

Although the panel acknowledges the appellant’s difficult circumstances, the panel is bound by the legislation, as is the ministry.

Conclusion In conclusion, the panel finds the ministry decision that determined the appellant is not eligible for dentures, was a reasonable application of the legislation in the circumstances of the appellant.

The ministry’s Reconsideration Decision is confirmed and the appellant’s appeal is not successful.

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Appeal Number 2024-0314

Schedule of Legislation

Employment and Assistance for Persons with Disabilities Regulation

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…

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…

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…

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…

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Schedule C

Appeal Number 2024-0314

Definitions 1 In this Schedule: "basic dental service" means a dental service that 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…

"emergency dental service" means a dental service necessary for the immediate relief of pain that, (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…