Are you in or out?
It has been a “rocky road” between the federal government and the dental profession since 2022. With the media announcements, lack of collaboration and consultancy with dentists, and the unknowns and mystery of what the NDP free dental insurance program really meant??? The 2022 public announcement and the 2023 application process to seniors caused confusion with dental associations across the country and chaos for dental offices not knowing how to answer patient inquiries about the Canadian Dental Care Plan for non-insured Canadians.
Finally, putting all politics aside and patient access to care at the forefront with the profession expected to deliver on the promises, the CDCP has now been defined with details of what, who, when and HOW to move forward with the voluntary choice of OPT IN or OPT OUT. March 11th, 2024, all denturists, dentists, hygienists, or specialists via Sun Life insurance will now decide if CDCP is a program they will participate in.
As with any decision of this magnitude, the pros and cons must be individually evaluated based on the personal alignment of professional vision and goals, whether it is a good fit with available capacity, and how it will serve a balance of patient care with revenue versus the cost to maintain a profitable business.
The OPT IN will require knowledge, preparation and understanding of the rules of engagement, team training, patient communication and modifications to operational systems, scheduling, collections of co-payment and accounts receivable.
The OPT OUT choice may seem easier if a professional believes they have all they need or want and are successful. However, not participating could have an impact on current active patient relationships, and attrition of non-insured patients leaving to find an oral health professional who is participating may happen.
Let’s begin this part of our series with a summary to make a choice by defining what, who and how the Canadian Dental Care Plan (CDCP) is. Parts 2 and 3 will drill down into how to communicate, adapt operations and billing, and innovate and automate for CDCP success.
CDCP is a federal government-funded dental benefit program for Canadian residents with no dental insurance in low- to middle-income households less than 90,000 annually. It is intended to ease the financial hardship of access to oral health services for those who have applied via CRA and or Service Canada.
The program eligibility is based on age, income, and disability on a rollout over 2024 and 2025. It has defined covered services and set fees and is in collaboration with claims and preauthorization with Sun Life, who will direct deposit reimbursement of covered amounts to the dental professional.
The patient who qualifies will receive an acceptance letter from Service Canada and an eligibility card from Sun Life insurance. The term of eligibility is one year, at which time they must reapply. The staged age group application timelines are as follows:
- December 2023: over 87 years of age
- Jan 2024: 77-86 years of age
- Feb 2024: 72-76 years of age
- March 2024: 70-71 years of age
- May 2024: over 65 years of age
In June of 2024, those who are registered with disability credit and children under 18 years can apply, with other age groups being added in 2025 along with orthodontic services.
In December 2023, the applications were launched to seniors with treatment commence dates as early as May 2024. It is estimated over 400,000 seniors have been accepted and will be inquiring to schedule dates for oral health services with a participating provider.
The services and codes covered are available on the Health Canada website resource, the Dental Benefit Grid. It includes a Schedule A of services, which can be billed now electronically beginning May 2024, and a Schedule B of procedures that require a preauthorization available November 2024.
The categories of services covered for reimbursement include diagnostic services of examinations and x-rays, preventive hygiene services for prevention, scaling, polishing, sealants and fluoride, restorative services of fillings, endodontic services, removable prosthodontic services (complete and partial removable dentures), periodontal services, including root planning and oral surgery procedures. Note: Orthodontics for children will be added in 2025.
The CDCP has a set fee guide for each province and can be found on the Health Canada website. The decision to participate in the CDAP means the dentist agrees to bill the fee guide of the program and collect co-payment from the patient based on their eligible percentage up to the amount assigned by the program.
The fees are lower than the current fee guide by approximately 10-15% depending on the province; however, more than most social services programs or NHIB amounts. The 3 reimbursement levels based on household income are less than $70,000 = 100% coverage, $71,000-$80,000 = 60% coverage, and $81,000-$90,000 = 40% coverage.
The OPT IN participation is with Sun Life, and professionals must sign a CDCP claims processing and payment agreement. By signing this agreement, the professional will be required to be responsible for validating the patient’s identity and verifying the eligibility category of coverage via the new or existing patient intake process before providing care.
The professional agrees to inform the patient of all eligible services and the fees covered and not covered by the CDCP before they provide care.
The provider agrees to receive payment from Sun Life directly per established fees and, when requested, to provide Sun Life information on submitted claims for verification of taxpayer’s dollars and keep all records for a minimum of two years.
The collection of the co-payment is left up to the professional on the difference of the total amount of the fees CDCP. The patient must give consent to the fee prior to treatment, and I recommend the co-pay is collected on the same day at the time of service of collections via a credit card, cash or debit to minimize statements and increase accounts receivable.
The termination of participation can be provided by either party at any time if it is not working out. If handled appropriately, I can see how the decision to opt in can be a positive practice-building decision. Starting with the shared strategy with the team. patient communication, re-alignment of scheduling and systems and automation of collections for the co-payments at the time of service. The decision to participate can not just be added one day and be successful by accident. It requires focus and a plan.
About the Author:
Lisa Philp, RDH, CMC, is the president of Transitions Group. She has worked as a leader for 30 years in practice growth, management, efficiency and enhanced patient care and profit.
