Australian Dental Association Inc. Child Dental Benefits Scheme – Grow Up Smiling 17 May 2013 Authorised by Dr Karin Alexander Federal President Australian Dental Association Inc. 14–16 Chandos Street St Leonards NSW 2065 PO Box 520 St Leonards NSW 1590 Tel: (02) 9906 4412 Fax: (02) 9906 4676 Email: [email protected] Website: www.ada.org.au Australian Dental Association
Child Dental Benefits Scheme - GUS
1. Introduction The Australian Dental Association (ADA) welcomes the opportunity to contribute to the development of the Child Dental Benefit Scheme “Grow Up Smiling” – GUS (the Scheme) as per the Consultation paper. The ADA is encouraged by the Government’s initiative to provide prevention and treatment for children who are most in need and to address the reported decline in children’s oral health. The ADA notes that the Consultation paper seeks feedback on specific issues in relation to the Scheme and therefore responds to each of the issues under consideration in turn. However, the ADA is also keen to ensure that by introducing the Scheme, the Australian Government puts conditions in place within National Partnership Agreements to maintain the current investments by states and territories towards school and children’s dental services. Schedule of Items – scope of services The ADA believes that in order to ensure that full and comprehensive treatment is provided under the Scheme it is necessary for the Scheme to encompass all treatments as specified in the ADA’s Schedule and Glossary of Services 10th edition (ADA Schedule), which can be accessed at http://www.ada.org.au/about/publications.schedule.aspx The Schedule of Items and Restrictions associated with the Scheme should reflect the definitions that are used within the ADA Schedule without additional qualifiers. The ADA appreciates that the Government seeks to limit treatments to “basic dental services”. However, to do so potentially limits the effectiveness of treatment, and in so doing compromises the level of care provided to children under the Scheme. No government wants to be known as the government that introduced “poor dentistry for poor people”. Currently, the Scheme as presented encourages two tiered dentistry – one for GUS recipients with a restricted range of services and another being the full gamut of dental services for private patients. The ADA accepts that some services may not be applicable on a routine basis for 2‐17 year olds, but to exclude services that may be required, regardless of frequency, is not a sound basis for a scheme for eligible recipients. The service provided should be based upon clinical necessity and not a "one model fits all" approach. The ADA Schedule has been developed recognising that each case has to be considered on its merits. In almost all instances, there are no restrictions placed on the frequency with which services can be provided. It does provide some clarity on when and in what circumstances services can be delivered but limitations and restrictions of available treatments impair the quality and safety of patient outcomes. A list of the additional concerns with the proposed item numbers and the proposed changes are listed in Attachment A. It is the view of the ADA that these amendments would serve to better meet the objectives of the Scheme. 1
Australian Dental Association
Child Dental Benefits Scheme - GUS
For example, the proposed schedule of items for the Scheme is not focused on prevention and minimal intervention dentistry. It provides only limited access to preventive treatments. There is significant information available to suggest that if dental disease can be avoided in childhood then it is likely to be avoided or significantly reduced in later life. Fees and Billing We note in the Consultation paper that it is suggested that one approach would be to set the level of fees for the Scheme in line with other Commonwealth dental benefits programs (for example, the Department of Veterans’ Affairs (DVA) dental schedule). The ADA has expressed considerable concerns about the fact that DVA schedule of fees are substantially lower than the level of fees customarily charged by dentists, as shown by the ADA Annual Fee Surveys. ADA Fee Surveys have shown that dentists have acted with admirable responsibility in that there have been only small increases in dental fees (below 3% in the last three years compared to health cost‐of‐living index of up to 7.7%). As the attached graph from 2007–2012 indicates (Attachment B), the gap between Health CPI and DVA fees and average ADA fees has grown significantly. The ADA’s comparative analysis of the 13 most common procedures performed by dentists (Attachment C) found that there is a 19.5% difference between the mean dental fees as detailed in the 2012 ADA Dental Fees Survey and the rebates offered by DVA as per the 2012 Fee Schedule of Dental Services for Dentists and Dental Specialists. Coupled with the fact that the Australian Tax Office’s Key Benchmark Ratios 2012 shows that the overheads for dentists were up to almost 80%, the result is that the return on services is minimal and, in some cases, non‐existent. DVA fees paid under the Scheme have never reached parity with ADA Fee Survey levels. More importantly, the reviews of dental fees under the Scheme have never kept pace with the moderate increases in fees as revealed by ADA Fee Surveys. What this has meant is that there has been a growing discrepancy between the fee levels demonstrated by the ADA Fee Survey and those provided under the DVA Scheme. The implications of this are that when practitioners provide treatment to DVA eligible patients, they either “break‐even” or incur a loss. This is now becoming an unsustainable situation. The dental profession cannot and should not be obligated to provide services to either DVA eligible patients or children at a loss. This lack of a reasonable level of remuneration for DVA eligible recipients cannot be sustained by the profession and should not be the basis for the new Scheme. The new Scheme should also ensure that there is an annual review of the fees paid for each service and an increase at the level of the CPI as a minimum requirement. It is noted that the Government expect that private providers will bulk bill quoting the Medicare Teen Dental Plan (MTDP) as an example of success in this area. The reason why there was a high rate of patient bulk billing under the MTDP was because there was little or no gap between the amount available under the scheme and the average fee charged by dentists for an exam and scale and clean, which were the most common services provided. 2
Australian Dental Association
Child Dental Benefits Scheme - GUS
Providers must be free to charge their usual and customary fees and patients should have the right to use their entitlement on the services that best fit their need. The rules in relation to the Scheme must therefore allow for co‐payments by patients without this impacting on the total rebate available to the patient. Any schedule of fees must be reviewed annually and variations based upon the health consumer index. The ADA would also recommend that patients should be able to claim any difference between the rebate amount and the total payment through their private health insurance (PHI). The ADA would assume that many privately insured patients eligible for services under the Scheme would, but for the scheme, have received services for which a private health insurer (insurers) would provide a rebate. Why Government chooses to enable insurers to avoid this liability is not well understood by the ADA. It appears that Government is encouraging people to take up PHI and then encourage cost shifting back to the tax payer. Service Restrictions The ADA has repeatedly indicated to all relevant government departments that it does not support schedules that include step down fees on the basis that provider’s fees already make provision for subsequent services. Each surgical procedure is a stand‐alone procedure and no less difficult than the first. It is the prerogative of the provider to determine any discount that might be applied. To use an analogy from another industry, one would not expect a tradesman laying tiles to accept a lesser price for laying the third and subsequent tiles in comparison to the first one. The labour required to cement each tile is the same. Why does the Government expect dentists to subsidise their services? Service requirements The ADA also urges the Government to allow dental services provided in a hospital or substitute setting to be claimed under the scheme, independent of the hospital costs. Again, the children who make up the target group are more likely to be in need of these services. Young children often need to be treated under sedation or general anaesthesia. This is particularly the case with Indigenous children and other high risk groups. The proposed arrangements do not allow for the utilisation of these services. There should be a review of the restrictions on the number of services that can be provided under sedation or general anaesthesia so that the required level of care can be provided. Dental Professional requirements for service provision and billing eligibility 3
Australian Dental Association
Child Dental Benefits Scheme - GUS
The ADA supports that the dental professional requirements for service provision under the Scheme should be consistent with the approved Dental Board of Australia (the Board) Scope of Practice Registration Standard (the Standard) for the dental profession pursuant to the Health Practitioner Registration National Law. Dental therapists and hygienists and oral health therapists The Standard referred to above requires that allied dental practitioners (dental hygienists, dental therapists and oral health therapists) work under the supervision of a dentist. This requirement is based on the Board’s understanding of the limited education and training these ADPs undertake and is in keeping with their key function – protection of the public. Current requirements require ADPs to work in a structured professional relationship with a dentist. This has been stipulated by the Board. It is based on its assessment of how safety and quality of services can be maintained and at the same time allowing these ADPs to provide services to patients. This must be maintained. There is no evidence that patient outcomes in regards to safety and quality are enhanced when unsupervised service delivery is provided by ADPs. The Board’s standard1 states: “3. Dentists work as independent practitioners who may practise all parts of dentistry and are the clinical team leaders. Dentists may supply and fit dental appliances for the treatment of sleep disorders. They must work in cooperation with the patient’s medical practitioner who is responsible for the medical aspects of the management of sleep disordered breathing. 6. Dental hygienists, dental therapists and oral health therapists exercise autonomous decision making in those areas in which they have been formally educated and trained. They may only practice within a structured professional relationship with a dentist. They must not practise as independent practitioners. They may practise in a range of environments that are not limited to direct supervision.” This means that dentists work as independent practitioners but requires all ADPs to practise within a structured professional relationship with a dentist. Furthermore, it states that they may not practise as independent practitioners. These standards have been written in this way so as to reinforce the key element of the National Law2, namely to ensure the safety and quality of all health services. The ADA believes that the current arrangements by which allied dental practitioners provide services within their scope of practice under the MTDP is the most effective and only safe manner that services under any government funded scheme can be effectively delivered. It is also consistent with how these practitioners provide services to patients eligible for services under the Department of Veterans’ Affairs (DVA) dental scheme. To 4
Australian Dental Association
Child Dental Benefits Scheme - GUS
introduce alternate arrangements for the Scheme would lead to inconsistency with other government funded schemes and potentially confusion among the professions as to the administrative requirements for each program of funding. The Consultation Paper indicates that the introduction of the GUS Scheme “provides an opportunity to discuss the current arrangements for provider eligibility and billing under the MTDP, with a view to assess if any changes are required for the Scheme to encourage increased take‐up of and access to services for the public”. The issue of provider eligibility and billing of services by ADPs has been dealt with on numerous recent occasions. The issue arises because a small number of outspoken ADPs feel that the provision of a Medicare provider number will somehow create a panacea for all sorts of perceived problems that have arisen under government schemes and in the delivery of care for patients who are privately insured. The notion that somehow this will address remote and very remote dental access issues is illogical. There is no evidence to suggest this would be successful, and in fact overseas examples have shown it an abject failure to resolve remote dental access, e.g. Colorado, USA3. Schemes such as the DVA and MTDP, together with services delivered to patients who are privately insured, have all worked well under the existing arrangements. No one can realistically claim that service delivery has in any way been impeded to eligible patients by requiring services be claimed for under the supervising dentist’s provider number. Indeed the ADA feels that should current regulatory arrangements alter, then the impact could well be a drop in essential services to those most in need as the services provided will not be on the prescription of the supervising dentist. If the Board’s standard is to be altered, then it can only be changed pursuant to a comprehensive review of the existing attributes and competencies of the ADPs. The competencies and attributes of ADPs have been created based on the Board analysing course content for approved courses of study for ADPs. The Board has satisfied itself as to the calibre of a graduate from these courses as being able to meet the attributes and competencies it has identified. These attributes and competencies assume the working environment will be one where the ADP works within this structured arrangement. If the standard is to be altered by removal of the requirement that the ADP work within a structured professional relationship, then the attributes and competencies (set to this requirement of being in place in a structured professional relationship) will have to be altered. If that is to occur then what must follow is the creation of new approved courses of study with substantial changes to the curricula that will enable ADPs to practise to this wider standard. There is no evidence of necessity for this action as the existing dentist workforce has already exhibited the capacity to assume delivery of a greater number of services as evidenced by the profession’s participation in the CDDS. This situation would also arise where someone other than a dentist is acknowledged as an eligible provider and the treatment required falls outside their scope of practice. In any event, Health Workforce Australia is undertaking its own evaluation of this issue. The Board is also similarly reviewing its standards. The ADA sees no reason for a further review being undertaken for the Scheme. 5
Australian Dental Association
Child Dental Benefits Scheme - GUS
The contemporary outlook for future dental demands is based upon prevention of dental disease. To this end the most preventive based ADP is the dental hygienist. The necessity for training ADPs should concentrate on this area of demand and these competencies. Where services are rendered by ADPs under the supervision of a dentist then those services are billed under the provider number of the dentist and as such are recognised by the PHI and government scheme alike. Rebates or benefits are subsequently paid for the service. The rendering of such an account informs the Scheme operator and PHI that the services provided have been provided in accordance with the standards and practice set down by the Board. Scheme operators and PHIs recognise that services carried out under the supervision of a dentist have been identified by the appropriately qualified practitioner as necessary for the proper treatment of the patient. What occurs in dentistry is similar to what occurs in the delivery of radiographic services. In billing for services in radiology, the account will specify the treatment provided. Invariably, the account will represent services provided by both the radiographer (who will have seen the patient and arranged the taking of the radiograph) and the analysis of the radiograph that will have been performed by the radiologist. Here there is a team delivering the service; each member providing the service they have been trained to do. The radiologist heads the team and takes responsibility for the procedure; and provides indirect supervision to the radiographer who performs a service and then the radiologist reports the outcome. While the radiographer’s role in the completion of the treatment is not separately recognised in the accounting, the service is ‘recognised by the third‐party payer (Medicare or PHI) and rebated accordingly’. The same occurs in dentistry with a similarly based distribution of service delivery. Compliance with the Board’s standards in fact allows Scheme operators and PHIs to both recognise services provided by dentists and ADPs, and more importantly ensures that consumers/patients receive services from practitioners they know to be both safe and of high quality. Without these provisions being enforced the safety of consumers would be compromised. There is an expectation by consumers that this type of delivery of service will continue. Another issue of concern is that the current arrangements place a vicarious liability under indemnity insurance upon the dentist for the service of the ADP. This ensures a high standard of care is maintained. ADPs under this arrangement enjoy a very low indemnity premium and are recognised by all indemnity providers. However, very significant indemnity insurance premium increases will occur if ADPs are not engaged under the supervision and prescription of a dentist. Examples overseas where ADPs are deemed independent have seen significant indemnity insurance cost increases. These issues were recently raised in the ACCC’s Report to the Australian Senate on anti‐
competitive and other practices by health insurers and providers in relation to private health insurance.4 This enquiry looked at the potential for restrictive practices being in place regarding the utilisation of ADPs. A very similar examination to that raised in this Consultation paper. The ACCC saw no reason for any action to be taken suggesting that the current arrangements were appropriate having regard to the Board’s requirements. 6
Australian Dental Association
Child Dental Benefits Scheme - GUS
Last year the Department of Veterans’ Affairs (DVA) also looked at the issue. It permitted ADPs to provide services under the Scheme, if they were:  registered with the Dental Board of Australia and comply with approved scope of practice registration standards;  covered by either their employer’s indemnity insurance or maintain their own insurance as mandated by the Dental Board of Australia; and  qualified and competent to provide the service. The ADA supports this approach and feels that an identical approach should be adopted under the Scheme. Lessons learned from previous Commonwealth dental benefits programs The ADA is eager that the administrative problems encountered with the Chronic Disease Dental Scheme (CDDS) not be repeated with Scheme. The ADA is happy to work with the Government to ensure that the administrative requirements are straight‐forward, time and cost‐effective and easily fit into the dental setting. Under the CDDS considerable time was expended by dental practices trying to confirm eligibility and the balance of funds available for treatment remaining for any given individual. One of the issues that arose under the CDDS was ‘dentist shopping’. There must be a clear process available to dentists to check that there are adequate funds available for the treatment required and no restriction on the ability to cover the dentist’s costs. For example, if a patient sees one dentist, has an examination, claims for that examination through Medicare and then the patient decides that they want to get another opinion, they will not be able to make another claim for the new examination. The same problem will apply when a dentist makes an initial diagnosis and refers a patient on to a specialist for treatment. This problem exists within the DVA schedule of services already. Compliance and reporting arrangements for providers The introduction of previous Commonwealth Government dental schemes assumed an understanding of the dental environment by those developing the rules of the schemes. What is clear to the ADA is that those developing schemes assumed that what works in a medical environment would be applicable to dentistry. This has now been proven to not be the case. Dental practice is not like general medical practice and as such, administrative arrangements, compliance and reporting arrangements for the new Scheme must be tailored to the dental environment. The ADA would welcome the opportunity to collaborate with the Government in developing an administrative system that would ensure that GUS’s administrative needs are met without placing onerous requirements on the dentists who will be providing the services. 7
Australian Dental Association
Child Dental Benefits Scheme - GUS
Education and communication with the profession and patients The ADA is the peak national professional body representing over 13,000 registered dentists engaged in clinical practice and dentist students. The ADA’s membership spans Australia and is impressive in its diversity – members are found in both the public and private sectors, in universities, and in volunteer groups and in various other agencies. The ADA represents the vast majority of dental care providers. The primary objectives of the ADA are to: • Encourage the improvement of the oral and general health of the public and to advance and promote the ethics, art and science of dentistry; and • To support members of the Association in enhancing their ability to provide safe, high quality professional oral healthcare. There are ADA Branches in all States and Territories other than in the ACT. Dentistry in Australia is predominantly practised in a small business environment with one or two dentists working in a team environment with other allied dental practitioners they employ. No other peak body is better placed, nor has the reach, to deliver communication and educational materials to the dental profession. As the majority of dental services are delivered in the private setting, our members’ practices are also best placed to act as a repository of information for patients. The ADA would be willing to work with the Government and its relevant departments to develop an education program that can be delivered to the profession, their employees and patients to ensure compliance with the administrative, quality and safety requirements of the Scheme. 1
See DBA –Dental Scope of Practice Registration Standard. Visit: http://www.dentalboard.gov.au/RegistrationStandards.aspx
2
See Health Practitioner National Law
3
Brown LJ, House DR, Nash KD. The economic aspects of unsupervised private hygiene practice and its impact on access
to care. Dental Health Policy Analysis Series. Chicago: American Dental Association, Health Policy Resources Center;
2005.
4
http://transition.accc.gov.au/content/index.phtml/itemId/1104510
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Grow Up Smiling – a new child dental benefit schedule
Attachment A: Schedule of Items and Restrictions
Recommended limits and restrictions on items
Additional comments ADA believes that all items included in the ADA Schedule should be included.
Diagnostic Services
Service Type
Examination
Diagnostic Services
Description
Item
Number
Time limits
Service restrictions
Additional comments
ADA Comments
Comprehensive oral examination
011
1 per provider per 2 years after Only 1 oral exam item (011, 012,
previous 011 or 012
013) per day
Service is to also include dietary advice and oral
hygiene instruction (ADA item number 131 and
141 respectively) as appropriate
This is inconsistent with other Australian
Government Schemes. The DVA
Schedule separates out items 131 and 141
Periodic oral examination
012
1 per provider per 6 months
Only 1 oral exam item (011, 012,
013) per day
Service is to also include dietary advice and oral
hygiene instruction (ADA item number 131 and
141 respectively) as appropriate
This is inconsistent with other Australian
Government Schemes. The DVA
Schedule separates out items 131 and 141
Oral examination – limited
013
3 per 3 months
Only 1 oral exam item (011, 012,
013) per day
022
4 per day
Radiograph Diagnostic Intraoral periapical or bitewing radiograph –
Services
per exposure
Intraoral radiograph – occlusal, maxillary,
mandibular – per exposure
The ADA Schedule has been developed
recognising that each case has to be
considered on its merits. In almost all
instances, there are no restrictions placed
on the frequency with which services can
be provided. It does provide some clarity
on when and in what circumstances
services can be delivered. Limitations and
restrictions of available treatments impair
the quality and safety of patient outcomes.
025
Preventive
Services
Service Type
Preventive and
Prophylactic Services
Description
Item
Number
Time limits
Service restrictions
Additional comments
Removal of plaque and/or stain
111
1 per 6 months
Not on same day as 114, 115
As per comment for item No. 022
Removal of calculus – first visit
114
1 per 6 months
Not on same day as 111, 115
As per comment for item No. 022
Removal of calculus – subsequent visit
115
2 per 12 months
Not on same day as 111, 114
As per comment for item No. 022
Topical application of remineralisation
and/or
cariostatic agents, one treatment
121
1 per 6 months
Fissure and/or tooth surface sealing – per
tooth (first four services)
161
4 per day
As per comment for item No. 022
Not same tooth, same day as
511535
Subsequent services use item 162
As per comment for item No. 022
Fissure and/or tooth surface sealing –
per tooth (subsequent services)
162
Not same tooth, same day as
511535
50% of the fee of 161
The ADA has repeatedly indicated to all
relevant government departments that it does
not support schedules that include step down
fees on the basis that provider’s fees already
make provision for subsequent services.
The ADA does not recognize item nos that
are not in the ADA Schedule
Periodontics
Service Type
Periodontics
Description
Item
Number
Time limits
Treatment of acute periodontal infection –
per
visit
213
2 per 12 months
Clinical periodontal analysis and recording
221
1 per 2 years
Service restrictions
Additional comments
Not with 415, same tooth, same
day
As per comment for item No. 022
This item will require all teeth and 6 sites per tooth
to be recorded. Written documentation of these
measurements must be retained.
As per comment for item No. 022
Page 9 of 13
Grow Up Smiling – a new child dental benefit schedule
Attachment A: Schedule of Items and Restrictions
Oral Surgery
Service Type
Extraction Oral
Surgery
Emergency Surgery
Oral Surgery
Description
Removal of a tooth or part(s) thereof first tooth extracted on a day
Item
Number
311
Time limits
1 311/314 per day,
subsequent extractions use
316
Service restrictions
1 311-326 per tooth
1 311/314 per day, subsequent
extractions use 316
1 311-326 per tooth
Additional comments
Subsequent extractions on the same day
should attract the same fee.
Sectional removal of a tooth or part(s)
thereof - first tooth extracted on a day
314
Additional extraction requiring removal of a
tooth or part(s) thereof, or sectional
removal of a tooth.
316
Surgical removal of a tooth or tooth
fragment not requiring removal of bone
or tooth division - first tooth extracted on
a day
322
1 322/323/324 per day,
subsequent extractions use
326
1 311-326 per tooth
Subsequent extractions on the same day
should attract the same fee.
Surgical removal of a tooth or tooth
fragment
requiring removal of bone - first
tooth extracted on a day
323
1 322/323/324 per day,
1 311-326 per tooth
subsequent extractions use 326
Subsequent extractions on the same day
should attract the same fee.
Surgical removal of a tooth or tooth
fragment requiring both removal of bone
and tooth division - first tooth extracted on
a day
324
1 322/323/324 per day,
1 311-326 per tooth;
subsequent extractions use 326 Limited to multi rooted teeth
only
Subsequent extractions on the same day
should attract the same fee.
Additional extraction requiring surgical
removal of a tooth or tooth fragment
326
1 311-326 per tooth
Repair of skin and subcutaneous tissue or
mucous membrane
351
Must be claimed on the same
day
as one of 384, 386, 387
Repositioning of displaced tooth/teeth –
per tooth
384
Not same tooth on any date after
311-326
Splinting of displaced tooth/teeth – per
tooth
386
Not same tooth on any date after
311-326
Replantation and splinting of a tooth
387
Not same tooth on any date after
311-326
Drainage of abscess
392
Not same tooth on any date after
311-326
1 311-326 per tooth
Subsequent extractions on the same day
should attract the same fee.
To be used for additional extractions on the
same day in conjunction with item 311 or
314
To be used for additional surgical extractions on
the same day in conjunction with item 322, 323
or 324
ADA does not support step down items
This does not allow for situations where
multiple extractions are required at the
ADA does not support step down items
This does not allow for situations where
multiple extractions are required at the
As per comment for item No. 022
Page 10 of 13
Grow Up Smiling – a new child dental benefit schedule
Attachment A: Schedule of Items and Restrictions
Endodontics
Service Type
Endodontics
Description
Direct pulp capping
Item
Numbe
411
Pulpotomy
414
Not same tooth, same day as 421
Not same day as 455
Complete chemo-mechanical preparation of
root canal – one canal
415
Not same day as 455
Complete chemo-mechanical preparation
of root canal – each additional canal
416
Root canal obturation – one canal
417
Root canal obturation – each additional canal
418
Extirpation of pulp or debridement of
root canal(s) – emergency or palliative
419
Not same tooth same day as 311326, 411-417, 421,455, 458, 511
to
535
Resorbable root canal filling – primary tooth
421
1 per primary tooth
Not same tooth, same day as 414
Additional visit for irrigation and/or dressing
of the root canal system – per tooth
455
Can't be used on the same day as
414-418, 421;
Can only be claimed
within 3 months of 415 or
416
Interim therapeutic root filling – per tooth
458
Time limits
2 per tooth per day
Service restrictions
Not same day as 455
Additional comments
Should be “not same tooth, same day”
Up to 2 additional canals - no extra fee for 4th
canal
Not same day as 455
2 per tooth per day
3 per 12 months
Not same tooth, same day as 419
Not same day as 455
No restrictions on number of canals.
Should be ‘not same tooth, same day”
Up to 2 additional canals - no extra fee for 4th
canal
No restrictions on number of canals.
415, 416 may be used on same
day, but then no other
endodontic treatment (except
455) within 3 months.
Page 11 of 13
Grow Up Smiling – a new child dental benefit schedule
Attachment A: Schedule of Items and Restrictions
Restorative Services
Service Type
Restoration
Restorative Services
Restoration
Restorative Services
Description
Metallic restoration – one surface – direct
Item
Number
511
Time limits
511-535 1 per tooth per day
(most appropriate item
number per tooth)
Service restrictions
Not same tooth, same day as
161 or 162
Additional comments
Metallic restoration – two surfaces – direct
512
See above
Not same tooth, same day as 161
or 162
Metallic restoration – three surfaces – direct
513
See above
Not same tooth, same day as 161
or 162
Metallic restoration – four surfaces – direct
514
See above
Not same tooth, same day as 161
or 162
Metallic restoration – five surfaces – direct
515
See above
Not same tooth, same day as 161
or 162
Adhesive restoration – one surface –
anterior tooth – direct
521
See above as well as limit of 5
per day
Not same tooth, same day as 161
or 162
Adhesive restoration – two surfaces –
anterior tooth – direct
522
See above
Not same tooth, same day as 161
or 162
Adhesive restoration – three surfaces –
anterior tooth – direct
523
See above
Not same tooth, same day as
161 or 162
Adhesive restoration – four surfaces –
anterior
tooth – direct
524
See above
Not same tooth, same day as 161
or 162
Adhesive restoration – five surfaces –
anterior tooth – direct
525
See above
Not same tooth, same day as
161 or 162
Adhesive restoration – one surface –
posterior tooth – direct
531
See above as well as limit of 5
per day
Not same tooth, same day as 161
or 162
Adhesive restoration – two surfaces –
posterior tooth – direct
532
See above
Not same tooth, same day as 161
or 162
Adhesive restoration – three surfaces –
posterior tooth – direct
533
See above
Not same tooth, same day as 161
or 162
Adhesive restoration – four surfaces –
posterior tooth – direct
534
See above
Not same tooth, same day as 161
or 162
Adhesive restoration – five surfaces –
posterior tooth – direct
535
See above
Not same tooth, same day as 161
or 162
As per comment for item No. 022
Provisional (Intermediate/temporary)
restoration - per tooth
572
3 per 3 months, not on same
day as 411-458 (except 419)
Metal band
574
Pin retention – per pin
575
Max 2 per tooth;
Must have at least one of 511535 on same tooth, same day.
As per comment for item No. 022
Metallic crown – preformed
576
Bonding of tooth fragment
579
Post – direct
597
Max 4 per day
As per comment for item No. 022
As per comment for item No. 022
2 per tooth;
Must have at least one of 511535 on same tooth, same day.
Page 12 of 13
Grow Up Smiling – a new child dental benefit schedule
Attachment A: Schedule of Items and Restrictions
Dentures
Service Type
Dentures and
denture
components
Description
Partial maxillary denture - resin, base only
Item
Number
721
Time limits
1 per 2 years
Service restrictions
As per comment for item No. 022
Partial mandibular denture - resin, base
only
722
Retainer - per tooth
731
4 per base (721/722)
Tooth/teeth (partial denture)
733
Immediate tooth replacement - per tooth
736
4 per base (721/722)
Limited to anterior
h
maximum
of 4 per base
Denture Maintenance Adjustment of a denture
741
Denture Repairs
Reattaching pre-existing clasp to denture
761
Replacing/adding clasp to denture - per
clasp
762
Repairing broken base of a partial denture
764
Replacing/adding new tooth on denture per
h
Reattaching
existing tooth on denture - per
765
Additional comments
1 per 2 years
As per comment for item No. 022
As per comment for item No. 022
As per comment for item No. 022
As per comment for item No. 022
Not same provider as 721/722
within 12 months
766
tooth
Adding tooth to partial denture to replace
an
extracted or decoronated tooth - per tooth
768
Impression - dental appliance
repair/modification
776
to a maximum of 4 teeth per base
As per comment for item No. 022
Miscellaneous and General Services
Service Type
Miscellaneous
General
Services
Description
Palliative care
Item
Number
911
Time limits
Service restrictions
Not to be claimed with any other
item by same provider on the
same day
Additional comments
Page 13 of 13
ATTACHMENT B
ATTACHMENT C
Annual Differences between ADA/DVA ($/%) for 13 most common procedures
Procedure
011 Oral Exam
Comprehensive
022 X-Ray-Per Film
114 Calculus Removal
2006
2007
2008
2009
2010
2011
2012
$ 3.40
7.3%
$
4.31
9.1%
$
7.12
14.6%
$
7.25
14.6%
$
8.45
16.7%
$
8.66
16.8%
$
7.84
14.9%
$ 1.77
$ 6.30
5.4%
7.9%
$
$
2.78
9.25
8.3%
11.4%
$ 4.25
$ 12.45
12.4%
15.0%
$ 4.32
$ 14.99
12.4%
17.7%
$ 5.06
$ 15.81
14.2%
18.3%
$ 4.79
$ 18.65
13.2%
21.2%
$ 4.67
$ 17.57
12.6%
19.6%
$ 2.95
161 Fissure Sealing-Per Tooth
311 Removal of Tooth or
$ 9.55
Part(s)
7.3%
$
4.34
10.4%
$
5.00
11.8%
$
6.25
14.4%
$
7.16
16.2%
$
8.60
19.0%
$
7.99
17.4%
8.2%
$ 15.14
12.8%
$ 21.89
18.1%
$ 26.52
21.4%
$ 30.79
24.4%
$ 34.63
26.9%
$ 36.16
27.5%
$ 12.92
6.8%
$ 23.92
12.4%
$ 27.61
14.0%
$ 31.65
15.6%
$ 37.57
18.2%
$ 36.01
17.1%
$ 38.95
18.2%
$ 3.05
3.4%
$
7.56
8.2%
$ 14.10
15.0%
$ 13.86
14.4%
$ 16.53
16.8%
$ 19.85
19.8%
$ 20.86
20.5%
$ 7.44
7.3%
$ 12.63
12.1%
$ 14.84
13.9%
$ 21.26
19.5%
$ 22.30
20.1%
$ 25.12
22.2%
$ 24.81
21.5%
$ 9.00
$ 9.17
7.3%
8.4%
$ 13.74
$ 12.93
10.9%
11.6%
$ 16.97
$ 16.99
13.1%
14.9%
$ 23.70
$ 21.01
17.9%
18.0%
$ 24.82
$ 23.00
18.4%
19.4%
$ 26.06
$ 24.44
18.9%
20.2%
$ 28.58
$ 24.91
20.4%
20.2%
$ 10.29
7.5%
$ 15.32
11.0%
$ 18.88
13.2%
$ 25.14
17.2%
$ 26.59
17.9%
$ 28.08
18.5%
$ 30.44
19.7%
6.9%
$ 112.41
9.8%
$ 154.07
13.2%
$ 173.97
14.6%
$ 197.20
16.2%
$ 191.01
15.4%
$ 195.00
15.4%
-13.2% -$ 172.36
12.00% $ 15.20
-16.0%
13.96%
$ 199.19
$ 47.27
21.7%
18.35%
$ 225.26
$ 50.09
24.1%
19.48%
$ 242.86
$ 52.36
25.5%
19.48%
415 Chemo-Prep-1Canal
416 Chemo-Prep Additional
Canal
521 Adhesive-1 Surface
Anterior
522 Adhesive-2 Surfaces
531 Adhesive-1 Surface
532 Adhesive-2 Surfaces
Posterior
615 Full Crown-Veneered
$ 77.10
Indirect
711 Denture
-$ 52.20
Average for all procedures $ 7.75
-5.8% -$ 93.20
6.00% $ 10.86
-9.8% -$ 133.82
9.09% $ 13.87