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Sep 5, 2024 · People who are now eligible for the plan include people with disabilities (who hold a Disability Tax Credit [DTC] certificate), as well as children under the age of 18 and people aged 65 and over. Applications will open for all other eligible Canadian residents in 2025.
- Overview
- On this page
- 1.0 Purpose of the Dental Benefits Guide
- 2.0 General principles
- 3.0 Terms and conditions
- 4.0 Definitions
- 5.0 CDCP dental procedures
- 6.0 Appendices
Effective date: May 2024
This guide provides information on the Canadian Dental Care Plan (CDCP), the “Plan”, and its policies relevant to participating oral health providers and clients. It explains the scope of the Plan’s coverage by describing the important elements of each associated policy.
•1.0 Purpose of the Dental Benefits Guide
•2.0 General principles
•Persons with Disabilities
•3.0 Terms and conditions
•4.0 Definitions
•5.0 CDCP dental procedures
The Dental Benefits Guide summarizes the terms and conditions, criteria, guidelines and policies under which the Plan covers dental services for eligible Plan clients.
•The Plan covers a range of dental procedures that prevent and treat oral disease and/or the consequences of oral disease
•Coverage of dental services is determined on an individual basis taking into consideration criteria such as the client’s oral health status
•The Plan may consider coverage beyond its frequency limitations for eligible dental services where the request meets the established policies, guidelines and criteria and is submitted for preauthorization. Services requiring preauthorization will be available starting in November 2024
•Certain dental services are not covered under the Plan (for example, temporomandibular joint therapy and appliances, extensive rehabilitation and cosmetic services). These services are defined as exclusions and will not be considered for coverage or for an appeal at any time
•Consistent with the Plan’s policies, the Plan does not cover any dental procedures related to non-eligible dental services, nor does it cover dental procedures related to a dental service reviewed by the Plan where it did not meet the established policies, guidelines and criteria
•Claims for dental benefits must be submitted by a participating oral health provider who is licensed and in good standing with the regulatory body of the province/territory in which they practice. Should a provider’s standing with their regulatory body change, the provider must contact the CDCP. A participating oral health provider may include:
This guide provides information on the CDCP and its policies relevant to providers and clients. It explains the scope of the CDCP’s coverage by describing the important elements of each associated policy.
To be eligible for payment of services rendered, providers must adhere to the CDCP Claims Processing and Payment Terms set out in the CDCP Claims Processing and Payment Agreement.
Appeal process:
A client-initiated or provider-initiated process (at the request and with the consent of the client) seeking reconsideration of a denied request under the Plan. Parents/guardians of a client can submit an appeal on their behalf, if the client is under 18 years of age. Exclusions will not be considered for appeal.
Benefit period:
The CDCP coverage period extends for twelve months, from July 1 to June 30, annually. Re-enrolment will be required, and will take place by July 1 of each year for clients who continue to be eligible for coverage under the CDCP.
CDCP client:
An individual assessed by Service Canada to meet the CDCP eligibility criteria and who is enrolled in the Plan. The provider must verify that the individual has been deemed eligible for coverage prior to every appointment.
5.1 Diagnostic services
5.1.1 Examinations Clients are eligible for up to 3 examinations in any 12 month period provided these examinations respect the frequency limitations. These examinations can include: complete oral examination and diagnosis new patient limited examination recall examination specific examination Frequency limitations take into account overall interactions between various examination services rendered by the same provider, different providers within the same office or different offices, as well as the eligibility period for each service. Examinations performed by dental specialists and denturists do not count against the maximum number of eligible annual examinations. 5.1.2 Radiographs All radiographs submitted with a treatment plan must be current, mounted, include the date of service, and of good diagnostic quality. The name of both the oral health provider and client must be indicated on the mount. Whenever duplicate radiographs are submitted, the oral health provider must indicate on the radiograph whether the radiograph is on the right or left side of the client's mouth. When submitting enlarged digital radiographs, of any type, oral health providers are requested to print a measurement scale on the radiograph to facilitate the assessment. Radiographs are considered "current" for preauthorization purposes if dated within the last 12 months (1 year) of the preauthorization submission. 5.1.3 Laboratory tests, analysis
5.2 Preventive services
For preventive services including polishing, scaling, topical fluoride treatments, pit and fissure sealants/preventive restorative resin services, please refer to the Preventive and Periodontal Policy in Section 5.5 Preventive and periodontal services. The Plan may consider coverage under the following circumstances: creation of space when done in conjunction with approved coverage for orthodontic services (available as of 2025) creation of space for erupting permanent teeth (applicable only to mesial of 53, 63, 73, 83 and the distal of 55, 65, 75 and 85)
5.3 Restorative services
Repeat restorations/extensions for the same tooth performed by the same provider or different provider in the same office, excluding a core or crown, within a 2 year time frame are subject to audit and require a written rationale documented in the client's chart on the date of service delivery. Restorations for incisal wear involving enamel and dentin are considered cosmetic/aesthetic services (exclusions) under the Plan and therefore will not be considered for payment. 5.3.1 Restorations, primary teeth Requirements for restoration of primary incisor teeth 51, 52, 61, 62, 71, 72, 81, 82: clients must be under the age of 5 eligibility is once per tooth in any 24-month period by the same provider, or different provider in the same office no combination of procedure codes/surfaces/classes should exceed in one visit the cost of the collective number of procedure codes/surfaces/classes restored, up to a maximum cost of a polycarbonate crown (the lesser amount to be paid) when both composite and amalgam procedure codes are billed on the same tooth, the system will pay the lesser amount up to a maximum cost of a polycarbonate crown bonded amalgams are covered at the rate of non-bonded equivalents Requirements for restoration of primary teeth 53, 54, 55, 63, 64, 65, 73, 74, 75, 83, 84, 85: eligibility is once per tooth in any 24-month period by the same provider, or different provider in the same office no combination of procedure codes/surfaces/classes should exceed in one visit the cost of the collective number of procedure codes/surfaces/classes restored, up to a maximum cost of a stainless steel crown (the lesser amount to be paid) when both composite and amalgam procedure codes are billed on the same tooth, the system will pay the cost of the lesser amount up to a maximum cost of a stainless steel crown bonded amalgams are covered at the rate of non-bonded equivalents 5.3.2 Restorations, permanent teeth Requirements for restoration of permanent anterior and posterior teeth: eligibility is once per tooth in any 24-month period by the same provider, or different provider in the same office no combination of procedure codes/surfaces/classes should exceed in 1 visit the cost applicable to the collective number of distinct surfaces restored, up to a maximum cost of 5 surface restorations or complete tooth reconstruction (the lesser amount to be paid) when both composite and amalgam procedure codes are billed on the same tooth, the system will pay the cost of the lesser amount up to a maximum cost of an amalgam five surface restoration/complete tooth reconstruction bonded amalgams are covered at the rate of non-bonded equivalents 5.3.3 Caries, trauma and pain control If requested on the same date of service and for the same tooth, caries, trauma and pain control procedures will not be considered for coverage in conjunction with any of the following procedures: restorations open and drain pulpectomy pulpotomy root canal treatment 5.3.4 Cores and posts Cores are eligible only if the existing restoration is greater than 24 months old and will be considered for coverage only in conjunction with an approved preauthorized crown request. Bonded amalgam cores are covered at the rate of non-bonded equivalents. A prefabricated post/pin is eligible only when inadequate coronal tooth structure is remaining to retain a restoration. Prefabricated posts in combination with a core, including pin(s) where applicable, will be considered for coverage only in conjunction with an approved preauthorized crown request. When a prefabricated post, pin(s), and core procedure codes are requested individually for the same tooth for a crown, the Plan will adjust the fee at the rate of the combined procedure codes. Cores, and prefabricated posts in combination with cores, are only covered for clients 18 years of age and older. 5.3.5 Crowns 5.3.5.1 Crown Policy – General principles The following types of single unit crowns are eligible for coverage: cast full metal porcelain/ceramic-fused to metal porcelain/ceramic These services require preauthorization The Plan will consider coverage of crowns for clients 18 years of age and older Frequency limitations are: 4 crowns in any 10-year period per client 1 crown per eligible tooth in any 8-year period (96 months) Any types of crowns supported by implants, as well as all implant-related procedures are not covered under the Plan. These procedures are considered exclusions and cannot be considered for an appeal All basic treatment addressing any existing active biological disease (caries and periodontal), must be completed before submitting requests for crowns The Plan will not consider coverage of a crown in the following circumstances: to improve aesthetics to treat sensitivity due to: cracked tooth syndrome erosion abrasion, or attrition to treat stress fractures or chipping on teeth that have a minimal restoration or no restoration for high caries risk individuals or those with generalized moderate to severe periodontal disease where there is evidence of long-standing, uncontrolled and/or untreated rampant biological disease (either caries or periodontal disease) 5.3.5.2 Crown Policy – Eligibility criteria 5.3.5.2.1 Tooth eligibility The Plan will consider coverage of a single unit crown on: incisors, canines, bicuspids, first and second molars; and third molars where the first and the second molars are missing and the third molar is in occlusion with a prosthetic or natural molar 5.3.5.2.2 Tooth restorability The Plan will consider coverage of a single unit crown on endodontically and non-endodontically treated teeth when all of the following criteria are met: adequate periodontal support, based on alveolar bone levels (crown to root ratio of at least 1:1), visible on submitted radiographs with absence of furcation involvement absence of active periodontal disease adequate remaining non-diseased tooth structure to ensure that biologic width (3 mm) is maintained and adequate ferrule (1.5 mm) is achieved during restoration an extensively restored tooth where the existing tooth structure can no longer support a direct restoration. The Plan defines an extensively restored tooth as follows: for all anterior teeth (endodontically and non-endodontically treated): restoration/loss of tooth structure involves the entire incisal edge, from mesial to distal, and extends cervically to both interproximal contacts for endodontically treated premolars and molars: restoration/loss of tooth structure involves 3 or more continuous surfaces and involves either both mesial and distal marginal ridges, or the entire destruction of a cusp, as demonstrated with radiographs. In addition, providers have the choice to submit photographs, if available for non-endodontically treated premolars and molars: restoration/loss of tooth structure involves 5 continuous surfaces a mesio-distal space (vertically and horizontally) equivalent to that of the natural tooth with no loss of space due to caries or crowding a tooth that does not require any additional treatment, such as crown lengthening, root re-sectioning or orthodontic treatment endodontically treated teeth must demonstrate on a postoperative periapical radiograph that healing has occurred 5.3.5.3 Crown Policy – Non-inserted crowns For non-inserted crowns, the Plan will consider paying up to 20% of the current CDCP professional fee and up to 100% of a reasonable laboratory fee associated with the fabrication of a crown, if applicable, under the following conditions: the crown has been completed but not inserted due to circumstances beyond the control of the oral health provider the provider has made substantial efforts to contact the client to schedule an insertion appointment the provider has communicated the details of the situation in writing to the CDCP Note: If a non-inserted crown has been claimed by the oral health provider without complying with the above-noted conditions, and has been paid in full by the Plan, this will result in a payment recovery.
Appendix A: CDCP Dental Benefit Grids
The CDCP Dental Benefit Grids list what services are eligible by placing coverage into 2 schedules: schedule for services that do not require preauthorization: outlines services that may be completed and billed directly to the claims processor for payment (without requiring preauthorization) within Plan policies (for example, frequency limitations) schedule for services requiring preauthorization: outlines services that always require an approved preauthorization (prior approval) to be claimed under the Plan. Services requiring preauthorization will be available starting in November 2024
Appendix B: Payment and reimbursement
All claims must be received by the CDCP within 1 year from the date of service to be eligible for payment or reimbursement. The service must be eligible for coverage under the CDCP as of the date of service, and all policies and requirements for coverage apply. Note: the 1 year policy applies to the initial claim submission and includes all subsequent resubmissions following a rejection under CDCP (for example, missing required data elements; incorrect procedure code used, client has alternative coverage, etc.) the coordination of benefits with other plans must also be completed within 1 year of the date of service Claims older than 1 year from the date of service are not eligible for payment or reimbursement and therefore will not be accepted for processing. A procedure code or procedure name in a client record is not sufficient to substantiate a claim for payment. If applicable, a detailed statement or Explanation of Benefits (EOB) from all other health plan(s)/program(s), through which the client receives coverage for dental services, must be provided. Laboratory fee submission: Certain dental services require laboratory work. Laboratory fee submissions will be considered for coverage under the CDCP only in conjunction with an approved procedure code. However, the CDCP reserves the right to require a copy of the laboratory report and to adjust the laboratory fee requested by oral health providers.
Appendix C: Appeal Process
Further detail regarding the CDCP’s appeal process will be made available on the CDCP website.
Aug 13, 2024 · Inform the dental office if you have mobility disabilities as soon as possible. Let the dental team know if someone will accompany you to the appointment and if they can offer additional assistance. Tell the clinic ahead of time if you know what dental services you might need.
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The ODA and Canadian Dental Association have developed resources for parents, caregivers and the dental team who care for persons with special health care needs. These materials are aimed at providing basic oral health care for persons with Autism Spectrum Disorder, Alzheimer’s and Dementia and to make their experiences more successful.
The Canadian Dental Care Plan (CDCP) is helping make the cost of dental care more affordable for eligible Canadian residents. Applications now open for: Seniors aged 65 and over. Children under the age of 18. Adults with a valid federal Disability Tax Credit certificate for 2023.
Most Canadians receive oral health care through privately operated dental clinics and pay for services through insurance or by paying for it themselves. Some dental services are covered through government dental programs. These programs are integral to the health and well-being of Canadians.
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Jun 27, 2024 · Today, the Honourable Jenna Sudds, Minister of Families, Children and Social Development announced that eligible children under the age of 18 and adults with a valid Disability Tax Credit certificate can now apply for the Canadian Dental Care Plan (CDCP).
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related to: does dent-x canada offer a dental office for adults with disabilities$0 Medicare Advantage plans that include preventive and comprehensive dental coverage. Top rated Medicare Advantage plans with dental coverage for exams, cleanings and X-rays
ClearChoice Dental Implant Centers, A Trusted National Network of Providers For 17 Years. Schedule Your Free Consultation at ClearChoice to Address Your Dental Health Needs.
