In 2023, Ottawa introduced the Canadian Dental Care Plan. This investment is a critical first step to ensuring dental coverage becomes a reality for an estimated nine million Canadians. As of now, the initiative mainly focuses on people and families who do not have dental insurance, with net yearly income of less than $90,000. The plan, to be implemented over several years, begins with universal coverage for all ages on June 1, 2024. That said, it has already encountered notable challenges. That’s right—report after report reveal that almost 50% of requests for coverage for complex dental treatment are denied.
This presents a denial rate, as reported by Health Canada, of a whopping 49%. This problematic high rejection figure has provoked concern from dental associations around the country. According to industry stakeholders, the challenges faced by dentists and patients in navigating the Canadian Dental Care Plan could hinder its intended benefits.
Overview of the Canadian Dental Care Plan
The Canadian Dental Care Plan was announced as part of a broader effort by the federal government to improve access to dental services for underserved populations. The program provides coverage for low-income Canadians, who are without dental insurance and have a family income of less than $90,000. The phased rollout, which began in May 2024, is expected to lead to full coverage eventually.
The plan is designed to ease the financial burden of dental care on families and individuals who previously struggled to afford necessary treatments. For reading, the response has been more lukewarm than we anticipated. Substantial barriers have bubbled up in the early phases of action that lie beneath the surface of implementation.
High Denial Rates Raise Concerns
Most recently, Health Canada’s report showing a 49% denial rate for complex dental care claims has sent the dental care community into a panic. Dr. Anita Gartner, president of the British Columbia Dental Association, called this consideration unfortunate. She noted that “patients are not receiving the care that they need,” emphasizing that high rejection rates could delay critical treatments.
The logic used to justify these denials is equally puzzling. As a result, almost 70% of the claims submitted for complex dental care coverage are said to be denied for being ineligible or for lacking necessary documentation. The overall denial rate returned to dentists has hit a whopping 68%, adding insult to injury for dentists and their affected patients alike.
According to Dr. Gartner, “Only [an average of] 30 per cent of dentists report that their … pre-authorization treatment requests to Sun Life are actually being approved.” This stat serves to highlight the challenges dental providers face in obtaining the prior authorizations their patients need.
Challenges in Navigating the System
There is still a learning curve for dental providers under the new fee-for-service model implemented by the Canadian Dental Care Plan. Vanamburg, a practicing dentist, noted that poorly filled-out submissions have been part of the explanation for the denial rates being so high. “There are a lot of providers who were still learning the system,” he said, highlighting that many claims were not submitted correctly during this transitional phase.
Additionally, Vanamburg explained that only one percent of requests even need pre-authorization. He elaborated that if there’s an unforeseen shift in the health of a patient’s teeth, they have the option to re-file their claims. So it’s never really a strict, hard no, ” he said.
We’ve seen a recent surge of patients with this plan seeking dental care. So, understandably, all of the current denial rates will lead to increasing frustration and confusion. Dentists have been raising the alarm about how these matters will hurt patient care in the future.
