NEW CDCP

Great news! The CDCP is here, and we accept patients who wish to use this insurance plan :)

The Canadian Dental Care Plan (CDCP) will help ease financial barriers to accessing oral health care for eligible Canadian residents. This plan will be carried out in phases depending on the age of patients. The first patients to be eligible to apply for this plan before April 30, 2024, are those who:

Are over 65 years of age
Who have an adjusted family net income of less than $90,000 and have filed their taxes in the previous year
Do not have access to dental insurance
Are a Canadian resident for tax purposes

The CDCP will reimburse a percentage of the cost, based on established CDCP fees and your adjusted family net income. You may have to pay additional charges directly to the oral health provider, if:

your adjusted family net income is between $70,000 and $89,999
the cost of your oral health care services is more than the established CDCP fees, or
you and your oral health care provider agree to services that the CDCP doesn’t cover
- you’ll need to pay the full cost of these services if you receive them

There has been a lot of confusion about the “percentage covered” by the CDCP, and a potential balance owed to the provider. This sentence, directly from the CDCP site, “the cost of your oral health care services is more than the established CDCP fees”, refers precisely to this issue.

The CDCP has a limited budget, which is why they are not able to cover the entirety of the prices set by providers.
The CDCP has identified specific costs they are willing to cover.
- For each of these costs, they inform the member of the corresponding coverage percentage.
- If a member’s coverage of the CDCP-approved costs is 100%, this indicates that the insurance will fully cover the amount covered by the CDCP.
- Members with a household income exceeding $70,000 may be eligible for coverage at reduced rates, such as 60% or 40%.
This does not mean that the costs the CDCP is willing to cover are the same as the prices set by providers. Each clinic charges fees they deem fit for their practice and according to guidelines set by their association. This is why whether you go to a dentist or a denturist, you may need to pay a balance for certain treatments/services.
- Example 1:
  - Let’s say the cost of a certain denture is 1000$.
  - The cost the CDCP is willing to cover for such a denture is 800$.
  - The patient’s coverage is 100% of the CDCP accepted fees.
  - The patient must pay 200$ to the provider.
  - The remaining 800$ will be claimed through the insurance company.
- Example 2:
  - Let’s say the cost of a certain denture is 1000$.
  - The cost the CDCP is willing to cover for such a denture is 800$.
  - The patient’s coverage is 60% of the CDCP accepted fees.
  - The patient must pay the remaining 40% of 800$ which is 320$.
  - The patient must also pay the remaining 200$ balance from the total 1000$ to the provider.
  - The total that must be paid by the patient is, therefore, 520$.
  - The remaining 480$ will be claimed through the insurance company.

Another area of confusion for CDCP members pertains to the pre-authorization process required for certain treatments and services.

In the case of dentists, for instance, crowns require pre-authorizations, and so far, it seems many patients have been refused by the CDCP.
In the case of denturists, the most common service that requires a pre-authorization is the fabrication of partial dentures.
- The patient must come for a first appointment for the pre-evaluation:
  - The denturist will perform an oral exam.
    - Please note that there are several criteria the patient must meet to be eligible for a new partial denture. One of the main criteria is the number of missing teeth. There are guidelines the provider must follow. For example, missing only 1 posterior tooth does not fall under this plan. And even if more than 2 posterior teeth are missing, it is important which ones exactly.
  - The first impressions will be taken. They will be used to create stone models.
  - The patient must fill out a file and answer questions regarding their dental history.
    - Main information the insurance needs to process the request for the CDCP coverage:
      - Details about extractions (dates, teeth numbers…) – We and the insurance company understand that patients do not always remember the details. You can always ask your dentist or provide approximate details to the best of your knowledge.
      - Date of the last time the patient saw a dentist (it is always highly recommended to see a dentist before getting partial dentures anyways, but the insurance company also wants to be sure no other dental treatments are necessary at the time of the request, in particular, any extractions).
      - They want to know if the patient has been missing any teeth congenitally and/or whether they lost any due to an accident.
    - The clinic will gather all the information and documentation including images of the stone models and send them to the insurance company. In our case, we send everything through a software so there are no postal delays.
    - Currently, the insurance company says it takes 20-30 business days for a response. However, due to extremely high demands and just how new this plan is, we have been seeing delays of 1-3 months for a final answer.
      - Hundreds of thousands of patients have been sending in requests all at once since November 2024; it is understandable that it is not an easy feat dealing with all the claims. Please be understanding of the insurance company employees as well.
      - Please also understand that once the required documentation is sent to the insurance company, the clinic can no longer do anything. The request cannot be rushed. This program has added a great load of administrative tasks for clinic staff. Everyone is doing their best to ensure the patient receives the treatment/services they need. Please understand that calling numerous times and inquiring about your pre-authorization will not accelerate the process. You are more than welcome to ask questions but please understand that the clinic staff cannot do anything about the delays, nor can they know exactly when an answer will be provided.