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Dental Care Plan (DCP) - Public Service of Canada
Introduction
The Public Service Dental Care Plan (DCP) introduced in 1987 is available to public servants and employees of a number of separate employers. The cost of the DCP is fully paid by the employer.
This booklet describes the benefits provided to you as a member of the DCP. It contains general information about membership, benefits, levels of reimbursement and limitations on benefits. It also explains how to submit a claim. For more specific information, contact your compensation specialist.
The complete terms and conditions of the plan are set out in the Dental Care Plan Rules. Since this booklet has been written for information only, the Rules will prevail if there is any conflict between the two.
Membership
Who is covered by the plan
The Dental Care Plan (DCP) covers all eligible employees and their eligible spouse or common-law partner and children.
Eligible employees
The plan covers full-time indeterminate employees, seasonal employees, employees appointed for a term of six (6) months or more, employees who have completed six (6) months of continuous employment, and part-time employees whose assigned work week is more that 1/3 of the normally scheduled hours for a full-time employee in the same occupational group.
Please contact your compensation specialist if you have questions regarding your eligibility.
Eligible spouse
For the purposes of this plan, "spouse" means a person legally married to you.
Eligible common-law partner
For the purpose of this plan, "common-law partner" means a person who has lived with you in a conjugal relationship for a continuous period of at least one (1) year.
Eligible children
For the purposes of this plan, "child" means your or your spouse or common-law partner's unmarried child or children (including an adopted child, a step-child or a foster-child)
- under twenty-one (21) years of age;
- between twenty-one (21) and twenty-five (25) years of age and in full-time attendance at a recognized educational institution; or
- twenty-one (21) years of age and over with a mental or physical impairment who is incapable of engaging in self-sustaining employment and who is primarily dependent upon you for support.
Note: This description must apply to your child on the date you become subject to the plan; otherwise the child has to have been covered under the plan immediately before his or her 21st birthday. If the child becomes impaired after reaching the age of 21, he or she must have been covered as a student at the time the impairment began.
A child who does not meet the above definition of eligible child but is a child for whom the member stands in loco parentis, may be considered for coverage upon approval of the Board of Management, which shall decide eligibility in such instances. Supporting documentation must be submitted to the appropriate Board of Management as outlined under Claims Disputes.
When coverage starts
When you become eligible, membership in the plan begins following a waiting period of exactly three (3) months of continuous employment. Coverage is extended to the employee's spouse or common-law partner and children on the same date.
New dependants enjoy dental coverage from the date they become eligible dependants.
If you are on leave of absence without pay or on seasonal lay-off on the day you would normally have become a member of the plan, your coverage will begin the first day of the month after the month you resume duty with pay and coverage for your eligible dependants will also begin on that date.
Seasonal employees
Once in the plan, seasonal employees have continuous year-round coverage, including the time of seasonal lay-off.
Leave without pay
If you go on authorized leave without pay for any of the following reasons, employer-paid coverage will be extended to you for the total period of absence.
- maternity
- parental leave (within the 52-week period following the birth or adoption of a child)
- illness or disability
- education to the advantage of the employer
- serving with another organization recognized as being to the advantage of the department or to the government
- to serve with the Canadian Forces
- to participate in a leave with income averaging or pre-retirement leave arrangement
If you proceed on any other type of leave without pay, employer-paid coverage will continue during the first three consecutive calendar months of leave. Thereafter, you can maintain your coverage by paying the full premium cost quarterly in advance, starting with the fourth (4th) month of leave of absence. A table of monthly contributions is included in this booklet as Appendix A. Contact your compensation specialist for further details.
If you fail to remit the required contributions within the applicable time, your membership will be suspended until the first of the month following the month you resume duty with pay.
Termination of coverage
Your membership in the plan ends automatically on the date you cease to be employed or on the date you cease to qualify as an eligible employee. For example, if you become a part-time employee working one-third (1/3) or less of the normally scheduled hours for a full-time employee in the same occupational group, your coverage stops.
Your spouse or common-law partner is no longer covered by the plan when he or she ceases to be your spouse or common-law partner, or when you are no longer a member of the plan.
Your child is no longer covered by the plan when he or she ceases to be an eligible child (for example a child reaches 21 years of age, or age 25 if in full-time attendance at a recognized educational institution) or when you are no longer a member of the plan.
Note:
If you are laid off, dental coverage may be continued for a period of up to one year provided you pay the full premium cost. Please contact your compensation specialist if you need further details regarding your eligibility under such circumstances.
Exceptions- If a given dental treatment requiring more than one sitting began while the employee and/or dependants were in the plan, coverage for that treatment will continue only if it is completed within 31 calendar days of the termination date. Examples include root canal treatment where the pulp chamber is opened prior to termination, a crown where the tooth is prepared and impressions are taken prior to termination of coverage, or ongoing active orthodontic treatment where the initial appliance was inserted prior to termination.
Identity card
Once you become subject to the plan, you will receive from your compensation specialist an identity card issued by the Administrator This card will indicate the effective date of your coverage and the certificate number that has been assigned to you, to identify you to the Administrator when you file your claims. You must record your certificate number on all claims submitted for yourself and your eligible dependants, and on all correspondence with the Administrator.
Should you lose your identity card, please contact your compensation specialist to obtain a replacement card.
Benefits
The Dental Care Plan provides coverage for specific services and supplies that are not covered under a provincial health or dental care plan. Further, the DCP covers only reasonable and customary dental treatment, necessary to prevent or correct dental disease or defect, provided the treatment is consistent with generally accepted dental practices.
Eligible services
Below is a summary of the major features of the plan's eligible services, by category.
Members should refer to the detailed description of eligible services in Appendix B for the specific limits on how often certain services will be reimbursed under the Plan. In addition, members are advised to take note of exclusions and limitations set out in Appendix C.
Benefits Reimbursed at 90%
Diagnostic
(excluding services related to major prosthodontic)
examinations, x-rays, laboratory examinations (including those related to orthodontic treatment)
Preventive
dental cleaning and polishing, topical application of fluoride, space maintainers
Minor Restorative
amalgam, silicate, acrylic or composite fillings
Endodontics
root canal therapy
Periodontics
treatment of gums
Minor Prosthodontic Services (removable dentures):
repairs and adjustments, relining and rebasing
Surgery
extractions of teeth, other surgical procedures
Adjunctive Services
emergency services not otherwise specified, anaesthesia
Benefits Reimbursed at 50%
Major Restorative
gold and porcelain restorations (inlays), crowns
Major Prosthodontic Services
diagnostic services, complete dentures, partial dentures, fixed bridges (abutments retainers, pontics), repairs of fixed bridges.
Orthodontic
surgical services, observation and adjustments, fixed appliances, removable appliances
Maximum reimbursement for dental services
Except for orthodontic services, there is a reimbursement limit of $1,250 per calendar year per covered person for all eligible dental services. If you, your eligible spouse or common-law partner and/or children join the DCP on or after July 1 of any given year, the maximum reimbursement amount per person, excluding orthodontic services, is $625 for that year.
From January 1, 2004 to December 31,2005, the reimbursement limit will be $1,500 per calendar year per covered person, and $750 if you or your eligible dependants join the DCP on or after July 1 of any given year.
Orthodontic services are subject to a separate lifetime limit of $2,500 for each covered person for all eligible orthodontic services.
Limitations on reimbursement
Deductible Amount
For each calendar year, there is a minimum deductible amount on all dental expenses. Only the eligible expenses you incur during the year that exceed that deductible amount are eligible for reimbursement under the plan.
The annual deductible amount is $25 per covered person. However, where eligible expenses are incurred for more than one person in a family in a calendar year, the deductible amount will be limited to $50.
Carry-over deductible:
If the first dental expenses in a calendar year are incurred in the last quarter of the year (October-December) and
the applicable deductible is satisfied, a new deductible will not be applied in the following year.
Co-insurance
The plan will reimburse you for a percentage of the cost of the covered expenses you have incurred. This percentage is applied to the amount of expenses that is in excess of the annual deductible amount. For example, the plan will reimburse you 50 per cent of the costs for major restorative, major prosthodontic and orthodontic services and 90 per cent for all other eligible services. You must pay the remainder.
The appropriate percentage applied to the amount of expenses is based on the relevant provincial or territorial dental fee guide as approved from time to time.
Covered charges
Canadian Residents
When you incur expenses for a particular eligible service or item, the plan recognizes only those amounts up to the tariff shown for the applicable service or item in the dental fee guide in effect in the province or territory in which the service is rendered. Dental expenses incurred on or after January 1, 2000 will be reimbursed based on the provincial or territorial dental fee schedule, and Specialist fee schedule where available, in effect the previous year. For dental treatment rendered in the province of Alberta on or after January 1, 2000, reimbursement of dental expenses will be based on a table of fees which is the 1997 Alberta fee schedule increased by an inflationary factor. You will have to bear any portion of an expense in excess of these general levels.
If you incur charges outside Canada on your behalf or on behalf of a covered spouse or common-law partner or child, the amounts recognized will be those that would have applied if the charges had been incurred in your province/territory of residence.
In the case of any of your children, this means that no reimbursement will be made under the plan for those services that would have been covered by a provincial/territorial dental plan if the services had been rendered in your province/territory of residence.
Residents Outside Canada
When you incur expenses for a particular service or item, the plan will reimburse benefits based on the actual incurred expenses provided those amounts are considered "reasonable and customary" in that region. Any portion of an expense in excess of that "reasonable and customary" amount will not be covered under the plan. The amount that would have been incurred in Ontario for the dental procedures involved will be used in determining the annual and lifetime limits on the reimbursement of expenses, so that employees who receive treatment abroad will be in the same relative position as if they had received treatment in Ontario.
Treatment Plans
When the estimated cost of treatment suggested by your dentist exceeds $300, you are strongly urged to submit a treatment plan to the Administrator before going ahead with these services. Upon receipt of a treatment plan, the Administrator will indicate to you the benefits payable under the plan for the services that are proposed. Consequently, it is in your own best interests to determine what will be paid before the work begins.
Furthermore, members are reminded to read all notes and remarks included on the Predetermination of Benefits Statement issued by the Administrator, as these are an integral part of the Treatment Plan assessment.
Claims procedure
If you have incurred expenses that are eligible for reimbursement, you should complete an authorized claim form with the appropriate information, showing your full name and address, including your postal code, your plan number and certificate number, your spouse or common-law partner's plan number and certificate number, when applicable, and sign the claim form. The dentist must also complete his or her section on the claim form. Claims that are found to be incomplete will be returned to you for completion. Attach your bills or receipts, making sure they give full details for services rendered or purchases made.
Your claims should be sent to the appropriate group benefit payment office as outlined in Appendix D.
Claims must be submitted to the Administrator within fifteen (15) months of the date on which the expense was incurred. For orthodontic treatment, a claim must be submitted within fifteen (15) months of the date of each monthly visit throughout the treatment period. Claims submitted after that fifteen (15) month period will not be paid unless the member can demonstrate that it was impossible to submit the claim within that time. Further, except in the case of legal incapacity, no claim will be paid if it is submitted more than twenty-four (24) months after the expense was incurred.
For claims submitted electronically, members should note that it is their responsibility to authorize their dentist to submit claims and to ensure that personal information included with the submission, such as plan and certificate number and address, is current.
Duplicate protection
a) Coverage under a provincial plan
If you live in a province that insures dental service, you should first submit your claim to the provincial authorities. When that claim has been processed, you may submit a claim to your dental plan for any remaining eligible expenses.
b) Coverage under employer sponsored dental plans
When you and your spouse or common-law partner are covered under two different plans, or as members each in your own right under the DCP (including the Canadian Forces/RCMP Dependants Dental Plan), you can benefit from the co-ordination of benefits for dental expenses incurred by yourself, your spouse or common-law partner and your eligible children. In all cases, the combined reimbursement from all plans cannot exceed the expenses incurred. Please note also that plan exclusions and individual maximum annual reimbursement limits apply separately under each plan.
Submitting your claims:
If you are a member of the DCP and are also covered under your spouse or common-law partner's plan as an eligible dependant, you should submit your claim to your own plan first.
If your spouse or common-law partner is covered under another plan and is also covered as an eligible dependant under your DCP membership, claims for your spouse or common-law partners expenses should be submitted to his or her own plan first.
When your children are covered under both your plan and your spouse or common-law partner's plan as eligible dependants, the plan that pays first will be determined by a general agreement that insurance companies have devised. Under this arrangement, the spouse or common-law partner whose birthday falls earlier in the year must claim the children's expenses first under his or her plan.
Note:
If you and your spouse or common-law partner are both members of the DCP, you may each claim dental expenses for
yourself and your eligible spouse or common-law partner and children. You may submit one claim form indicating both
Public Service Dental Care Plan policy and certificate numbers. The Administrator of the plan will then process the
eligible claims under both memberships. Payment made under the spouse or common-law spouse's membership will be payable
to him or her, unless he or she authorizes the Administrator to issue the payment directly to you by completing the
"Authorization to Redirect Payment."
c) Coverage under the Public Service Health Care Plan
If you are a member of this plan and of the Public Service Health Care Plan, you benefit from combined protection for certain types of complex surgical dental services and for dental services required as a result of injury to natural teeth.
If such services are rendered to you or your covered dependants:
Because of Injury
You first submit a claim to the Public Service Health Care Plan. If you do not obtain full reimbursement for your dental expenses, you may then submit a duplicate of your claim form, along with a copy of the Public Service Health Care Plan explanation of benefits, to the DCP.
For Surgical Procedures
First submit your claim to the DCP and, where applicable, you may submit a claim for any unpaid expenses to the Public Service Health Care Plan.
You can obtain additional information on this matter by contacting your compensation specialist.
Claims payment
When your claim has been approved, an Explanation of Benefits will be forwarded to you by the Administrator, with your benefit. Payment will be issued to you or, on signed instructions from you, may be issued to your spouse or common-law partner (Authorization to Redirect Payment form) or to the dentist (claim form). Payments are normally made in a lump sum. However, for orthodontic services, the Administrator will normally reimburse you on a monthly basis, provided receipts are forwarded to the Administrator. The calculations for these payments will be based on the information submitted by the orthodontist on the treatment plan.
Claims dispute
Occasionally, a dispute may occur about a declined claim. Generally, such disagreements should be handled through the Administrator. When all other remedies have been exhausted, the matter should be referred to the appropriate Board of Management at the address indicated below. The member, compensation specialist or bargaining agent referring the matter should ensure that all the particulars of the case are provided.
For members represented by PSAC, details of the case should be addressed to:
Board of Management
Dental Care Plan (PSAC)
300 Laurier West, 5th Floor
Ottawa, Ontario
K1A 0R5
For all other members, details of the case should be addressed to:
Board of Management
Dental Care Plan (NJC)
P.O. Box 1525, Station B
240 Sparks Street West
7th Floor
Ottawa, Ontario
K1P 5V2
Appendix A - Table of monthly contributions
Effective April 1, 2000:
|
Employee only |
$23.00 |
|
Employee and spouse or Employee with children |
$46.00 |
|
Employee, spouse and children |
$69.00 |
Prior to April 1, 2000
|
Employee only |
$17.00 |
|
Employee and spouse or common-law partner or |
$34.00 |
|
Employee, spouse or common-law partner and Children |
$51.00 |
Appendix B - Eligible Dental Services
Eligible dental services mean services listed hereafter, when rendered by a dentist or dental specialist, or rendered by a dental hygienist under the direct supervision of a dentist or dental specialist, or rendered by a dental mechanic (also referred to as a denturist or denturologist) who is licensed to provide services in the province or territory in which the service was received, and who is permitted by law to deal directly with the public. This section should be read in conjunction with Appendix C, which lists exclusions and limitations on dental services and supplies.
Where it cannot be ascertained that the dental services rendered are covered services, the Administrator will identify which of the covered services listed below can be considered to be alternative services, and will base reimbursement on those services.
|
Examination and Diagnosis |
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Tests, Laboratory Examinations |
|
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Radiographs |
|
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Routine Services |
|
|
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Minor |
|
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|
| Note: Expenses for fillings for the same tooth and surface are covered no more than once every 24 months. | |
|
Major |
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Note: Up to 6 additional units of scaling/root planing can be allowed in cases of documented periodontitis with the pre-approval of a treatment plan.
|
| Notes: One (1) time unit means 15 minutes. Prior to January 1, 2000, scaling/root planing was limited to 6 time units per 12 running months |
|
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Minor Services for Removable Dentures |
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Major |
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Diagnostic |
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Observation and Adjustment |
|
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Appliances |
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ADJUNCTIVE GENERAL SERVICES |
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Appendix C - Exclusions and limitations
General
No benefit is payable under the DCP for the following dental services and supplies:
- services and supplies, or any portion thereof, that are covered under any provincial, territorial or other public dental, hospital or health plan under which the person is eligible;
- services and supplies, or any portion thereof, that are the legal liability of any other party;
- services and supplies rendered or provided to which a person is entitled without charge pursuant to any law, including, but not limited to, Workers' Compensation or similar law, or for which there is no cost to the person except for the existence of insurance against such cost;
- services and supplies received in a hospital owned or operated by a government, unless the person is required to pay for such services or supplies regardless of the existence of insurance;
- services and supplies rendered outside Canada to persons residing in Canada, or to children of a member residing in Canada, that would be payable under a provincial health, dental or hospital plan if the services had been rendered in Canada;
- dental treatment involving the use of precious and non-precious metals, if such treatment could have been rendered at lower cost by means of a reasonable substitute consistent with generally accepted dental practice, except for that portion of expenses that would have been incurred for treatment by means of a reasonable substitute;
- user fees, co-insurance charges or similar charges that are in excess of charges payable by a government dental, hospital or health plan;
- dental treatment that is not yet approved by the Canadian Dental Association or that, in the opinion of the Administrator, is clearly experimental in nature;
- services and supplies that, in the opinion of the Administrator, are rendered principally for cosmetic purposes including, but not limited to, porcelain or composite facings on crowns or pontics on molar teeth;
- services and supplies related to the purchase, repair, modification or replacement of a duplicate prosthodontic appliance, for any reasons;
- services rendered and supplies purchased before the date the persons became covered under this plan;
- charges for an appliance or a modification of one where an impression is made for such appliance or modification before the person became covered under this plan; charges for crowns, bridges and gold restorations for which a tooth was prepared before the person became covered under this Plan; charges for root canal therapy where the pulp chamber was opened before the person became covered under this plan;
- services and supplies rendered as a result of a congenital or developmental malformation that is not a Class I, II or III malocclusion, except for a child under 19 years of age;
- charges for a periodontal appliance, occlusal equilibration, and other related service as a result of a temporo-mandibular joint dysfunction (TMJ dysfunction) or vertical dimension correction;
- implants.
Specific limitations with respect to major services
1. Services for the installation of prosthodontic appliances (for example, fixed bridges, pontics and abutments, temporary or permanent, partial or complete dentures) constitute eligible dental services only if they are rendered for:
- an initial prosthodontic appliance, or
- the replacement of an existing prosthodontic appliance, including the addition of teeth to an existing appliance, if
(i) 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, only the expense for that portion of the replacement appliance that replaces the teeth extracted shall be covered;
(ii) the existing appliance is at least five (5) years old and cannot be made serviceable (irrespective of who paid for the existing appliance);
(iii) the existing appliance was temporarily installed, provided that the replacement appliance is installed within twelve (12) months of insertion of the temporary appliance and that such replacement appliance will thereafter be deemed permanent for the purposes of this provision;
Effective January 1, 2004: When a temporary prosthodontic appliance is installed as part of major restorative services, plan coverage for permanent prosthodontic appliances will be provided without regard to when the temporary appliances was first installed provided that the person was covered under the plan when the temporary appliance was installed. This removes the 12-month limitation on the replacement of temporary prosthodontic appliances.
(iv) 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 (v) 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.
Effective January 1, 2004:
2. The necessary replacement of fillings (same tooth and surface) will be paid under this plan once every 24 months irrespective of the age of the filling. The necessary replacement of crowns will be paid under this plan once every 60 months irrespective of the age of the crown. This assures coverage for fillings and crowns on initial treatment under the Plan.
Appendix D - Claims Offices
All claims should be sent to the DCP Administrator, the Great-West Life Assurance Company, to one of the following mailing addresses, as appropriate.
For Quebec residents, other than the National Capital Region:
Montreal Benefit Payment Office
Suite 5800
800 de la Gauchetiere Street West
Place Bonaventure
Montreal, Quebec
H5A 1B9
Toll free number: 1-800-663-2817 (service in English and French)
For all other Canadian residents:
Health and Dental Claims Centre
P.O. Box 6025, Station Main
Winnipeg, Manitoba
R3C 3C7
Toll free numbers: 1-800-957-9777 (service in English)
1-800-663-2817 (service in French)
For employees residing outside Canada
Foreign Benefits Payments
P.O. Box 6000
Winnipeg, Manitoba
R3C 3A5
Toll free numbers: 1-800-957-9777 (service in English)
1-800-663-2817 (service in French)
