This contains general information and is intended as a reference only. It is not a substitute for independent legal advice regarding your situation. Printable PDF
Dental benefits that are provided through the employer and under a group insurance program, are usually reimbursed according to the Ontario Dental Association’s (ODA) suggested fee guide for general practitioners. Some dental benefit plans may have a lag in the year of the ODA Fee Guide on which they will pay. For instance, if the year is 2025, and a plan has a 1-year lag, dental expenses will be paid based on the ODA Fee Guide that was in effect for 2024. You will be responsible for the difference.
Coverage for dental services can vary greatly from plan to plan. Dental benefit services can generally be broken down into three different categories:
Basic Services
While every plan is different, basic services are usually reimbursed at a higher rate than major services or orthodontics. A typical plan will cover anywhere from 75-100% of costs for Basic Services.
Examples of Basic Services:
- Oral examinations such as initial, recall and emergency exams
- X-rays, fillings, polishing/cleaning and topical fluoride treatment (fluoride is sometimes limited to children)
- Diagnostic testing
- Retentive pins
- Extraction of teeth
- Endodontics, periodontics and oral surgery
Major Services
While every plan is different (not all plans cover major services). Major Services are usually covered at a lower rate than Basic Services. If a plan covers Major Services, it will typically reimburse anywhere from 50-75% of Major Services costs.
Examples of Major Services:
- Dentures, partial dentures, complete dentures, lab fees and repairs
- Bridges and repairs to bridges
- Crowns and repairs to crowns
- Inlays and onlays
- Pins in inlays, onlays and crowns
- Post and core
Orthodontics
Some dental plans do not cover orthodontics. When a dental plan does provide for orthodontic coverage, it is often for children up to the age of 18 (sometimes longer); coverage for adults is sometimes seen, but more often coverage is provided for children only. Reimbursement can range 40-75%. This benefit will usually have its own yearly or lifetime maximum that is separate and apart from Basic and/or Major Services.
Examples of Orthodontic Services:
- Diagnostic services, orthodontic cast, observation & adjustment, repairs, alterations, re-cementations
- Fixed bilateral/unilateral or removable orthodontic appliances
- Appliances to control oral habits
It is important to note, that most plans will also have provisions that will only allow reimbursement over a period of time (usually the length of the treatment plan suggested by the orthodontist). Insurers will often only pay up to 30% up front. Even if the provider offers a discount to pay via lump sum, it is important to note that you will only be reimbursed a maximum amount and that will be reimbursed over time, even if you pay in a lump.
In every instance, get a pre-determination!
Be sure of what your dental plan will pay – Get a predetermination!
Before you undertake any significant dental work, it is imperative to seek a predetermination. A predetermination is a way of getting a commitment from the insurance company of what they will pay, before you get the work done.
You can ask your dentist to request a predetermination before any major dental work. They will send a treatment plan to the insurance company. The insurance company will then assess the proposed course of dental treatment and provide an estimate of what will be reimbursed under the dental plan.
By submitting a predetermination, you can avoid any unpleasant surprises with respect to your dental coverage and be assured of payment.
Insurance companies will often allow for direct electronic payment to your dentist, so that you need only pay the outstanding amount. However, it is up to the dental office as to whether they accept this form of payment; therefore it is important to ask this question prior to your appointment so there are no surprises.
What to do if you are denied a dental benefit by the insurance company?
Reasons for a denial will be outlined in the predetermination or explanation of benefits from the insurer and can include:
- Insufficient documentation was submitted
- There is no coverage under your plan for the type of benefit you are requesting
- You have already reached your maximum allowed – yearly or lifetime
You should call the dental insurer and inquire why you were denied and if there is any additional information you could submit that would allow the claim. Keep copies of all paperwork you submit and receive from your dental insurer. You may need this documentation later if there is a dispute.
If the insurer maintains the denial and no further documentation will assist, then contact your employer and/or local union representative to confirm your coverage, and if the claim was correctly denied.
OPSEU/SEFPO does not represent members in appeals for dental benefits unless there is a formal Joint Insurance Committee in place through your Collective Agreement. You may have the option to grieve denial of your extended health care benefits. You should refer to your collective agreement and/or contact your local representative to confirm.
Bargaining Benefit Improvements
Should the insurer correctly deny the coverage, but you believe this coverage is important for your employer to provide, it will be important to identify the lack of coverage to your local leadership and colleagues. In order for coverage to be extended to provide for the benefit you believe should be included, it will likely need to be negotiated with the Employer in a future round of bargaining. If you and your colleagues believe a specific benefit is important, providing information, education and resources to your local leadership and your colleagues will be important to garner support for the change you want to see within your Collective Agreement. Bargaining begins essentially as soon as a Collective Agreement is ratified, meaning, you need to provide information and education to your co-workers often and early. That way, when your next round of bargaining is imminent, the seeds have
already been planted and you’ll ideally already have the support necessary to support the change you want to see. If you’ve rallied your colleagues, they too will ideally complete the bargaining survey and attend the demand set asking for the change to the Collective Agreement.
If you wish to contact the Pensions and Benefits unit, please email us at [email protected]