Pensioners' Dental Services Plan - Rules (June 1, 2010)

Rule 6. Benefits

Eligible Dental Services

6(1)

Where any province, state or country outside Canada employs a coding of procedures for individual dental treatment which is different from that of the Canadian Dental Association, the appropriate codes of the Canadian Dental Association for an equivalent procedure shall apply.
Where the dental service rendered in any province, state or country outside Canada differs from the Eligible Dental Services, the benefit will be based on the alternative service listed in Schedule 2 which is closest to the service actually rendered.

Specific Limitations with Respect to Major Services

6(2)

The services listed in Schedule 2 dealing with the installation of prosthodontic appliances (e.g. fixed bridge, pontics and abutments, temporary or permanent, partial or complete dentures), constitute eligible dental services if they are rendered for an initial prosthodontic appliance.
Similarly, the services listed in Schedule 2 dealing with the installation of prosthodontic appliances (e.g. fixed bridge, pontics and abutments, temporary or permanent, partial or complete dentures), constitute Eligible Dental Services if they are rendered for the replacement of an existing prosthodontic appliance, including the addition of teeth to an existing appliance, if
1. the replacement, or the addition of teeth is required because at least one additional natural tooth was extracted after the insertion of the existing appliance, and the appliance could not have been made serviceable;. if the existing appliance could have been made serviceable, the expense for only that portion of the replacement appliance which replaces the teeth extracted shall be covered;
2. the existing appliance is at least five (5) years old and cannot be made serviceable;
3. the existing temporary appliance is replaced; the replacement appliance will be considered permanent for the purposes of this provision (effective January 1, 2005);
4. the replacement appliance is required as a result of the installation of an initial opposing denture after the date the person becomes covered under the Plan; or
5. the replacement appliance is required as a result of accidental dental injury to a natural tooth that occurred after the date the person became covered under the Plan.
With respect to the services listed in Schedule 2 dealing with crowns, onlays and veneers, if a crown, onlay or veneer cannot be made serviceable the services for the replacement of a crown, onlay or veneer are eligible once every 60 months, regardless of the age of the original crown, onlay or veneer.
Services with respect to gold foils, as listed in Schedule 2, are eligible once every 60 months.

Amount of Benefit

6(3) Subject to the other provisions of Rule 6, where a Member incurs covered expenses in respect of a person covered by the Plan, the Member is entitled to a benefit for all such covered expenses incurred in respect of such covered person in any calendar year equal to the co-insurance percentage of those covered expenses which exceeds the calendar year deductible, up to but not exceeding the maximum reimbursement amounts for the applicable covered expenses.

Table of Benefits

6(4) For the purpose of calculating the Member's benefit under Rule 6(3), the Co-insurance Percentages, deductibles and maximum reimbursement amounts shall be as follows:

Co-insurance Percentages:
1. 50% for the following services:
  1. major restorative services (listed under provision 3(ii) of Schedule 2)
  2. major prosthodontic services (listed under provision 6(ii) of Schedule 2), and
  3. orthodontic services (listed under provisions 8(ii) and (iii) of Schedule 2);
2. 90% for all other services listed in Schedule 2.
Calendar Year Deductibles:
1. individual deductible: $25;
2. combined deductible: $50.
the maximum reimbursement amounts listed in Schedule 5.

Treatment Plan Provision

6(5)

The Member should submit a treatment plan to the Administrator for benefit determination when the estimated cost of a course of treatment is $300 or more.
Such treatment plan is not valid if treatment does not commence within one hundred and eighty (180) days of the date on which the Member submitted it.
When the Administrator receives a treatment plan, the Administrator shall advise the Member of the estimated amount payable on the basis only of the treatment plan estimate at the time of benefit determination.

Date an Expense is Incurred

6(6)

Generally, a covered expense is deemed to be incurred on the date the particular service is rendered or the supply purchased. Where multiple appointments are required for a single service, the covered expenses shall be deemed to be incurred on the date such service is complete.
Where applicable, a procedure involving the installation of an appliance shall be deemed to be completed on the date the appliance is installed. However, in the case of orthodontic services, covered expenses shall be deemed to be incurred monthly, starting with the first date the appliance is installed, and at the same date of each subsequent month falling during the treatment period.
Where the cost estimates given in the orthodontic treatment plan do not provide for specific fees with respect to the initial consultation, the amount of covered expenses incurred for each month shall be equal to the total amount of covered charges for the treatment divided by the number of months in the treatment period.
Where the cost estimates given in the orthodontic treatment plan contain fees with respect to the initial consultation, the amount of covered charges incurred for each month shall be equal to
1. with respect to the first month of treatment, the lesser of 25% of the total amount of covered charges for the treatment and the fees shown for the initial consultation;
2. with respect to subsequent months, the difference between the total amount of covered charges for the treatment and the covered charges for the first month, divided by the number of subsequent months in the treatment period.

Method of Payment

6(7)

Reimbursement under this Plan shall be made in a single payment for each claim. However, in the case of orthodontic services, payments shall be made monthly, the amount of each reimbursement being equal to the benefit payable with respect to covered expenses incurred during such month, as determined under Rule 6(6).
All benefits under this Plan, are payable to
1. the Member;
2. the Member's Spouse, Common Law Partner, or person with care and custody of a covered family member if so directed by the Member for this purpose on the Prescribed Form; or
3. the Member's eligible dental service provider, if so directed by the Member.

Extension of Benefits

6(8) Notwithstanding any other provision of the Plan,

where coverage for a person is terminated, coverage for the following services shall be extended for a period of thirty-one (31) days after the termination date, provided the services commenced as defined below, before such date
1. endodontic services, where the pulp chamber is opened before the termination date: services listed under provision 4 of Schedule 2 for "root canal therapy";
2. prosthodontic services involving an appliance for which an impression was taken before the termination date;
3. services listed under provision 6 of Schedule 2 for "relining or rebasing", "addition of tooth to a removable denture", "complete dentures" and "partial dentures";
4. major restorative and prosthodontic services for which a tooth was prepared before the termination date;
  
  major restorative services listed under provision 3 of Schedule 2 for "gold inlays", "crowns" and "other restorative services";
  
  prosthodontic services listed under provision 6 of Schedule 2 for "pontics", "retainers", "abutments", "retentive pins in abutments" and "repairs of fixed appliances".
5. orthodontic services for which a Member was entitled to a benefit prior to the date of termination of coverage.

Conditions for Benefit Payment

6(9)

A Member entitled to a benefit under the Plan, or a person designated for this purpose by the Member on the Prescribed Form, must submit to the Administrator, within fifteen (15) months of the date the expense is incurred or deemed to be incurred under the Plan, notice and proof of claim satisfactory to the Administrator.
If the Member or designated person fails to provide the notice and proof within the time required, the claim shall not be invalid if it was not reasonably possible for the Member to provide proof within such time, so long as the Member provides such proof as soon as reasonably possible and in no event, except in the case of incapacity, later than twenty-four (24) months after the expense was incurred.

Co-ordination of Benefits

6(10)

All covered expenses shall be subject to co-ordination of benefits as defined in this Rule 6(10).
Rule 6(10) shall apply in determining the benefits in respect of a person covered under this Plan for any calendar year if, for the Allowable Expenses incurred in respect of such person during such year, the sum of the benefits that would be payable under this Plan [in the absence of Rule 6(10)] and the benefits that would be payable under all plans [in the absence in those plans of provisions of similar purpose to Rule 6(10)], exceeds such Allowable Expenses.
For any calendar year to which Rule 6(10) applies, the benefits that would be payable under this Plan [in the absence of Rule 6(10)] for the Allowable Expenses incurred in respect of such person during that calendar year shall be reduced to the extent that the sum of the reduced benefits and all the benefits payable for such allowable expenses under all plans including this Plan, except as provided under Rule 6(10)(d), shall not exceed the total of such Allowable Expenses. Benefits payable under another plan include the benefits that would have been payable had a claim been made for them.
If
1. another plan which is involved in Rule 6(10)(c) contains a provision co-ordinating its benefits with those of this Plan and would, according to its rules, determine its benefits after the benefits of this Plan have been determined, and
2. Rule 6(10)(e) would require this Plan to determine its benefits before such other plan,
  
  the benefits of such other plan shall be ignored for the purpose of determining the benefits under this Plan.
For the purpose of Rule 6(10)(d),
1. benefits shall be determined first under the plan which covers the person for whom expenses have been incurred other than as a Spouse or a Common Law Partner or Child or as a Child of the person whose date of birth, excluding year of birth, is earlier in the calendar year;
2. subject to Rule 6(10)(e)(iii), where Rule 6(10)(e)(i) does not establish an order of benefit determination, or another plan contains different rules, benefits will be pro-rated between or amongst the plans in proportion to the amounts that would have been paid under each plan in the absence of other coverage; and
3. notwithstanding Rule 6(10)(e)(ii), where the other plan is the Public Service Health Care Plan, benefits shall be determined first under the Public Service Health Care Plan for allowable expenses on account of accidental dental injury and first under this Plan for allowable expenses with respect to oral surgery.
When this provision operates to reduce the total amount of benefits otherwise payable in respect of a person covered under this Plan during any calendar year, each benefit that would be payable in the absence of Rule 6(10)(e)(iii) shall be reduced proportionately, and such reduced amount shall be charged against any applicable maximum reimbursement amount of this Plan.
Any person claiming benefits under this Plan shall provide the Administrator with such information, or with a release to obtain information from any insurance company or other organization, as may be necessary to implement the terms of Rule 6(10) or of any provision of similar purpose in any other plan.

Covered Expenses Limitations

6(11) Covered expenses do not include

expenses incurred for the services, treatments and supplies listed in Schedule 3; and
expenses incurred for services, treatments, and supplies that are reimbursed pursuant to the Extension of Benefits provision of the Public Service Dental Care Plan.

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