Solid Group Plans Made Simple
In the current group and individual benefits market, much of the attention is given to the area of health – physical and mental – which includes such topics as inflationary cost trends, workplace wellness initiatives, impact of COVID-19, but to name a few.
However, a substantial cost within a typical group insurance plan is dental coverage. Most comprehensive standard dental plans are structured in three levels:
- Plan A covers basic diagnostic and preventative services, including examinations, x-rays, basic restorations, root canals, periodontal cleaning, maintenance of dentures, and extractions
- Plan B covers major restorative procedures such as crowns, inlays and onlays, bridgework and dentures
- Plan C covers services related to orthodontics (the treatment used to straighten teeth and align the bite)
Reasonable & customary fees
Dentists have a legal and ethical obligation to obtain their patients’ informed consent prior to the start of any dental treatment plan. This includes discussing the proposed treatment plan, associated risks, and what the treatment will cost, before the patient agrees to proceed. Cost estimates should include the cost of materials and laboratory “at-cost” fees and can be offered to the patient within a range of lowest and highest costs.
All provinces and two territories, excluding Nunavut, annually publish a fee guide for dental treatments, as do some insurers, such as Pacific Blue Cross (PBC). These fees are deemed “reasonable and customary” for specific procedures within that province/territory. Dentists must inform a patient if they intend to charge fees that are above the fees listed in the guide, as it is likely that the group insurer will not cover these additional costs.
Many group dental plans require the dentist to obtain a preauthorization prior to beginning the proposed service. A preauthorization provides written advance approval for the planned treatment, which is generally valid for 60 days. Failure to obtain it may result in the denial of the claim.
Government dental plans
In Canada, dental and other oral health care in not included in the Canada Health Act. Most Canadians receive coverage through privately operated dental clinics, paid for by insurance (group or individual), or paid for by the individual.
There has been more discussion at the federal government level in recent years of universal dental care, however today, provinces are providing only very basic services, for a very limited portion of residents, based on income or disability status.
We note below some of the provinces who offer coverages beyond the very basic level.
Saskatchewan: provides coverage for government wards and inmates of provincial correctional institutions; emergency only dental benefits for first six months, then basic full benefits for adults; children automatically qualify for full benefits
Manitoba: offers a community water fluoridation program as part of the Public Health Oral Health initiative; 95% of provincial population currently in receipt of fluoridation of their water systems
Ontario: offers specific financial support designed to assist families of children and young adults who must cope with expenses due to cleft lip and palate/cranial dental conditions
Quebec: in hospitals, every insured person is entitled to certain oral surgery services in the event of trauma or an illness, e.g. drainage of an abscess, removal of a cyst or tumour, or a reduction of a fracture, and include examinations, local or general anesthesia and xrays; children under 10 can receive basic dental services for free under this program.
COVID-19 and teledentistry
In 2020, 215 Canadian dentists and oral health experts from 96 clinics across the country reacted to the new restrictions and resulting health concerns created by COVID-19 by launching “Dentistry Online”.
All standards of practice, and professional and legal obligations that apply to in-person dental care applies to dental care provided by teledentistry.
Services commonly provided by teledentistry include:
- Chipped tooth
- Jaw pain
- Crown issues
Designed to lower patient anxiety, particularly during lockdown periods, services can be provided through
- Live video interaction
- Transmission of recorded health information (e.g., xrays, photographs, video, digital impressions of patients) for remote patient monitoring and care
- Mobile health (mHealth) practice and education supported by mobile communication devices, such as cell phones, tablet computers and personal digital assistants (PDA).