REPORT EVIDENCE A Review of Dental Care Services for ... · • Eligibility, or the broad...

A Review of Dental Care Services for Adults in Receipt of Social Assistance in Ontario

August 2019

Integrating health, economic and equity evidence to inform policy

Aaron Burry, Ted Cohen, Carlos QuiñonezFaculty of Dentistry, University of Toronto

About this ReportConverge3 commissioned the Faculty of Dentistry at the University of Toronto to conduct a review of dental care services for adults in receipt of social assistance in Ontario. Converge3 receives funding from the Province of Ontario. The views expressed in this report are those of the authors and do not necessarily reflect those of Converge3 or the Province of Ontario.

Suggested CitationBurry A, Cohen T, Quiñonez C (Faculty of Dentistry, University of Toronto). A Review of Dental Care Services for Adults in Receipt of Social Assistance in Ontario. Converge3: Toronto, Canada. 30 August 2019. Available from: https://converge3.ca/publication/evidence-dental-care-services-adults-receipt-social-assistance-ontario.

About Converge3Converge3 is a policy research centre based in the Institute of Health Policy, Management and Evaluation at the University of Toronto that focuses on integrating health, economic and equity evidence to inform policy. The Centre is funded by the Province of Ontario and includes multiple partner organizations, including Li Ka Shing Knowledge Institute at St. Michael’s Hospital, McMaster University, Ottawa Hospital Research Institute, ICES, Health Quality Ontario, Public Health Ontario, and the Ontario Ministry of Health.

Contact InformationConverge3 Institute of Health Policy, Management and EvaluationDalla Lana School of Public HealthUniversity of Toronto155 College Street – 4th FloorToronto, Ontario M5T 3M6 Canada

https://converge3.ca

info@converge3.ca

@converge3_ca

A Review of Dental Care Services for Adults in Receipt of Social Assistance in Ontario

Executive Summary ........................................................................................................................ 2

1.0 Introduction and Background .............................................................................................. 3

1.1 The Historical Perspective ............................................................................................................ 3

2.0 Methods .............................................................................................................................. 5

3.0 Findings ................................................................................................................................ 8

3.1 Descriptive Summary.................................................................................................................... 8

3.2 Program Transparency ............................................................................................................... 16

3.3 Program Administration: Approval of Covered Services, Adjudication and Payment of Claims . 17

3.4 Program Eligibility for Dental Benefits........................................................................................ 20

3.5 Supplemental Public Clinics and Access to Care for Adults Receiving OW .................................. 21

3.6 Assessment and Comparison of Benefits Offered to Adults Receiving OW................................. 23

3.7 MCCSS Fee Comparison .............................................................................................................. 28

Appendix A – Comparison of Dental Coverage ............................................................................. 31

Appendix B – Comparison of Select Fee Codes ............................................................................. 33

ExecutiveSummaryThisreportwascommissionedbyConverge3toaddressthefollowingquestion:WhatisthestatusofdentalcareservicesofferedtoadultsinreceiptofsocialassistanceinOntario?Assuch,thisreportdescribesandcomparesthediscretionarydentalbenefitsthatareavailabletoOntarioWorks(OW)recipientsandtheirspousewhoare18yearsofageorolder(adultsreceivingOW)acrossOntariomunicipalities.Inaddition,itexamineswhereadditionalsupportwithdentureservicesareofferedtoadultsreceivingOW.OWisalegislatedsocialassistanceprogramfundedbytheMinistryofChildren,CommunityandSocialServices(MCCSS)andislocallydeliveredacrossOntarioby47ConsolidatedMunicipalServicesManagers(CMSM)orDistrictServicesAdministrationBoards(DSAB).DentalcareforadultsreceivingOWisclassifiedasa“discretionaryhealthbenefit,”meaningthattheCMSM/DSAB(OWadministrators)determinethelevelofhealthbenefitanddeliveryaspartofpolicyandbudgetprocessesoflocalmunicipalcouncilsandadministrativeboards.Italsomeansthattheabilitytosupportdiscretionarybenefitsisimpactedbythefinancialcapacityofthelocalcommunity.Overthelast30years,howsocialassistanceisfundedhaschangedinOntario.Thischangehasresultedinshiftstofundingandcost-sharingformulasand,ingeneralterms,areductionindentalcarebenefitsforOWrecipientstowards“basic”and“emergency/urgent”careonly.Thesereductionshavealsobeencoupledtorestrictionsonservices(e.g.settingfrequencylimitsandincreasingpreapprovals)andthegradualeliminationofitemssuchasdentures.Fromacomparativeperspective,programsand/orbenefitsvaryconsiderablyacrosstheprovinceintermsof:

• Transparency,orhowreadilyaccessibletheinformationistoclientsandproviders• Policyandprocesselements,orthebroadadministrativeapproachtoprovidingandpayingfor

clientbenefits• Eligibility,orthebroadconsiderationsrelatedtoreceiptofdentalservices• Benefits,orthelevelofservicesofferedsuchas“emergencydentalplan,”“basicdentalplan,”

“dentureplan,”“reliefofpainonly,”and/orwhethercontactwiththeOWadministratororcase-workerisrequired

• Serviceplandetails,orwhetherthereisareadilyaccessibledescriptionorlistingoftheservicesthatarecoveredoroffered,and

• Pricing,orthedifferencesinfeesforthesameservicesacrossprogramsand/orwhencomparedtotheMCCSSserviceschedule.

Thecurrentstateofdentalprogramsand/orbenefitsforadultsreceivingOWacrosstheprovinceisdefinedbysubstantialvariationacrossalltheparametersinvestigated,includinghowbenefitsareaccessed,howtheyareadministered,whatservicesareincludedorexcluded,whatmaximumannuallimitsapply,andthelevelsofreimbursementincluded.Fromahealthequityperspective,suchvariationrepresentsatargetforhealthpolicyintervention.Ultimately,policyquestionsfordecision-makersinclude:Shouldtheseservicesremaindiscretionaryorbecomemandatory?Whatoutcomesaregovernmentstryingtoachievebyfundingsuchservices?Whatwaysoforganizing,financinganddeliveringtheseservicesarenecessary?Whatservicesshouldbefundedandforwhatreasons?AndwhatexpertiseisneededtodeliverefficientandequitabledentalcareforadultsreceivingOW?

1.0 IntroductionandBackgroundThisreportwascommissionedbyConverge3toaddressthefollowingquestion:WhatisthestatusofdentalcareservicesofferedtoadultsinreceiptofsocialassistanceinOntario?Assuch,thisreportdescribesandcomparesthediscretionarydentalbenefitsthatareavailabletoOntarioWorks(OW)recipientsandtheirspousewhoare18yearsofageorolder(adultsreceivingOW)acrossOntariomunicipalities.Inaddition,itexamineswhereadditionalsupportwithdentureservicesareofferedtoadultsreceivingOW,orrecipientsoftheOntarioDisabilitySupportProgram(ODSP)andtheirdependents.1OWisalegislatedsocialassistanceprogramfundedbytheMinistryofChildren,CommunityandSocialServices(MCCSS)andislocallydeliveredacrossOntarioby47ConsolidatedMunicipalServicesManagers(CMSM)orDistrictServicesAdministrationBoards(DSAB).TheOWprogramobjectivesare:

1. Providefinancialassistancetothosewhoareinneedofhelpwithbasicitemslikefood,shelterandclothing,aswellasassistancewithhealthbenefitsfortherecipientandtheirdependents.

2. Provideemploymentassistancetohelpclientsfind,prepareandkeepajob.Thisassistancemayinclude:resumewriting,interviewing,jobcounsellingworkshops,andjobspecifictrainingtoassistclientstoimprovetheirlanguageskillsorfinishhighschool.

3. Provideemergencyassistanceforpeoplewhoareincrisisoranemergencysituation.OntariansareeligibleforOWiftheyarelivinginahouseholdthatdoesnothavesufficientfinancialresourcestomeetbasiclivingexpensesandiftheyarewillingtomakereasonableeffortstofind,prepareforandkeepajob(unlessspecificcircumstancestemporarilypreventdoingso,suchasanillnessorcaregivingresponsibilities).ToqualifyforODSP,anindividualmustbeatleast18yearsold,anOntarioresident,infinancialneed,andmeettheprogram’sdefinitionofapersonwithadisabilityorbeamemberofaPrescribedClass.21.1 TheHistoricalPerspectiveSomehistoricalperspectiveisusefulforunderstandingthenatureofdentalbenefitsavailabletoadultsonsocialassistanceinOntario.DentalcareforadultsonOWisclassifiedasa“discretionaryhealthbenefit,”meaningthattheCMSM/DSAB(OWadministrators)determinethelevelofhealthbenefitanddeliveryaspartofpolicyandbudgetprocessesoflocalmunicipalcouncilsandadministrativeboards.Italsomeansthattheabilitytosupportdiscretionarybenefitsisimpactedbythefinancialcapacityofthelocalcommunity.Forthesereasons,variationinadultdentalservicesacrossjurisdictionsisexpected.Ontario’sapproachtofundingsocialassistanceisuniqueinCanadawhereinlocalpropertytaxoffsetsaportionofthecosts.Municipalitiesalsodeliversocialassistanceonbehalfoftheprovince.Importantly,howsocialassistanceisfundedhaschangedinOntarioacrosstime.31TheMCCSSprovidesabasicdentalplantoODSPrecipientsandtheirdependents,whichiscentrallyadministered.2AsperMCCSS,“[p]rescribedclassesarespecificcategoriesofpeoplewhodonothavetogothroughthedisabilityadjudicationprocesstoqualifyforODSPIncomeSupport.”See:EligibilityforODSPIncomeSupport.Availableat:https://www.mcss.gov.on.ca/en/mcss/programs/social/odsp/income_support/IS_Eligibility.aspx3See:OfficeoftheAuditorGeneralofOntario.AnnualReport2018.Chapter3.Section3.11OntarioWorks(pp.494-546).Toronto:OfficeoftheAuditorGeneralofOntario,2018;AssociationofMunicipalitiesofOntario(AMO).The2008UploadAgreement(Provincial-MunicipalFiscalandServiceDeliveryReview).Toronto:AMO,August2017;BélandD,DaigneaultPM,editors.WelfarereforminCanada:provincialsocialassistanceincomparativeperspective.UniversityofTorontoPress;2015Sep18;MunirS.ReportoftheCommissionfortheReviewofSocialAssistanceinOntario:TakingStockTwoYearsLater.SPPResearchPaper.2015Mar31;8(8);QuiñonezC,SherretL,GrootendorstP,ShimMS,AzarpazhoohA,

Priorto1995,theprovincefundedthefullcostofmonthlysocialassistance,50%of“discretionaryhealthbenefits”(includingdental),and50%ofthe“costofadministration”forsocialassistancelocally.After1995,municipalitiesbecameresponsiblefor20%ofthecostofmonthlysocialassistance;however,theprovinceincreasedtheportionofdiscretionarybenefitsitwouldcost-shareto80%.Municipalitieswereabletoleveragethecost-sharingwiththeprovincetoattractadditionalprovincialdollars(80centdollars)totheircommunitiesandthereforeoffermoreservicestothoseinneed.In1996,thefirstfundingcapsontotalexpendituresfordiscretionaryhealthbenefitsandchangestothecostofadministrationformulaswereintroducedbytheprovince.Thechangeinfundingformulascreatedlocalfinancialshortfalls.Asaresult,severalmajorjurisdictions,whichofferedabroadsuiteofbasicdentalcareservices,beganadjustingtheirprogramstoprovide“emergencydentalcareonly”foradultsocialassistancerecipients.Thechangesin1996wereapreludetothe1998majorrestructuringofsocialassistanceintowhatisknowntodayasOWandODSP.Aspartofthechangestolegislation,agreateremphasisonemploymentandtrainingwasaddedandaportionofthecostofsocialassistancewasdownloadedtothemunicipalities.Thismeantanincreasedportionofthepropertytaxrevenuefundedmonthlysocialassistancepayments.Municipaladministratorswerealsorequiredtocoveraportion(20%)ofthemonthlycostofODSP(eventhoughtheydidnotdeliverODSP)and20%ofthehealthbenefitsforODSP.Theyear2008markedanothersignificanttransition,withtheprovinceagreeingtoassumethecostofallsocialassistanceover10years.In2012,administrationofOWwaschangedtoapercaseformularatherthantheprevious50/50costsharingarrangement.OWadministratorswerealsonolongerrequiredtocost-sharediscretionarybenefits;however,theprovinceintroducedapercapitafundingmodelforalldiscretionaryhealthbenefitsataflatrateof$10perOW/ODSPrecipientperfiscalyear,basedonitstotalexpendituresin2010.Byfixingtheamountpercase,municipalitieswhowereinvestingmorethantheflatrateunderthe80/20formulatendedtoreceivelessprovincialfundingfordiscretionarybenefitsthantheywereaccustomedto,andthosewhoinvestedlesstendedtoreceivemore.Overall,thechangesdescribedabovehavetendedtoreducedentalcarebenefitsforOWrecipientsto“basic”or“emergency/urgentlevel.”Thesereductionshavealsobeencoupledtorestrictionsonservices(e.g.settingfrequencylimitsandincreasingpreapprovals)andthegradualeliminationofitemssuchasdentures.Importantly,whilespecificsocialassistancedentalcareexpendituresarenotavailable,overall,publiclyavailableinformationdemonstratesvariabilityinprovincialgovernmentfundeddentalcareexpendituresbasedonthechangesoutlinedabove(Figure1).

LockerD.Anenvironmentalscanofprovincial/territorialdentalpublichealthprograms.Ottawa:OfficeoftheChiefDentalOfficer,HealthCanada,2007;HerdD,MitchellA,LightmanE.Ritualsofdegradation:AdministrationaspolicyintheOntarioWorksProgramme.SocialPolicy&Administration.2005Feb;39(1):65-79;HerdD.Rhetoricandretrenchment‘commonsense’welfarereforminOntario.Benefits.2002Jun1;10(2):105-10;GrahamKA,PhillipsSD.“WhoDoesWhat”inOntario:Theprocessofprovincial-municipaldisentanglement.CanadianPublicAdministration.1998Jun;41(2):175-209;MorrisonI,PearceG.Undertheaxe:socialassistanceinOntarioin1995.JournalofLawandSocialPolicy.1995;11:1.

Figure1.Provincialgovernmentfundeddentalcareexpenditures,Ontario,1975to2017($2017,‘000000).Source:NationalHealthExpenditureDatabase,CanadianInstituteforHealthInformation

2.0 MethodsThiswasadescriptivestudybasedonareviewofwebsites,documents,andinformationsourcedfromtheInternetandthroughrequeststoOWadministrators.Specifically,informationwasobtainedthroughanonlinesearchoftheCMSMorDSABwebsites/portalsorthird-partyorganizationswithwhichtheCMSMorDSABhaspartnered(i.e.PublicHealthUnit[PHU])orcontracted(i.e.AccertaClaimServicorpInc.[Accerta],TheGreat-WestLifeAssuranceCompany[Great-WestLife])toadministerdiscretionarydentalbenefitsforOWrecipients.Informationwassummarizedandcollatedinavarietyofways.Anoveralldescriptivesummarybyjurisdictionisprovidedforthefollowingelements:

• Transparency,orhowreadilyaccessibletheinformationistoclientsandproviders• Policyandprocesselements,orthebroadadministrativeapproachtoprovidingandpayingfor

clientbenefits• Eligibility,orthebroadconsiderationsrelatedtoreceiptofdentalservices• Benefits,orthelevelofservicesofferedsuchas“emergencydentalplan,”“basicdentalplan,”

“dentureplan,”“reliefofpainonly,”and/orwhethercontactwiththeOWadministratororcase-workerisrequiredandanyannuallimit

• Serviceplandetails,orwhetherthereisareadilyaccessibledescriptionorlistingoftheservicesthatarecoveredoroffered,and

• Notes,oradditionalrelevantdetails.

Amoredetailedanalysisbasedontheaboveelementsisprovidedbeyondjustsimpledescription.Areviewofthepublic(directdelivery)clinicsandapproachestakenintheseclinicsisincluded.A

conveniencesampleofdentalbenefitplansisreviewedtodetermineandcomparethelevelofservicesbeingofferedbymunicipaladministrators.Thebroadareasreviewedinclude:

• Theannuallevelofbenefitsavailable• Whetherpredeterminationorpreauthorizationforservicesisrequired• Whetherproceduresincommoncategoriesarecovered• Specificlimitationsforreimbursement(servicecodes,frequencyandotherlimitations),and• Thegeneralconstructionoftheplanandcoveragefordentures.

Andanassessmenttoolwasalsodevelopedthatconsiders30differentparameters,whichareusedtocomparejurisdictionsinAppendixA--ComparisonofDentalCoverage.Table1belowprovidesadescriptionforeachoftheparameters.

Table1.ParameterstocomparedetailsofaconveniencesampleofdentalbenefitplansofferedbymunicipaladministratorsParameter AssessmentparameterdescriptionDollarlimit Paymentlimitordollarlimitoftheplanina12-monthperiodPredetermination/preauthorization(PD)

Dentistsarerequiredtosubmitinformationforapprovalforspecificservicesorwhentreatmentcostsareexpectedtoexceedacertaindollarlimitlevel

MCCSSFees ArethereimbursementlevelsintheplanthesameasfoundJanuary2018MCCSSScheduleofDentalServicesandFees(yesorno)?

Amalgam&composite Doestheplanreimbursecompositerestorationstothesamerate?Complete Referstoacomprehensivedentalexamination,whichisdonewhenapatient

seestheirdentistforthefirsttimeorperiodically(generallyeveryfiveyears)Emergency Referstoanemergencyexaminationtoinvestigateanurgentdentalproblem

whenthepatientpresentswithpainorinfectionSpecific Likeanemergencyexamination,reimbursedatthesamelevel;someplans

placelimitationsonhowmanyspecificoremergencyexamscanbeclaimedwhileothersareopenended,forexample,aplanthatindicatesanycombinationofanemergencyexamandspecificexamsuptothreeduringasix-monthperiod(describedas3/6inthechart)

Recall Referstoreimbursementforaperiodicre-examinationofexistingpatient;notconsideredascomprehensiveasacompleteexam;usuallynotincludedinplanswherethefocusistheimmediatereliefofpainanddiscomfort(emergencydentalplan)

Film Referstoradiographs(x-rays),orthenumberthatwillbereimbursedinagivenperiod

Panoramic Generalfull-faceorsurvey(x-ray)oftheentireteethandjawsBiopsy Referstoassessinggrowthsorlesionsinthemouththataresuspiciousand

removingthesuspecttissueandsendingforanalysisPreventative Referstothreeelementsdefinedunderprevention:polishing,scalingand

topicalfluoridetreatments;emergencydentalplanstypicallydonotincludethiscomponent

Caries,TraumaandPainControl(CTPC)

Referstotheplacementofvariousdressingsintheteethandgumstostoppain

Amalgam Planreimbursesamalgam(silver)fillingsComp(A) Planreimburseswhite(compositeresin)fillingsinthefrontteeth(12front

teeth)Comp(P) Planreimbursesforwhite(compositeresin)fillingsinthebackteeth(12back

teeth)Pulpotomy ReferstoproceduresremovingpartofthenerveofapainfultoothPulpectomy ReferstoproceduresforremovingallthenervetissueofapainfultoothRootCanalTherapy Referstosealingthecanalspaceleftafterthenervetissuehasbeenremoved,

cleanedandshapedPerio42831 Referstotreatingapainfulinfectioninthegums(gumabscess)Basicremovals ReferstoremovingorextractingteethorotherdamagedtissuesinthemouthReplant Referstoputtingatoothbackintoplaceifitisknockedoutormovedbya

blowLimited8’s ReferstolimitationintheremovalofimpactedwisdomteethGeneralAnesthetic(GA) ReferstogeneralanestheticbeingacoveredserviceSedation ReferstotheadministrationofintravenousdrugstosedateapatientNitrousOxide(NO) Referstonitrousoxideor“laughinggas”Dentures ReferstocoverageforacrylicdentureseithercompleteorpartialCastRemovalPartialDenture(RPD) Referstopartialdenturesthathavecastmetalcomponents;usuallymore

expensivethancompletelyplasticdenturesRepairs ReferstorepairingofadentureReline Referstotheadditionofnewmaterialtoadenturetofillinareaswherethe

tissuehasshrunk;improvesfitofdenture

3.0 Findings3.1 DescriptiveSummaryTables2to4belowprovidedatakeysforinterpretinganoveralldescriptivesummaryofprogramsandbenefitsbyjurisdiction.ThissummaryisincludedinTable5,whichhighlightsprogramtransparency,policyandprocesselements,eligibility,benefits,availabledetailsoftheserviceplan,andanyadditionalrelevantinformation.ThedatapresentedinTable5(alsobelow)indicatesthatthereisvariationintheapproachtoprogramsandbenefits.Morespecifically,thereremaingeographicdifferencesinhowservicesareadministered,theservicesthatareoffered,andhowtheyareoffered.Forexample,somejurisdictionshavedevelopedlocalinitiativestoaddressaccesstodentalcarechallengesbyexpandingclinicseitherwithinCommunityHealthCentresoraspartofthelocalPHUinfrastructure.Theseclinicsarefundedthroughacombinationofprovincialgrants,localgrantsand/orcontributionsfromcharitableorganizations.Insomejurisdictions,thereisafixedandtransparentcommitmenttotheseprogramsandbenefitsavailabletoclientsforagivenperiodoftime,whichareclearlyoutlinedinofficialpoliciesandsupportedbybudgetallocationsandrelatedtenderingprocesses.However,forsomemunicipaladministrators,thereisadegreeofopacityrelatedtotheinformationavailableregardingwhatdentalcarebenefitsareoffered.Thisisarguablyduetosomejurisdictions’needtomanagethedemandforarangeofassistance,andforstafftomaintaindiscretionintheapprovalprocess.Thedatacollectedreflectsasnapshotintimethatcontinuestoevolveasjurisdictionsreviewtheirprogramsaspartoftheirpolicyandannualbudgetcycles.Table2.Datakey1:TransparencyA InformationavailableforclientsandprovidersaboutthebenefitsofferedontheOW

administrator’ssiteB InformationavailableforclientsaboutthebenefitsofferedontheOWadministrator’ssiteC Informationavailableforprovidersthroughthird-partybenefitsadministratorD Informationavailablethroughasecondarywebsiteinthelocaladministrativeareasuchasa

communityorPHUwebsiteE Noinformationavailableandclientsrequiredtospeakwiththeirworkertodeterminewhat

assistancemightbeavailableF Indicationthatassistancemaybeofferedbutnodetails

Table3.Datakey2:PolicyandprocesselementsDirectlyadministered

OWadministratordirectlyauthorizesandpaysforservices

Third-partyadministered

OWadministratorhascontractedwiththird-partytoadjudicateandpayforserviceclaims

PHUadministered

OWadministratorhaspartneredwithPHUtoprovidearangeofadministrativeservices,fromadjudicationandpaymentofserviceclaims,toprovidingcaredirectlyinPHUdentalclinics

Table4.Datakey3:Eligibility1 Assistancewiththecostofemergencydentalcare:Adultsanddependentsovertheageof18up

tothelastmonthadultisinreceiptofOW2 Assistancewiththecostofdentures:Adultsanddependentsovertheageof18uptothelast

monthadultisinreceiptofOW3 Reliefofpainonly:Adultsanddependentsovertheageof18uptothelastmonthadultisin

receiptofOW4 Pre-reviewbyOWadministratortoseeifassistancemaybeprovided:Adultsanddependentsover

theageof18uptothelastmonthadultisinreceiptofOW

Table5.SummaryofprogramsandbenefitsbyjurisdictionJurisdiction Transparency Policyandprocess

elementEligibility Benefits Service

plandetails

Toronto B/C Third-partyadministered,definedbenefitclaimsadjudicatedbyGreat-WestLife

1/2 Emergencydentalplananddentureplan,noannualdollarlimit

Yes Announcementin2016thatOWclientscouldattendTorontoPublicHealthdentalclinics

Cornwall E Directlyadministered

2 Reimburse,tothedentaloffice,$75dollarspertoothforemergencyrelatedwork

No EasternOntarioHealthUnitprovidingdentalservicestoOWclientsonaprobonobasisbeyondthe$75dollarsforanemergencyextraction

Durham A PHUadministered 1/2 Emergencydentalplananddentureplan,predeterminationforvariousotherservices

CountyofHastings

F Directlyadministered

4 GatewayCommunityHealthCentredentalclinicoffersservices,$50pervisit

No ClinicstartedatGatewayCommunityHealthCentredentalclinicstartedforOW/ODSPclientsaswellaslowincomeclients,$50pervisitirrespectiveofcostoftreatmentforthosewithoutcoverage

KawarthaLakes/Haliburton

C/F Third-partyadministered,definedbenefitclaimsadjudicatedbyAccerta

1/2 Emergencydentalanddentureplan

Kingston F Directlyadministered

1 Emergencydentalplan,upto$350annually

No ClinicstartedatKingstonCommunityHealthCentre.Staffdentistsprovidecare.Acceptthe$350annuallyandprovidecareoutsidethelimit.Additionalsourcesoffundingavailablethatsomeclientscanaccessfundedbythemunicipality,alocalcharity,aswellasblockfundingfromtheLocalHealth

Jurisdiction Transparency Policyandprocesselement

Eligibility Benefits Serviceplandetails

IntegrationNetwork.Programandservicescontinuetoevolve.

LanarkCounty D Directlyadministered

1 Emergencydentalplan,upto$400annually

LeedsGrenville D Noonlineinformation

1 Basicdentalplan,upto$400annually

Northumberland A/C Third-partyadministered,definedbenefitclaimsadjudicatedbyAccerta

1/2 Emergencydentalanddentureplan

CityofOttawa A/C PHUadministeredanddirectadministrationofdentureprogram

1/2 Emergencydentalplanwithinclinicsanddentureplanwhichispreauthorizedaccordingtoclinicalneed

No DentalcareprovidedthroughtheOttawaPublicHealthclinics.Variableservicesavailableyear-over-yearpendingbudgetaryapprovalfromCityCouncil.

Peterborough A Third-partyadministered,definedbenefitclaimsadjudicatedbyAccertaanddirectadministrationofdentureservices

1/2 Accertabasicdentalplanupto$600pertreatmentplanandupto$1500fordenturesevery5years

Prescott-Russell F Directlyadministered

3 Emergencydentalplan,limitedto$75

No EasternOntarioHealthUnitoffersclinicsinCornwallandHawkesburywhereclientscanattendatnocharge.Clinicdoesacceptthelimitedpaymentbutbroaderdentalneedsmaybeaddressed.

PrinceEdward/LennoxandAddington

C/D Third-partyadministered,definedbenefit

1 Accertaemergencydentalplan

claimsadjudicatedbyAccerta

CountyofRenfrew

C/D Third-partyadministered,definedbenefitclaimsadjudicatedbyAccerta

1 Accertaemergencyplanupto$500annually

CountyofDufferin

D Directlyadministered

1 Emergencyplan,$300per12months

HaltonRegion D PHUadministered 1/4 Upto$200thenpreauthorizationrequired

Peel A Third-partyadministered,definedbenefitclaimsadjudicatedbyGreat-WestLife

1/2 Emergencydentalplananddentureplan

SimcoeCounty C/D PHUadministered 1/2 Emergencydentalanddenturebenefitplan

Waterloo A PHUadministered 1/2 Emergencydentalanddenturebenefitplan

CountyofWellington

A Thirdpartyadministered,definedbenefitclaimsadjudicatedbyAccerta

1 Accertabasicdentalplan,upto$1000percalendaryear

YorkRegion A Third-partyadministered,definedbenefitclaimsadjudicatedbyAccerta

1/2 Accertaemergencydentalplananddentureplan

Brantford E Directlyadministered

4 Reliefofpain,contactwithcaseworkerrequired

BruceCounty F Directlyadministered

4 Directfollow-uprequiredtoseehowOWadministratorwillassist

Chatham-Kent F Directlyadministered

CountyofGrey C/F Third-partyadministered,definedbenefitclaimsadjudicatedbyAccerta

CityofHamilton A Directlyadministered

1/2 Emergencydentalplananddentureplan

HuronCounty B/C Third-partyadministered,definedbenefitclaimsadjudicatedbyAccerta

LambtonCounty B PHUadministered 1 Emergencydentalplan

CityofLondon A DirectlyAdministered

1 Emergencydentalplan

No Twoteethpersixmonths,fillingorextractionsonly

Niagara B Directlyadministered

1/4 Upto$135permonth,thenfollow-upwithcaseworker

NorfolkCounty F Directlyadministered

3 Directfollow-upwithOWcase

worker,vouchersystem

OxfordCounty E Directlyadministered

CityofSt.Thomas

F Directlyadministered

CityofStratford C/F Third-partyadministered,definedbenefitclaimsadjudicatedbyAccerta

CityofWindsor A Directlyadministered

1 Basicdentalplan,$300percalendaryear

Algoma C/E Third-partyadministered,definedbenefitclaimsadjudicatedbyAccerta

Cochrane C/E Third-partyadministered,definedbenefitclaimsadjudicatedbyAccerta

Kenora C/F PHUadministered 1 Basicdentalplan No Manitoulin-Sudbury

A Third-partyadministered,definedbenefitclaimsadjudicatedbyAccerta

Muskoka A PHUadministered 1/2 Emergencydentalplananddentureplan

Nipissing E Directlyadministered

3 OWadministratorprovidesvoucherforreliefofpain

ParrySound C PHUadministered 1/2 Emergencydentalplananddentureplan

RainyRiver C/F PHUadministered 1 Indicationthatbenefitsareavailable,butnodetails

SaultSte.Marie B/C Third-partyadministered,definedbenefitclaimsadjudicatedbyAccerta

1/2 Accertaemergencydentalanddentureplan

Sudbury E Directlyadministered

3 Contactwithcaseworkedforvoucher,limitedtopain

ThunderBay B/C Third-partyadministered,definedbenefitclaimsadjudicatedbyAccerta

Timiskaming C/E Third-partyadministered,definedbenefitclaimsadjudicatedbyAccerta

3.2 ProgramTransparencyTable6belowsummarizesthedatarelatedtoprogramtransparency,ortheeaseoffindingprograminformationrelatedtothedentalprogram.Table6.ProgramtransparencyCategory Description CountofOWmunicipal

administratorsA Informationavailableforclientsandprovidersaboutthe

benefitsofferedontheOWadministrator’ssite131

B InformationavailableforclientsaboutthebenefitsofferedontheOWadministrator’ssite

C Informationavailableforprovidersthroughthird-partybenefitsadministrator

D InformationavailablethroughasecondarywebsiteinthelocaladministrativeareasuchasacommunityorPHUwebsite

E Noinformationavailableandclientsrequiredtospeakwiththeirworkertodeterminewhatassistancemightbeavailable

F Indicationthatassistancemaybeofferedbutnodetails 1251Two of the 13municipalities refer and direct dental providers to Accerta for information about thebenefitsplan.2FourofthesixmunicipalitiesreferanddirectdentalproviderstoAccerta.InthecaseofToronto,theinformationcanbeobtainedfromGreat-WestLife.3Forthreeofsevenmunicipalities,theplanswereavailableelectronicallyandtheinformationpostedfordentalofficesanddenturists.4Threeof theeightmunicipalitieshavecontractswithAccertaand the informationwas foundon theAccertawebsite.Theinformationwouldbemoretransparenttodentalofficesbutlesstoclientsinthesecases.5Forfiveofthe12municipalities,althoughthereisnopublicinformationeasilyaccessible,informationwasobtaineddirectlyfromtheAccertawebsite.Intermsoftransparency,an“A”ratingisthemostdesirable.Thismeansthatboththeclientandpotentialdentalproviderhaveaclearindicationofwhatwillbecoveredorpaidforbythemunicipaladministrator.Forthesurveyperiodin2017,thisrepresentedapproximatelyoneinfourmunicipaladministrators.Attheotherendofthespectrum,categoryF,therewasonlyanindicationthatdiscretionarydentalbenefitsmightbeavailable.Withineachprogram,therewasvariationintheleveloftransparency.Theareaofleasttransparency(withtheexceptionofthosewithpublishedplans)wasrelatedtodentureplans.Incomparisontoemergencyplans,fordentureplans,therewasoftennoinformationatallorastatementindicatingclientscouldspeakwiththeircaseworkertoseeifassistanceisavailable.Themajorityofprogramsdoprovideinformationonline;however,inanumberofcasesfindinginformationrelatedtoprogramswasdifficult.Fortheseprograms,municipaladministratorswerecontactedtoseekadditioninformation.Whileinformationrelatedtoseveralplanswasobtainedthroughtheirassistance,inmanycasesthemunicipaladministratorshadnoinformationavailableandindicatedthatclientswouldneedtospeakwithaninternalcaseworkertoobtaininformation.And

often,thecaseworkerwouldonlysupplyinformationtoindividualswhowereregisteredintheprogram.AsignificantsourceofadditionalinformationwasobtainedfromPHUsandisreflectedincategoryD,whereinformationrelatedtodentalservicesofferedbythemunicipaladministratorcouldbefoundthroughthePHUwebsite.Thesewebsitesfrequentlyofferedsummariesofalldentalprogramsandservicesbycategory(children,adults,lowincomeandseniors,includingadultsonOW)thatwereavailableinthatjurisdictionorsurroundingjurisdictions.Inthesejurisdictions,clientsseekingadditionalinformationarethusmorelikelytocallthePHU.Astheresultsdemonstrate,theextenttowhichassistanceisavailablevariesandinformationrelatedtotheprogramscanbeopaque.Althoughalladministratorsoffersomeassistance,thereisvariationinhoweasyitistoanswerabasicquestion:WhathelpisavailabletomeifIhaveatoothacheandamanadultonOntarioWorks?Itispossibletogetaclearanswertothisquestionfromsomemunicipaladministrators.Inothercases,adentalofficethatacceptsOWclientsintheirareawillhavetoprovidetheinformationandcanassistandexplaintheentitlements.Andinothercases,themunicipaladministratorstates“itdepends,”andclientsneedtospeakwithanOWcaseworkerdirectly,whereinsomecasestheclientisrequiredtoobtainestimatesfromdentalofficespriortoassistancebeingapproved.Ultimately,formanyOWclientsinOntario,itisdifficulttoknowiftheycanobtainassistancefortheirdentalproblemsorwhethertheywillberesponsibleforpayingforaportionorallofthecostsofcare.Thesetwofactorsarebarrierstoseekingandreceivingdentalcare.WhilePHUscanbeakeysourceofinformationandmayhelpclientsnavigatingthesystem,thisisnotconsistentacrossOntarioeither.Transparencyintermsofprocessisalsoimportanttoproviders.Indeed,aprovider’sdecisiontoparticipateinaprogramandacceptOWclientsarguablyrelatestotheeaseofofficestaffconfirmingaclientiseligiblefortheprogram,clarityaroundservicesthatarecoveredwithminimalrequirementforfollow-upwiththirdparties(predeterminationoradditionalrequests),availabilityofinformationdirectlyrelatedtothelevelsofreimbursement(feestobepaid),aswellasaclearindicationofthelimitationsinthescopeofprocedures,andpromptpaymentpreferablythroughanelectronicsubmissionandpaymentsystem.Whentheseelementsarenotinplaceorreadilyavailablethereisanincreasedlikelihoodthataproviderwilloptnottoparticipateinagovernmentplan.43.3 ProgramAdministration:ApprovalofCoveredServices,AdjudicationandPaymentofClaimsDiscretionarydentalbenefitshavebeenavailableforsocialassistancerecipientsinOntarioforatleastfivedecades.5Municipaladministratorsassessanindividual’slevelofeligibilityfordentalassistancetoaddresstheirdentalneedsandbalancetheneedtoprovideshort-termassistancewithavailablefunding.

4See:QuiñonezCR,FigueiredoR,LockerD.Canadiandentists'opinionsonpubliclyfinanceddentalcare.Journalofpublichealthdentistry.2009Mar;69(2):64-73; Quiñonez C, Figueiredo R, Azarpazhooh A, Locker D. Public preferences for seeking publicly financed dental care andprofessionalpreferencesforstructuringit.Communitydentistryandoralepidemiology.2010Apr;38(2):152-8.5See:QuiñonezC,SherretL,GrootendorstP,ShimMS,AzarpazhoohA,LockerD.Anenvironmentalscanofprovincial/territorialdentalpublichealthprograms.OfficeoftheChiefDentalOfficer,HealthCanada;2007.

TherearespecificmandatorybenefitsorentitlementsforeligibleOWrecipients(e.g.adefinedmonthlyallowance),andOWclientshavearighttoappealthedecisionsofmunicipaladministrators(generallywhentheadministratorhasdeniedbenefits)totheSocialBenefitsTribunal(SBT).Importantly,municipaladministratorssetpolicieswithrespecttoeligibilityfordiscretionarybenefits,whichcannotbeappealedtotheSBT.Municipaladministratorsdeterminethescopeofbenefitstobeofferedandgenerallyadministerthesebenefitsdirectly(issueavoucherorrequisitionforthespecifiedservice);however,arrangementswithathird-partyclaims-payeroraPHU(departmentorBoardofHealth)alsoexist.Beyondtheadministrativearrangementstherearealsovariationsinprogramdelivery.Table7belowsummarizestheadministrativeapproachestoadjudicatingandreimbursingprovidersforcoveredservices.Asdescribed,approximately40%ofdiscretionarydentalbenefitsareadministereddirectlybyOWadministrators.Thepercentageishigherfordentureplans,assomeOWadministratorsthathavethird-partyarrangementsstillretainadministrationofthedentureplancomponent.ThesearenotedinthedetailedsummaryinformationrelatedtoplansfoundinAppendixA–ComparisonofDentalCoverage.Approximately33%areusingthirty-partyclaimadjudicationarrangements,primarilyAccertaorintwocasesGreat-WestLife.Approximately24%havearrangementwithaPHUstooverseetheirprograms.Theapproachvaries,includingadjudicatingspecificdentalbenefitsandreimbursingclaims,assessingandauthorizingspecifictreatment,and/orprovidingcaredirectlythroughpublicclinics.Table7.AdministrativeapproachestoadjudicatingandreimbursingprovidersApproach Description

CountofOWmunicipal

administrators

Directlyadministered

OWadministratordirectlyauthorizesandpaysforservices 21

Third-partyadministered

OWadministratorhascontractedwiththird-partytoadjudicateandpayforserviceclaims

PHUadministered

OWadministratorhaspartneredwithPHUtoprovidearangeofadministrativeservices,fromadjudicationandpaymentofserviceclaims,toprovidingcaredirectlyinPHUdentalclinics

Ingeneralterms,thefollowingaretheprogrambenefitadministrationapproaches:

1. Definedbenefitandpayment.Thedentalproviderandpatientdeterminethecourseoftreatmentandthemunicipaladministratoragreestoreimburseeligibleproceduresundertermsofthecontract.Theentitlementsavailablemayormaynotaddressalltreatmentneeds.Noadditionalconsiderationforcareexitsoutsideoftheprogramlimitations.Themajorityofmunicipaladministratorspayfordiscretionarydentalservicesdirectly.One-thirdhasengagedathird-partycarriertoadjudicateandpayclaims.

2. Definedbenefitandpaymentwithconsiderationtoadditionalexpenses.Similarto1;however,

themunicipaladministratormayapproveadditionalassistanceonacase-by-casebasis.Third-partyadministratorsarenotinvolvedinthisprocessandOWadministratorsauthorizetheadditionalexpensesdirectly.

3. Caseworkerrequest/approval.Theclientrequestsassistancewithdentalcareandtheircaseworkerprovidesa“requisition”tocoversomeportionofthevisit.Thiscantakeavarietyofformsfromarequisitionthatwillcoveramaximumcostforthevisitproblemtoapprovingaspecificestimateforservicesthatissubmittedbytheproviderorclient.

4. Pre-assessmentandauthorization.Clientsrequestassistanceandarescreenedorasubmission

reviewedbyadentalprofessionalandaspecificauthorizationforcareisprovidedtotheclientthattheclientcanthentaketoadentist.Insomeinstances,theassessmentisbeingdoneinpublichealthclinicsthatoffer“preventive”and“cleanings”butdonotprovidefillingsandextractions,whichtheyauthorizeandtheclientcanthenseeaprivatedentist.

5. Directdelivery.OWclientsattendpublicclinicsandseeastaffdentist.Thedentistassessesthe

clientandprovidescare.Programslikethishaveadegreeofflexibilitytoexpandwhatisofferedbasedontheclient’sneedsthatmaybebeyondadefinedschedulewhilestillconsistentwithstabilizinganindividual’sdentalcondition.Theseclinicsoperateonacost-recoverybasisandmayormaynothaveadditionalgovernmentcontributions.Forexample,theCityofOttawahasusedthisapproachforover30yearsandhasfourclinicstoserveadultsreceivingOWamongitspatientgroup.

6. Mixeddelivery.OWclientsareprovidedemergencylevelcoverageorbenefitsbutcanalso

attendpublicclinicsthatmayofferadditionalbasiccare.Forexample,theCityofTorontohasopeneditpublicclinicstoOWrecipientsspecificallyforthisreason.

Giventheabove,itisclearthatmunicipaladministratorshaveconsiderableflexibilityinhowprogramsaredesignedanddelivered,particularlybecausethesearecompletelydiscretionarybenefits.Thisisreflectedintheadministrativeapproaches,variationinprogramdelivery,andthebenefitsoffered.Cost-sharingwasanimportantincentivetoprovidingtheseserviceswhentheprovincepaid80%ofthecostofdiscretionaryhealthbenefits(includingdentalcare).Withtheintroductionofper-capitafundingfordiscretionarybenefits,thereareindicationsthatthedesignanddeliveryoftheseprogramsisevolving.Forexample,third-partyadministrationisincreasinglycommon-place,whetherselectedthroughaformaltenderingprocess(Toronto),sole-sourcedtoaspecificprovider(Renfrew),orareacontinuationofarrangementsthathavebeeninplaceformanyyears(Ottawa,Waterloo,Hamilton).Engagingathird-partygenerallysignalsthatthemunicipaladministratorhasmovedawayfrommakingdeterminationsinternallyonacase-by-casebasistoadoptingadefinedbenefitwithuniformclaimsprocessing.Thistendstoprovidegreaterclaritytoprovidersandtoclientsaboutwhatcareiscovered,andissuggestedtoachievecostcontainmentthroughplandesignthatlimitstherangeandfrequencyofservices.Accerta,forinstance,claimsthattheyhelp“provide[municipal]clientswithacomprehensive,high-qualityoralhealthcaresocialservicesprogramwhilecurtailingcosts,reducingfraudulentclaims,andincreasingoverallefficiency.”6PHUsalsoactasthird-partyprocessorsforsomemunicipaladministrators.TheyperformthesamefunctionsasclaimprocessingandpaymentcompaniessuchasAccertaandGreat-WestLife.Someincorporateadditionalreviewandauthorizationfunctionsandtakemoreofaprogrammaticapproachthatincorporatesplandesign,assessmentofclinicalcircumstancesandauthorizationofadditionalcarethatisoutsideofadefinedplan.Plans/programsadministeredbyPHUshavehigherlevelsofpreandpostdeterminationsincorporatedintotheadministrationingeneralbasedonthereviewofthe

6See:Accerta.DentalCarePlanManagement.Availableat:https://www.accerta.ca/dental

documentedplans,policiesandproceduresherein.Theseaddedaccountabilitymeasuresaredesignedtoarguablycontaincostsbylimitedreimbursementbutalsohaveprovisionstoapproveadditionalcareundercertaincircumstancestoaddressaspecificclient’shealthneeds.Basedonproviderdiscussionsconductedbytheauthorsofthisreport,thisdoesresultinaddedeffort,timedelaysandhasthepotentialforproviderstofeeltheyhavetounnecessarilyjustifythecaretheyareproviding.Additionaladministrativeburdenisafactorinproviderselectingnottoacceptgovernmentplans.73.4 ProgramEligibilityforDentalBenefitsAllmunicipaladministratorsoffersomeformofassistancewithemergencydentalneedstoadultclients,between18and65yearsofage,whiletheyareeligibleforOW.Table8belowsummarizesthetypicallevelofdiscretionarybenefitsofferedandarereflectiveoflocalpolicyrelatedtoreliefofpainonly,tobroaderemergencydentalcare,andwhetherdenturebenefitsareoffered.Table8.LevelofdiscretionarybenefitsofferedDescription CountofOW

municipaladministrators

Assistancewiththecostofemergencydentalcare:Adultsanddependentsovertheageof18uptothelastmonthadultisinreceiptofOW

Assistancewiththecostofemergencydentalcareanddentures:Adultsanddependentsovertheageof18uptothelastmonthadultisinreceiptofOW

Assistancewiththecostofemergencydentalcareandwithapre-reviewforassistancewithdentures:Adultsanddependentsovertheageof18uptothelastmonthadultisinreceiptofOW

Reliefofpainonly:Adultsanddependentsovertheageof18uptothelastmonthadultisinreceiptofOW

Pre-reviewbyOWadministratortoseeifassistancemaybeprovided:Adultsanddependentsovertheageof18uptothelastmonthadultisinreceiptofOW

TheOWclientstatementofbenefitsservesasproofofeligibilityinmostjurisdictions.Theclientpresentsthisstatementatthetimeofavisittoadentalofficeasproofofeligibility.Themaindifferenceineligibilityiswhetheraprovidercanproceedandprovidecarewithinthescopeofbenefitsavailable(automaticallyeligible)orwhetheraspecificrequesthastobemadebytheclientorthedentalprovideronbehalfoftheclientbeforetreatmentcanproceed.Forsomemunicipaladministratorsbothemergencydentalanddenturesbenefitsareautomaticallyprovidedtoeligiblerecipients.Forothermunicipaladministrators,clientsareautomaticallyeligiblefortheemergencydentalplanhoweverdentureplanassistancemustbepreauthorized.Sevenmunicipaladministratorsprovidecoveragethataddressesreliefofpainonlywhereremovingatoothbutarelessclearastowhetherafillingofatoothmightbecovered.Caseworkersaremoredirectlyinvolvedinapprovingthebenefitinsuchcases.Itisdifficulttoaccesswritteninternalmunicipaladministrativeguidelines;however,anelectroniccopywasprovidedbyManitoulin-Sudbury.Manitoulin-Sudburyisanexampleofamunicipaladministratorthathasathird-partyprocessercontractedtoadjudicateandpayclaimstodentaloffices(Accerta).Their

7See:QuiñonezCR,FigueiredoR,LockerD.Canadiandentists'opinionsonpubliclyfinanceddentalcare.Journalofpublichealthdentistry.2009Mar;69(2):64-73; Quiñonez C, Figueiredo R, Azarpazhooh A, Locker D. Public preferences for seeking publicly financed dental care andprofessionalpreferencesforstructuringit.Communitydentistryandoralepidemiology.2010Apr;38(2):152-8.

policyallowsforadditionalcareoutsidethatplantobeauthorizedandpaidfordirectlybythemunicipaladministrator.ThefollowingisanexcerptfromtheManitoulin-SudburyDistrictServicesBoard,policyandproceduremanuallastrevisedJanuary2009:

Emergencyisdefinedasbeinganunscheduledeventwhereanindividualappearsinimmediatedistressandrequirescare,andimmediateappropriatetreatmentisneededtocorrecttheproblem.TheDirectorofIntegratedSocialServicesmayapprovecostsfordentalservicesprovidedtoadultmembersofthebenefitunitfor:Emergencydentalcare(dentalserviceswhicharenecessarytorelievepainorformedicalortherapeuticreasons);Dentalcarewhichsupportstheperson’semployabilityorparticipationrequirements(e.g.orthodonticanddentureservices);AnyexceptionalcircumstanceswheredeemedmedicallynecessaryatthediscretionoftheDirectorofIntegratedSocialServicestakingintoconsiderationtheHealthandWelfareoftheindividual.Thisserviceisavailabletoparticipantsandbeneficiarieswhoarenotdependentchildren.DentalcoveragefordependentchildrenisamandatoryitemofassistanceunderOW.

Basedonanumberofconversationswithmunicipaladministrators,aswellastwooftheauthors’(AB,CQ)experiencetreatingpatientsorconsultingfordifferentpublicdentalprogramsacrossOntario,manymunicipaladministratorshavesimilarinternalprocedurestoapproveadditionalassistanceoutsideofprescribedbenefitplans.Thenumberofprogramsthatprovideadditionalassistanceisnotpossibletodetermineandwouldrequiresignificantfollow-upanddiscussionwithmunicipaladministrators.Giventheabove,itisclearthatallmunicipaladministratorsoffersomeformofemergencydentalbenefitorassistance.Municipaladministrators,withformalplansforbothemergencydentalanddenturebenefits,haveinessencecreatedaquasi-mandatorybenefit.Clientscanaccesscareasneededandreceivetreatmentanddentalofficesarereimbursedinaccordancewithspecificserviceandfrequencylimitations.Theprimaryobjectiveofthisapproachisarguablytoachieveclarityofbenefitsreimbursedandtoadministerplansthataredesignedtoensuresomelevelofcost-containment.Othermunicipaladministratorssee“dental”asacompletelydiscretionarybenefitwiththedeterminationmadebycaseworkers.Minimalpainrelief(forexamplecostofanextraction)arereimbursedaspartofasingleemergencyappointmentwithadditionalservicesbeyondthefirstappointmentrequiringpre-approval.Thisresultsinuncertaintyforboththeclientsanddentaloffices.Basedonthereviewofmunicipaladministrators’websitematerials,factorsrelatedtoqualityoflife,health,andemployabilityarepartoftheoverallgoalsforprovidingdiscretionaryassistance,whichsupportoralhealthgoalsandobjectiveslessdirectly.Onlyafterpre-approvalisreceivedwillclientsknowwhatserviceswillbeprovided.Dentalofficesarerequiredtoprepareestimatesandwaitfornotificationofauthorizationpriortoproceedingwithcare.Thecriteriausedtodeterminewhatwillbeauthorizedornotauthorizedbymunicipaladministrativestaffisgenerallynotpubliclyavailable.Importantly,somejurisdictions(Ottawa)havesystematicassessmenttoolsandpoliciesthatareusedbystaffdentiststoreview,performandapprovereferralforcare.3.5 SupplementalPublicClinicsandAccesstoCareforAdultsReceivingOWThemajorityofmunicipalitiesuseadefinedbenefitplanwhereprivateprovidersdelivercareandarereimbursedforservicesprovidedthroughaclaimsadjudicationandpaymentprocess.Adjudicationandclaimspaymentprocessesareincreasinglyrapidandprovidedbyanumberofthird-partyadministratorsandinsurancecarriers.TherehasbeenatrendtowardscentralizationofclaimspaymentforsocialassistanceinOntario(HealthySmilesOntario(HSO)andODSP).Theapproachreliesonaclearsetof

proceduresthatdefinewhichproceduresareeligibleforreimbursement.Themajorlimitationisthat,bydesign,claimsadjudicatingandpaymentprocessesmustmeetfinancialparameterswhilenotnecessarilyaddressingthecareneedsofallclients.ThereareagrowingnumberofOntariocommunitieswhere,inadditiontothedefinedbenefitsplans,fixedpublicclinicshavebeenestablished(Toronto,Kingston,Hawkesbury,Tweed,NorthBay,Cornwallasexamples),ashavemobilepublicclinics(NiagaraRegion,HamiltonandPeel),withtheinitialcapitalcostssupportedbyprovincialandlocalinitiativesandoperatingfundsderivedfromvarioussources.Theseclinicshaveprogramsthatserveprimarilylow-incomeOntarianswhohavedifficultyaccessingprivatecare(somealsoincluderecipientsoftheFederalNon-InsuredHealthBenefits(NIHB),ODSPandOWprograms).Theseclinicalprogramsweredevelopedindependentlyofoneanotherandthereisconsiderablevariationintheiroperationsandservicesoffered.Thelevelofintegrationwiththelocalmunicipaladministratorandothernot-for-profitorganizationslikecommunityhealthcentresandPHUsalsovaries.Insomeinstances,thehostnot-for-profitorganizationhasaspecificcontractualandfundingarrangementinplacewithmunicipaladministrators.Inothercases,OWclientsareacceptedbytheclinicandtheclinicisreimbursedforservicessimilartootherprovidersorreceivesblockfundingthattheclinicshadow-billsagainst.Dependingonfunding,clinicsofferservicesfromonetofivedaysormoreperweek.Theclinicsgenerallyofferthesamelevelofcaretoallclientswhoseekservicesandfunctionasadirectaccessclinicalprogram.Demandforservicesishighandthereforeeffectivemanagementoftheservicesofferediscriticaltoensureurgentproblemsareprioritized.TheCityofOttawaistheonlymunicipaladministratorthatprovidesdirectcaretoalladultsreceivingOW.Themunicipaladministrator(abranchofcitygovernment)hasenteredintoanagreementwithOttawaPublicHealth.Underthisagreement,OttawaPublicHealthisresponsibleforalldental-relatedmattersforOWclients.OWprogramstaffarenotabletogeneraterequisitionsrelatedtodentalservicesanddirecttheirclientsforalldental-relatedmatterstotheclosestclinic.Throughtheclinics,clientsareoffereddentalserviceswithreferralstospecialistsarrangedasrequired.OttawaoperatesthreeclinicscurrentlyspecificallydedicatedtoadultsreceivingOWandlow-incomeindividuals,aswellaschildrenthroughtheHSOprogram.8Thefinancialeligibilityfortheprogramisconfirmedbythemunicipaladministratorthroughacentralizedfinancialassessmentprocess.AllOWclientsareeligibletoreceiveservicesatanyofthethreeclinics.DentalcardsorproofofeligibilityforOWarenotrequiredbecausedentalclinicsarepartofthecity’sintegratedinformationsystem.Theprogramhaswell-developedpolicyandassessmentparametersforthecaretobeprovided.Theprogramprioritizesurgentproblems,offerssame-dayornext-dayappointmentsandfocusesonmeasurestohelppreventfurtherproblems.TheprogramencouragesadultsreceivingOWtotakeadvantageofthetwodentalhygienetrainingprogramsatthetwocommunitycollegestohelpmaintaintheiroralhealthoncetheurgentproblemorproblemshavebeenaddressed.DenturesareofferedthroughaspecificpartnershipprogramwiththeOttawaDentalandDenturistSocieties.Staffdentistsassessandauthorizingspecificdentureservices.Thisapproachwasintroduced

8OttawaPublicHealthoperatesadentalclinicattheWabanoCentreandprovidesdentalservicestoIndigenousadultsincludingthosewhoareinreceiptofOW.

inthelate1990’sandresultedinbetteroutcomesbecauseitensuredthatclientshadallthenecessarypre-workcompletedpriortothepatientshavingtheirpartialorfulldenturesmade.Staffdentistscanpreauthorizeadditionalserviceswhererequiredtoimproveoutcomesandworkdirectlywithexternalproviders.Overallthough,basedonareviewoftheplansobtainedforthisstudy,themajorityofmunicipaladministratorsareusingadefineddentalbenefitplanthatfunctionsinasimilarmannertoemployer-sponsoredplans,butoffermorelimitedcoveragewhencomparedtoemployer-sponsoredplans(whichincludemorecoveredproceduresandopportunityforregularvisitsandmaintenance).Importantly,inmanycommunitiestheOWadultplanswillpayforurgentcarethatotherlow-incomeOntarianscannotafford.Andoneofthekeyissuesrelatedtothisistheissueutilization,meaningdentalplansforlow-incomeOntarianshavehigherutilizationratesthannon-insuredpopulationsyetlowerutilizationratesthanemployer-sponsoredplans.9Giventhis,alimitednumberofmunicipaladministratorsfundlocalprogramswhichallowlow-incomeadultstoaccessthesamediscretionarybenefitsasadultsreceivingOW.Inaddition,OWadministratorsincommunitiesincludingKingston,Cornwall,andTweed,forexample,reportedtotheresearchersthattheyopenedpublicclinicstoassistagrowingnumberofindividualswhocannotaffordtoaccesscareandthatarenotcoveredbypublicprograms.Theclinicsoperatebasedonacombinationoffee-for-service,grants,localfundingandorlocalcharitablecontributions.Althoughtheseapproachesappeartohaveincreasedinrecentyears,theyremaintheexceptionratherthanthenorm.3.6 AssessmentandComparisonofBenefitsOfferedtoAdultsReceivingOWInOntario,servicesperformedbydentists(examination,diagnosis,fillingsetc.)havespecificdescriptionsandareassignedaspecificfive-digitnumericcode.TheseservicedescriptionsandtheircorrespondingcodesarereferredtoastheUniformSystemofCodingandListofServices(USC&LS).TheUSC&LSisproducedandownedbytheCanadianDentalAssociation.InOntario,theOntarioDentalAssociation(ODA)producestheODASuggestedFeeGuideforGeneralPractitioners,whichassignsasuggestedfeetospecificcodesfromtheUSC&LS.SpecialityassociationsinOntarioalsoproducetheirownschedulesfortheirmembers.Aruleofthumbisthatspecialistfeesare20%higherthangeneralpractitionerfees.Governmentdentalplans,likeOW,HSOorODSP,usetheUSC&LSunderlicense.ThesepublicplanscontainaselectionorpartiallistofcodesthatappearintheODAsuggestedfeeguideandarereimbursedunderthetermsofthepublicplan(totalfeeandfrequency).TheHSOandODSPplansarecommonlyreferredtoas“basicdentalplans”.Asanexample,takingandinterpretingapanoramicradiographicisdescribedbycode02601,iscoveredonceeveryfiveyears,isreimbursedat$31.54forageneraldentistor$37.85foraregistereddentalspecialistlicensedbytheRoyalCollegeofDentistsofOntario(RCDSO).OWadultplans(withacoupleofexceptions)coverfewerservices(codes)orlowerallowancesorfrequencyandarecommonlyreferredtoas“emergencydentalplans”.Wheremunicipaladministrators

9See:QuiñonezC,SherretL,GrootendorstP,ShimMS,AzarpazhoohA,LockerD.Anenvironmentalscanofprovincial/territorialdentalpublichealthprograms.OfficeoftheChiefDentalOfficer,HealthCanada;2007;QuiñonezC,FigueiredoR.Sorrydoctor,Ican’taffordtherootcanal,Ihaveajob:Canadiandentalcarepolicyandtheworkingpoor.CanadianJournalofPublicHealth.2010Nov1;101(6):481-5;RamrajC,SadeghiL,LawrenceHP,DempsterL,QuiñonezC.Isaccessingdentalcarebecomingmoredifficult?EvidencefromCanada'smiddle-incomepopulation.PloSone.2013Feb20;8(2):e57377.

coverservicesbyissuingarequisitioninresponsetoanestimatesuppliedbytheclientfromadentaloffice,theactualservicescovered,feesassessedandwhatisactuallyreimbursedislessclear.Thisreviewwasabletoobtain26publishedplansrepresenting56%ofmunicipaladministratorsacrossOntario.Theremainingadministratorsdonothavepublishedplansorschedulesthatcanbereferenced.TherearenotwoplansinOntariothatareexactlyalike,butanattempthasbeenmadetocomparethembasedonaseriesofparameters(seemethodssection).AppendixA–ComparisonofDentalCoverageprovidesadetaileddescriptionoftheuniquefeaturesofeachofthe26benefitplans,butingeneralterms,itcanbesaidthatthereisvariationbasedon:

• Specificservicesbeingcovered• Frequencywithwhichcertainservicesarecovered• Inclusionofcertaintreatmentsforallteeth• Exclusionofcertaintreatmentsforcertainteeth• Amountoftimereimbursedforservicesthatarebilledbasedonatimebasis• Limitstothetotalamountthatcanbereimbursedina12-monthperiodorotherperiod• ReimbursementoffeesasoutlinedintheMCCSSfeeguide,and• Otherspecificfeaturessuchaswhenexceptionscanbecoveredorarespecificallynot

considered.Itcannotbeoverstatedthatthevariationacrossandwithintheparametersmakesitdifficulttoestablishandidentifycommonalitiesamongstplans.Table9belowisadescriptivesummarythatillustrateswherethereiscommonality(likelypointingtothediversity)inthediscretionarydentalbenefitsofferedbyOWadministratorsthroughtheadultdentalplans.Table9.Commonality(diversity)indiscretionarydentalbenefitsParameter Descriptionofcommonality(diversity)Annualreimbursementlevels

Eightof26planshavea12-monthtotalreimbursementmaximum:Wellington$1,000,Grey$1000,Huron$1000,Peterborough$600,Renfrew$500,ParrySound$425,SimcoeCo.$400,andWindsor$300.Allremainingplansdonothaveanannuallimit.

Reimbursementperdentistorperclient

Thelimitationsaregenerallyperpatientpertimeframe.Insomeplansandforsomeservicesthewordingisperdentist.

Fullexaminations Threemunicipaladministrators,Peterborough(1/60months),YorkRegion(1/60months),andSaultSt.Marie(1/36months),coveracompleteexaminationatdifferentfrequencies.PeterboroughwillprovidecoverageforarecallexaminationafterninemonthsandYorkwillmatchthesamelevelofbenefitasODSPadultrecipients.Noneoftheotherplansincludearecallexamination.

Radiographs Coveragevariessignificantlybetweenplans.Forexample,ParrySoundwillreimbursethreeperiapicalradiographs(PA)peremergencyvisit,whileThunderBayorNorthumberlandreimbursethreePAevery12months.Thereisvariationaswhetherbitewing(BW)radiographsareincludedinthecountswithPA,inadditiontoPA,ornotincludedatall.ParrySoundcoverstwoBWeveryninemonths,TorontoreimbursessixPAorBWina12-monthperiod,whereasPeterborough,YorkandThunderBayallowforeightPAin12monthsandtwoBW.Durhamwillreimburseforthreefilmsclaimedinathree-monthperiodincludingBW.Incontrast,SaultSt.Marieprovidesforfivefilmsina12-monthperiod.Torontoexcludespanoramicradiographs(PAN),whileThunderBay,WellingtonandGreyCountyincludeaPANaspartofthetotalcountofthreeradiographsper12-months,whereasSaultSt.MariewillreimburseforaPANonceevery36monthsandPeterboroughonceevery24months.

Preventiveservices Scaling,polishingandfluoridetreatmentsareincludedinPeterborough’splan($600totalplanreimbursementlimitper12months).YorkRegion’splancoversscalingandfluoridetreatmentbutnotpolishing.NorthumberlandincludesuptofourunitsofscalingforOWadultwomenduringpregnancy.

Posteriorcomposites

Thesefillingsinthemolarteethareincludedasabenefitinallplans,exceptforToronto,wheretheyarenotanincludedbenefit.Torontowillreimburseforsilveramalgamfillingsinthemolarteeth.YorkandHamiltonincludeposteriorcompositesbutonlyreimbursethesamefeeasforanamalgamrestoration(feesarelower).PlansadministeredthroughAccertacontainageneraldisclaimerrelatedtoonlyreimbursingsilveramalgamfeesifatoothisfilledwithtwoseparatematerialsatthesametimebutdoreimbursehigherfeesforcompositerestorations.

Rootcanaltherapy(RCT)

PeterboroughwillcoverRCT.Yorkwillcoveroneortwocanaledteeth,SaultSt.MariewillreimburseforRCTonthefrontteeth(nocoverageforpremolarormolarteeth),Durhamrequirespredeterminationandcoversonlythefrontteethandlimitsthereimbursementtothefeeforonecanal.ParrySound,Simcoecoverone-canaledteeth.Fortheremainderofmunicipalities,includingToronto,ThunderBay,Wellington,GreyCounty,Windsor,Stratford,partialRCT(pulpectomy)iscovered.

Basicanddifficultextractions

Allplanscoverbasicandcomplexextractions.Durhamrequirespredeterminationforremovalofwisdomteeththatareimpacted.Allplans,withtheexceptionofToronto,paytore-implantatooththathasbeendislodgedorknockedout.TheMuskokaandSimcoeOWareaplansrequiretheprovidertosubmitanexplanationanddetailsoftheproceduresusedwhensubmittingforcomplexextractions.

Sedation Mostadministratorsdonotofferreimbursementprovidinggeneralanesthesia,deepsedationorconscioussedation.Peterborough,HuronandPeelcoveruptoeightunits(1.5hours)ofsedationpervisit.Torontowillreimburseforconscioussedationuptoeightunitsperyear.SaultSt.Mariereimbursesuptosixunits(75minutes)ofanycombinationofgeneralanesthesia,deepsedationorconscioussedationina12-monthperiod,whereasHamiltonwillreimbursefourunitsina12-monthperiod.TheSimcoeandMuskokaareaplanshaveprovisionstoconsidersedationunderverylimitedcircumstancesandrequireanexpertletterjustifyingthemedicalneedpriortobeingconsideredandauthorised

Intermsofdentureplans,ofthe46municipalities,13(25%)havepublisheddentureplans.Thisdoesnotnecessarilymeanthatothermunicipalitiesdonotprovidesuchassistance,astheymaybeofferedonacase-by-casebasisdirectlythroughcontactwithacaseworker.Liketheplansdescribedabove,therearenotwoplansthatarethesame.AnassessmentofeachplanisalsoincludedinAppendixA–ComparisonofDentalCoverage.Thedatahighlightsthefollowing:someplansaremoregenerousandwillprovidefornewdentures(onceeveryfiveyears),allowformorefrequentrepairsandmaintenance,periodicreliningorrebasingtoaddressmanydenture-relatedneedsand/orextendthelifeofanexistingdenture;otherscontainfewerservices(relinesorrebasesnotcovered),havelongerreplacementfrequencies,excludecastpartialdenturesandcaptotalreimbursementindifferentways.

Toillustratethevariation,Northumberlandwillcoveranewpairofdenturesevery60monthsbutnotrelinesorrepairstoexistingdenturesorthoseconstructedundertheplan.Torontocoversasetofdenturesorpartialseveryfiveyears(coversonlyacrylictypepartials),arelineonceevery36monthsand$88dollarsreimbursementina12-monthperiodforrepair.Haltonincontrastcoversanewfullorpartialdentureseveryfiveyears,uptofourrepairsperyearandcoverstissueconditioning,whichmostplansdonotinclude.SaultSt.Mariecoversanewdenturebenefitonceinalifetime,onerepairandarelineeverytwoyears.

Therewasalsonoconsistencyintermsoffeespaidfordenture-relatedservices.Forexample,Durhamwillreimburseamaximumfeeof$580.27perdentureandSaultSt.Marie$495.00.Theoppositeistrueforrelines/rebases,whereDurhamreimburses$163.86andSaultSt.Mariereimbursesamaximumfeeof$180.Fromthepointofviewofpolicy,thefollowingstatementfromWellingtonisreflectiveofthegeneralpolicyintentofmostplans:

Theintentofcoverage-PlansponsorsdoNOTintendtoprovideon-going,regulardentalcarefortheirclients.Theintentofthisplanistoprovideemergencycareonlywiththeconstraintsofthisprogram.Anemergencyinvolvesbleeding,pain,infectionortrauma.Itrequirestreatmentofasymptomaticpatientwhenthepatientappearsindistressandappropriatetreatmentisinstitutedforthatspecificemergencyproblem(s).Resolutionoftheproblemmayrequiremorethanoneappointment.

Whilemostoftheplandesignsemphasizeprovidingalimitedcourseoftreatment,allgenerallyreimbursethecostofabasicexam,aradiograph(s)andassistancetoremoveatooth,ortoplaceaverybasicfilling,whichisinconsistentwiththestatedintentofthepolicies.AnotherkeyissueisthelackofclarityforanOWadultclientintermsofthelevelofassistancetheycanreceiverelatedtoaparticulardentalproblem.Theinformationinplansisdesignedandtargetedtodentalprofessionalsandthelimitationsandservicescoveredarecomplexforthegeneralreaderorsomeonethatisnotfamiliarwithdentalterminology.AndincontrasttootherdiscretionarybenefitswhereanOWcaseworkercan,inrelativeterms,accuratelydescribethebenefit(assistancewitheyeglassesforexample),dentalcarerequiresexaminationanddiscussionwithaprovider.Afurtherandrelatedconsiderationisthat,whileextrabillingisnotpermittedforserviceswithintheplan,dentistsarepermittedtochargeforservicesoutsidetheplan.Thus,thereisthepotentialforclientstobeunsureaboutthelevelofassistanceavailableandconcernedaboutthepotentialofhavingtopayforsomeservices.Basedontheexperienceoftwooftheauthors(AB,CQ)inmanagingandadjudicatingdentalservicesforsocialservicesadultrecipients,thiscanresultinOWclientseitherdelayingornotseekingcare.ThediversityinplansalsomeansthatinsomeareasofOntario,theassistanceofferedcanhelpOWclientsmaintainorpotentiallyimprovetheiroralhealthduringthetimetheyareonassistance(Peterborough,YorkandtoalesserextentOttawa),whereasinotherareasofOntario(suchasWindsor),offersofassistancecoveronlyonedentalproblemorpossiblyasecondinstanceiftherearefundsremainingwithintheirannualdollarvaluelimit.ThisisconsistentwiththenotionthatOWis“shorttermassistance”andverybasicsupportsareprovidedtoclientstoachieveself-sufficiencyintheshortesttimepossible.Thisalsomeansthatplansdonotconsideranindividual’sbaselineoralhealthor“timeonassistance,”specificallycaseswhereindividualsreturntosocialassistancerepeatedly,orwhereassistanceisongoingandintergenerational,whichasindicatorsofpoverty,alsolikelymeansthatoralhealthstatusispoorerthanmoresocioeconomicallystableOntarians.10Sedation(specificallynitrousoxide,intravenoussedationandgeneralanesthesia)isapolicyareawhichrequirescarefulconsiderationwhendesigningpublicprograms.Therehasbeenconsiderableexpansion

10See:SadeghiL,MansonH,QuiñonezC.ReportonaccesstodentalcareandoralhealthinequalitiesinOntario.PublicHealthOntario;2013.

inthepromotionandavailabilityofsedationindentalpracticeinOntario;whileatthesametime,thereisdeclineinthenumberofpractitionerswhotreatveryanxiouspatientsbecauseoftheadditionaldemands(timeandemotion)onthedentalteamtoproperlysupportaclientwithdentalanxiety,whichisarguablymadeworsewhencoupledwithlowerreimbursementrates.11Aswasnotedinthefindingsonlyfivemunicipaladministratorsincludeassistancewiththecostsofsedationandthereisvariationintheamountcovered(twoothersofferlimitedreimbursementunderexceptionalmedicalcircumstances).Sedationcostsoftenequalorexceedthecostoftreatmentprovidedduringanappointmentandarethereforenotinsignificant.Someofthefiveplanshavelanguagethatspecificallyexcludessedationrelatedtoanxietyorfearofthedentist,andrequireanothermedically-relatedjustificationforittobereimbursed.Duringthegatheringofinformationrelatedtocase-by-caseauthorizations,itwasevidentthatinsomeinstances,municipaladministratorswereapprovingsedationinexceptionalcircumstances(removalofanimpactedtoothorwherethereareconcurrentmedicalproblemsmakingsedationcriticaltoprovidingtreatmentsafely).TheextenttowhichadultsreceivingOWareavoidingcarebecausetheycannotaccesssedationorarepayingforsedationservicesaspartofemergencydentalcareisunclear.Municipaladministratorsworkwithinspecificfinancialconstraintsandpolicyframeworksthatareapprovedlocally.TheplansreviewedforthisreportarguablyreflectarangeoflocalpolicyoutcomesthatbalancefinancialconstraintswiththelocalrealitiesofthecompositionofOWcaseloadsandthechallengesofgeography(ruralversusurbanforexample).Theapproachtoaddressingtheseconstraintsdiffers.PlansadministeredthroughPHUssuchasSimcoeandParrySoundhavecarecoveredannually($400/$425peryearandincludebothpre-treatmentandpost-treatmentadjudicationrequirements,suchassupplementalinformationandradiographswhenclaimingforthehigherfeeassociatedwiththeextractionofatoothorpreauthorizationforremovalofmorethanonewisdomtooth).Inthisapproach,andwhencomparedtothoseplansthatareadjudicatedbyotherthird-parties,therecanbeabroaderrangeofservicescoveredwithinasimilarfinanciallimitlikelybecauseofthehigherlevelofaccountabilityforexpenditures.Low-incomeadultsandadultsonsocialassistancehavehigherdentalneeds(poororalhealth)thanthegeneralpopulation.12Publicdentalplansforadultsonsocialassistancehavealsochangedlittleoverthelast30yearsintermsofthescopeofcoveredprocedures,andgenerallyonlyaddressanurgentdentalproblems.13MunicipaladministratorsthathaveplansthatareclosertotheODSPlevelofbenefithaveagreaterpotentialtoassistclientsmaintainorimprovetheiroralhealthwhileonassistancebecausetheplanincludesabroaderrangeofcoverageforroutinepreventivecare,restorative,endodonticcare,surgicalservicesandanesthesia.ProvidinganODSPlevelofbenefittoallOWadultclientswouldentailasignificantincreaseinexpendituresovercurrentlevelsinOntario.ItisalsoimportanttonotethatevenanODSPbenefitlevelwouldnotallowallOWadultclients’oralhealthtobemaintainedand/orrestored

11See:ChanpongB,HaasDA,LockerD.Needanddemandforsedationorgeneralanesthesiaindentistry:anationalsurveyoftheCanadianpopulation.Anesthesiaprogress.2005Mar;52(1):3-11;AdamsA,YarascavitchC,QuiñonezC.UseofandAccesstoDeepSedationandGeneralAnesthesiaforDentalPatients:ASurveyofOntarioDentists.JCanDentAssoc.2017;83(h4):1488-2159.12See:QuiñonezC,FigueiredoR.Sorrydoctor, Ican’taffordtherootcanal, Ihavea job:Canadiandentalcarepolicyandtheworkingpoor.CanadianJournalofPublicHealth.2010Nov1;101(6):481-5;HealthCanada.SummaryreportonthefindingsoftheoralhealthcomponentoftheCanadianHealthMeasuresSurvey,2007-2009.Ottawa:HealthCanada,2010;CanadianAcademyofHealthSciences.ImprovingaccesstooralhealthcareforvulnerablepeoplelivinginCanada.Ottawa:CanadianAcademyofHealthSciences,2014.13See:QuiñonezC,SherretL,GrootendorstP,ShimMS,AzarpazhoohA,LockerD.Anenvironmentalscanofprovincial/territorialdentalpublichealthprograms.OfficeoftheChiefDentalOfficer,HealthCanada;2007;ShawJ,FarmerJ.AnenvironmentalscanofpubliclyfinanceddentalcareinCanada:2015update.Toronto:FacultyofDentistry,UniversityofToronto,2016.

tofullfunction.Manylow-incomepatientsgowithoutdentalcareforsignificantperiodsoftimeandneedmoreadvancedtreatment,14whichisoutsidethescopeoftheODSPormostpublicplansinCanada.Finally,clinicslikethoseinEasternOntario,Kingston,NorthBay,andOttawaoftenhelpclosesomeofthegapinaccesstocareandservicesbyofferingcarethatresemblesthecarereceivedthroughHSOorODSPforadefinedperiod.ThistypeofextendedaccessisnotavailableineverycommunityinOntario,ornotpromotedopenlyduetothecommunity’slimitedcapacity.ThisreflectsthediversityanddisparityofapproachesofaccesstocareacrossOntario.3.7 MCCSSFeeComparisonAspresentedintheprevioussection,mostOWadultdentalbenefitplansfollowtheMCCSSscheduleofbenefits(levelofreimbursement).Thisreviewfoundthat:

• 17ofthe26plansreimbursethesamefeesforthesamecodesasfoundastheMCCSSschedule• SevenplanshavepaymentschedulesthatexceededtheMCCSSschedule,and• ThecurrentversionoftheplanfortheCityofTorontoprovidedbyGreat-WestLifeshowfees

thatarebelowthoseoftheMCCSSschedulewhilethoseintheRegionofPeelschedulewereverymarginallylower.

AppendixB–ComparisonofSelectFeeCodescontainsasummaryofthedifferentialinfeesforsevencommonlyusedcodesinemergencytreatment:

1. 01204,specificexamination2. 01205,emergencyexamination3. 02112,twoPAradiographs4. 20111,caries,painandtraumacontrol5. 21243,largesilveramalgamfillinginbacktooth6. 23323,largecompositeresinfillinginbacktooth7. 71201,complicatedextraction(removal)ofatooth

ForthesevenplansthatexceededtheMCCSSschedule,thedifferenceinfeesforthevariouscodesassessedwerebetween23.2and244%greater.Withinthesevenplans,therewerenotwofeestructuresthatmatched.Code20111showedthegreatestrangecomparedtotheMCCSSschedule,114.6to244%greater.Whereas01205variedfrom23.2to100%greater(doublethefeeintheMCCSSschedule).TheMCCSSscheduleofbenefitshasremainedlargelyunchangedformanyyears.Thesevenof26publiclyavailableplansthatarepayinginexcessoftheapprovedschedulesareoutsideofthemajorurbanareasoftheprovinceandareadministeredbyAccerta.Anassessmentoftherationalandvariationoflocalplansisbeyondthescopeofthisproject,butmaywarrantfurtherdiscussionswiththe

14See:LockerD,MaggiriasJ,QuiñonezC.Income,dentalinsurancecoverage,andfinancialbarrierstodentalcareamongCanadianadults.Journalofpublichealthdentistry.2011Sep;71(4):327-34;ThompsonB,CooneyP,LawrenceH,RavaghiV,QuiñonezC.Thepotentialoralhealthimpactofcostbarrierstodentalcare:findingsfromaCanadianpopulation-basedstudy.BMCOralHealth.2014Dec;14(1):78;ThompsonB,CooneyP,LawrenceH,RavaghiV,QuiñonezC.Costasabarriertoaccessingdentalcare:findingsfromaCanadianpopulation-basedstudy.Journalofpublichealthdentistry.2014Aug;74(3):210-8;RamrajC,AzarpazhoohA,DempsterL,RavaghiV,QuiñonezC.DentaltreatmentneedsintheCanadianpopulation:analysisofanationwidecross-sectionalsurvey.BMCoralhealth.2012Dec;12(1):46.

specificadministratorstoverifythemethodologyusedtodeterminereimbursementlevelsforspecificfeesandthebasisofthedecisiontodeviatefromtheMCCSSschedule.Ultimately,itisagoodworkingassumptionthattheclosergovernmentplansresembleemployer-sponsoredplans,themorelikelytheseplansaretobeacceptedbydentists.15Also,thereiscurrentlynoclearlydefinedsocialcontractwiththedentistsinOntario.Dentistsareundernoobligationtoacceptgovernmentplansandcanlimithowmanyclientstheywillacceptintheirpractice.ThecurrentdiscourseamongdentistsisthatthecurrentMCCSSschedulerepresentsonly“30centsonthedollar”foradentalpracticeandthereforedentistsarepersonallysubsidizingthegovernmentplans.16Indeed,beforethemostrecentelection,theOntarioDentalAssociation(ODA)hadapubliccampaignarguingforincreasestotheprovincialgovernment’sinvestmentinexistingpublicdentalplans.4.0 ConclusionsThisreportprovidedadescriptiveanalysisofthecurrentstateofdentalprogramsand/orbenefitsforadultsreceivingOWacrosstheprovince.Itdemonstratedsubstantialvariationacrossallparameterscompared,includinghowbenefitsareaccessed,howtheyareadministered,whateligibleservicesareincludedorexcluded,whatmaximumannuallimitsapplyandthelevelsofreimbursementincluded.Thesefindingssuggestseveralpolicyoptions.Thewidevariationpresentamongmunicipalitiesislikelyrelatedtothediscretionarynatureoforalhealthcaredeliveryforadultsreceivingsocialassistance.Thisvariationcouldbeaddressedbyguidancefromtheprovinceregardinghowtheseservicesaretobeorganized(managed),financed,anddelivered.Alternatively,governmentscouldsetorganizational,financing,anddeliverystandardsforthedeliveryoforalhealthcaretosocialassistancepopulationsbymakingclearwhatservicesaremandatorytodeliver.TheobjectivesofprovidingoralhealthcaretoadultsreceivingOWinOntariohavenotbeenclearlyarticulated.Identifyingspecificgoalscanindicatepolicyoptions.Forexample,ifthegoalistoincentivizeandincreasethechancesofemploymentamongadultsreceivingOW,approachestocarecouldincludecoordinationbetweencaseworkersandothersocialservicesorPHUstaffthatisfocusedonemploymentoutcomes.Alternatively,ifthegoalistoachieveimprovedhealth,approachescouldincludecoordinationbetweencaseworkersandothersocialservicesorPHUstaffthatisfocusedonhealthoutcomes.Importantly,thesearenotmutuallyexclusivestrategies.Notably,theevidenceofanassociationbetweenreceivingdentalservicesandleavingsocialassistanceforemploymentisweak,17yetindividualsdoreportimprovementstoemployment-relatedfactorswhensurveyedpreandpostdentaltreatment,includingimprovementstosubjectivemeasuresoforalhealth.18

15See:QuiñonezCR,FigueiredoR,LockerD.Canadiandentists'opinionsonpubliclyfinanceddentalcare.Journalofpublichealthdentistry.2009Mar;69(2):64-73; Quiñonez C, Figueiredo R, Azarpazhooh A, Locker D. Public preferences for seeking publicly financed dental care andprofessionalpreferencesforstructuringit.Communitydentistryandoralepidemiology.2010Apr;38(2):152-8.16 See:CBCNews. 'Ugly,awful secret:'Ontariodentistsareduckingsomepatients—and theysay theyhavenochoice.Deburary08,2018.Availableat:https://www.cbc.ca/news/canada/sudbury/healthy-smile-cost-money-1.4525204;TheAgendawithStevePaikin.Ontario’sDentalCare:BitingOffMyths.May14,2018.Availableat:https://www.tvo.org/video/ontarios-dental-care-biting-off-myths.17SeeSinghalS,CorreaR,QuinonezC.Theimpactofdentaltreatmentonemploymentoutcomes:asystematicreview.Healthpolicy.2013Jan1;109(1):88-96andSinghalS,MamdaniM,MitchellA,TenenbaumH,LebovicG,QuiñonezC.DentaltreatmentandemploymentoutcomesamongsocialassistancerecipientsinOntario,Canada.HealthPolicy.2016Oct1;120(10):1202-8.18SeeSinghalS,MamdaniM,MitchellA,TenenbaumH,QuiñonezC.Anexploratorypilotstudytoassessself-perceivedchangesamongsocialassistancerecipientsregardingemploymentprospectsafterreceivingdentaltreatment.BMCoralhealth.2015Dec;15(1):138.

Animportantpolicyquestionistheappropriatemixofpublicdeliveryofservices,privatedelivery,orboth(mixeddelivery).Almostalldevelopednationsworkonamixeddeliverymodel,19giventhatnotallservicedeliverycontextsareappropriateforallpopulations.20Economicevaluationsmayhelptodeterminetheefficiencyofblockfundingtheorganization,management,anddeliveryofpublicservices(PHUclinics,communityhealthsectorclinics),whileorganizing,financing,anddeliveringprivateservicesthroughtheuseofacentralizedclaimsprocessor,ascurrentlydonewiththeHSOprogram.Inonesense,theabovedecisionsarestructuralinnature.Theyinvolvequestionsastowhichlevelofgovernmentwillassumethefundingofsuchcare,whetheralocalsafetynetapproachwillbeprioritizedorsimplythepaymentofservices,whetherthegoalistocreatestrongpublicandprivatesystemsaroundtheoralhealthcaredeliveredtosocialassistancepopulations,andwhetherthefocuswillbearoundthosewithteethorthosewithout.Theseareobviouslyfalsedichotomies,buttheydopaintapictureofthetypesofdecisionsthatarerequired.AnotherimportantquestionforOntarioisthelevelofflexibilitythatisoptimalatthelocallevel.Forexample,localadministratorsareoftenfacedwiththechallengeofwhattodoforapersonwho,fromexperience,willlikelyonlybeonOWforaveryshorttime,versusapersonwho,againfromexperience,maybeheadedtowardsODSP.Flexibilityisparticularlyimportantintheformercase,assomeonemaynotneedtobeonOW,butsimplyneedssupportforatoothextractionorsomeotherbasicdentalcare.Blockfundingoftheseservicesprovidesforthistypeofflexibility,especiallyinlocationswherepublicclinicsareavailable,orwhereprivateclinicsaretheonlyoption.Fromanequityperspective,thewidevariationinwhatisavailabletowhomandthroughwhatprocessesmaybeparticularlyconcerning.Thisreporthashighlightedsuchvariation,whichhasimplicationsforfairaccesstoservicesandoutcomesacrosstheprovince,forachievingpositiveoutcomesinthesepopulationsingeneral,andforappropriateandeffectiveuseofscarceresources.Fromaneconomicperspective,rationalizingoralhealthcarecanhelpindecidingwhatservicesshouldbecoveredandatwhatcost.Dentistry,forgoodorbad,isarguablyuniqueinthatdifferenttreatmentregimens—oftenwithlargelyvaryingprices—canachieverelativelysimilaroutcomes(e.g.implantsvs.denturesinthetreatmentofmissingteeth,rootcanalsandfillingstodealwithaspecificlevelofdiseasevs.combiningextractionswithdenturestodealwiththesamelevelofdisease).Clinicalandvaluejudgmentsareimportantfordetermininghowservicesfundedbypublicprogramsarebestused(e.g.payingforarootcanalandcrownorpayingforextractionforapatientwithgivenprognosticfactors).Finally,formalizingdentalpublichealthexpertiseandleadershipcentrallymayimprovedecisionmakingprocesses(currently,thereisnoprovincialchiefdentalpublichealthofficer),andattheregional/locallevel(manymunicipalitieshavenosuchexpertiseavailable).Thiscanhelptoaddressconcernsaboutinequityinoralhealthservicesandmaximizethepotentialforefficientuseofresourcesinpublicdentalcareprogramming.

19SeeVujicicM,BernabéE,GarbinNeumannD,QuiñonezC,MertzE.(2016)DentalCare.WorldScientificHandbookofGlobalHealthEconomicsand Public Policy, Volume 2 – Health Determinants and Outcomes, Edited by Richard M. Scheffler. Singapore: World Scientific PublishingCompany,pp.83-121.20 See Quiñonez C, Figueiredo R, Azarpazhooh A, Locker D. Public preferences for seeking publicly financed dental care and professionalpreferencesforstructuringit.Communitydentistryandoralepidemiology.2010Apr;38(2):152-8.

AppendixA–ComparisonofDentalCoverageAbbreviation DescriptionGWL Great-WestLifeAssuranceCompanyAccerta AccertaClaimServicorpInc.NC NotcoveredX IncludedintheplanPD Pre-determinationR 3periapicalradiographs(PA)or1panoramicradiographper12months- Noplan

Toronto Durham ThunderBay

S.StMarie

Wellington GreyCounty Peterborough Windsori Stratford Waterlooii Haltoniii

Admin GWL PHU Accerta Accerta Accerta Accerta Accerta&OWadminiv

Accerta&OWadminv

Accerta PHUvi PHU

$limit none none none none $1000 $1000 $600 $300 none PD4teeth/yearvii

PD NO YESviii NO NO NO NO NO YES(Dentures) NO DenturesandRCT

Screeningfornonemergix

MCCSSFees

NO YES YES NO NO YES YES YES YES YES YES

Amalgam&composite

NO NO NO NO NO NO NO NO NOx NO NO

Complete NC NC NC 1/36 NC NC Xxi NC NC NC PD1per60mo

Emergency Xxii 3/12 3/6 3/12 3/6 3/6 X 2exams/year 3/12mocombined

X Unlimited

Specific X X X NI X X X 2exams/yr 3/12mocombinedxiii

X 1/12mo

Recall NC NC NC NC NC NC X NC NC NC NC

Film 6/12 3/12 3/12 5/12 3/12 3/12 8/12+2BW/9 3PA/3yrs 3PA/12mocombinedxiv

X 5/12mo

Toronto Durham ThunderBay

S.StMarie

Wellington GreyCounty Peterborough Windsori Stratford Waterlooii Haltoniii

Panoramic NC X Rxv 1/36 R R 1/24 1/3yrsxvi R X 1/24mo

Biopsy X X X X X X X X X X X

Prevention NC NC NC NC NC NC YESxvii NC NC NC PDupto4unitsscalingxviii

CTPC NCxix X X X X X X X X X X

Amalgam X X X X X X X X X X X

Comp(A) X X X X X X X X X X X

Comp(P) NC X X X X X X X X X X

Pulpotomy NC NC NC 13to43 NC NC YES X - SeeRCT SeeRCT

Pulpectomy X PD X 13to43 X X YES X X SeeRCT SeeRCT

RCT NC PDxx NC 13to43 NC NC YES NC NC PDxxi PD3per5years

Perio42831

NC X X X X X X NC X X 4unitsincludingscaling

Basicremovals

X X/PD8’s X X X X X X X X X

Replant X X X X X X X X X X X

GA NC NC NC Xxxii NC NC 8units/appt NC X NC NC

Sedation NC NC NC X NC NC 8units/visit NC X NC NC

NO X NC NC X NC NC 8units/visit NC NC NC NC

Denturesxxiii 1/5yrs PDxxiv - ONCE - - YES 1/10yrs - 1/5yrsxxv 1/5yrs

CastRDP NC NC - ONCE - - YES 1/10yrs - 1/5yrs 1/5yrs

Repairs $88/12mo

PD - 1/2yrs - - yes 1perappliance/year

- 1/3years 4/year

Reline 1/36xxvi PD - ½yrs - - yes 1perappliance/year

- 1/3yrsxxvii 1/3yrsxxviii

AppendixB–ComparisonofSelectFeeCodesFeecode 01204 01205 02112 20111 21243 23323 71201

MCCSSGP $19.00 $19.00 $16.33 $31.68 $79.32 $102.88 $88.69

Toronto$13.29(-30.1%)

$13.29(-30.1%)

$11.88(-27.3%)

N/A$55.40(-30.2%)

N/A$62.04(-30.0%)

Algoma$28.08(+51.6%)

$28.08(+51.6%)

$24.00(+47.0%)

$68.00(+114.6%)

$128.80(+62.4%)

$171.20(+66.4%)

$161.60(+82.2%)

KawarthaLakes$38.00

(+100.0%)$38.00

(+100.0%)$34.00

(+108.2%)$109.00(+244.1%)

$128.80(+62.4%)

$171.20(+66.4%)

$217.00(+144.7%)

Northumberland$29.60(+55.8%)

$29.60(+55.8%)

$26.40(+61.7%)

$83.20(+162.6%)

$152.80(+92.6%)

$152.80(+48.5%)

$167.20(+88.5%)

Peel$18.93(-0.4%)

$18.93(-0.4%)

$16.27(-0.4%)

$31.56(-0.4%)

$79.02(-0.4%)

$102.50(-0.4%)

$88.36(-0.4%)

SaultStMarie N/A$23.40(+23.2%)

$19.50(+19.4%)

$55.25(+74.4%)

$125.45(+58.2%)

$128.70(+25.1%)

$131.30(+48.0%)

ManitoulinSudbury

$38.00(+100.0%)

$38.00(+100.00)

$33.00(+100.00)

$108.00(+240.9%)

$208.00(+162.2%)

$239.00(+132.3%)

$210.00(+136.8%)

Huron$33.30(+75.3%)

$33.30(+75.3%)

$29.70(+81.9%)

$93.60(+195.5%)

$171.90(+116.7%)

$202.50(+96.8%)

$188.10(+112.1%)

Wellington$32.40(+70.5%)

$32.40(+70.5%)

$27.00(+65.3%)

$76.50(+141.5%)

$144.90(+82.7%)

$192,60(+87.2%)

$181.80(+105.0%)

iPlaninthepreambleindicatesreliefofpainonlyforthedentalplanandspecificallyindicatedthatnoextrabillingispermitted.

iiTheWaterlooplancoversupto4extractionsor3fillingspertheschedule.Treatmentbeyondthatlevelhastobepreauthorized.

iii“HaltonRegiondoesnotintendtoprovideon-goingregulardentalcaretoadultsintheOWprogram.TheOWAdultsdentalprogramisnotaninsuranceplan.Thisprogramprovidesthreetypesofcare:Emergencycareforconditionsinvolvingpain,infection,ortrauma.Denturecaretorestorechewingabilityand/orspeech.Non-emergencydentalserviceswillonlybecoveredunderspecialcircumstances.”ivDenturesare$750forupper/$750foralowerper5years;caseworkerdetermined.

vThemunicipaladministratorprocessesclaimsfordenturesinternallybuttheDiscretionaryDentalBenefitsProgramclaimsprocessingisdonebyAccerta.

viAdultsandtheirdependentchildren,18yearsandolder,canreceiveemergencycare.AsanOntarioWorksclient,youwillreceiveadentalcardwithyourstatementeachmonth.Ifyouhaveaspecificdentalproblemyoucangotoadentalcareproviderandhaveitchecked.Youcanhaveanexam,limitednumberofx-raysanduptothreeteethfilledoruptofourteethremoved.

viiPreamblefortheplanindicateswheredentistcansendtheirauthorizationsforcareandprovidesanumberfordentalofficestocall.

viii“PredeterminationofBenefitsifrequiredforanytreatmentotherthanthatprovidedatthetimeoftheinitialappointmenttorelievepainorbeyondthetwoteethtreatable[…].”

ixNon-emergencies;adultswithnon-emergencydentalconditionsmustfirstbescreenedbyHaltonRegionOralHealthstaff.� xThepreambleindicatesthatifatoothisrestoredwithmorethanonematerialthantheamalgamrateapplies.

xiIncludesany2examinationsper12monthsforemergency.Acompleteexamevery60monthsandarecallexaminationevery9monthsor9monthsafteracompleteexam.

xiiForeitheremergencyorspecificexamcoversonly1unitoftime(feeadjustedaccordingly).

xiiiPlanallowsforanycombinationof3exams(specificoremergencyper12-monthperiod).

xivTheplanallowsforeither3PA’sor1panorexper12months.

xvThebenefitiseither3filmsper12monthsor1panorex(BW’sexcluded).

xviPlanlimitseither3PA’sor1panorexper3years.

xviiIncludespolishing1per9months,scaling4unitsper12months,fluoridetreatment.

xviiiPlanalsohas1unitofsmokingcounselingasacoveredbenefit.

xixTheplanlists20131/9,whicharefortraumacontrol.

xxSetmaximumfeeof$253.39anteriorteethonly.

xxiWaterlooplan:1timepertooth:3teethperpatientsper60monthsexcludingtheanteriorteeth1-2to2-3.

xxii6unitsperdentistperyearforallthreecombinedGA,SedationorNO.

xxiiiInformationforthosemunicipaladministratorswithpublicplans.Thosenotindicatingaplandoesnotmeantthatitmaynotbeavailableandtypicallyclientshavetorequestassistance.

xxivAlldentureservicesarePD.Theplanreimbursesfeethatincludesprofessionalandlabcomponents.

xxvPlanalsocoversimmediatedentures.

xxviRelinesarelimitedtoonceevery36months,arenotcovereduntilafter3monthsifanewdenturehasbeenpaidforanddentureswillnotbereplacedifarelinefeehasbeenpainwithin6months.Repairsarelimitedto$88perdentureper12consecutivemonths

xxviiAlsocoversasoftrelineonceperdenture.

xxviiiPlanalsocoversupto4timesperyeartissueconditioning.

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