CDCP Coverage for Patients

Strap in -- this is going to be a long, thorough breakdown of your CDCP coverage. Grab a snack.

The Canadian Dental Plan has been a great resource for many Canadians. However, it is not without some draw backs.

Does everyone qualify for CDCP?

Yes and No.

There are only two factors which may exclude a Canadian citizen from being eligible for the CDCP plan.

1. You already have dental insurance.

   
   

   1. Example: You have a dental plan through your employer, you pay for an individual plan, or you are covered through a partner, spouse, or parent's dental plan

2. Your annual income is too high.

CDCP coverage has 3 tiers based on your household's net annual income. Net means after taxes (thankfully!).

Now, here is where some of the confusion begins!

What the CDCP considers 100% is not actually 100% of real dental fees. You see, dental office prices are determined by the Dental Association of your province of residence.

For Ontarians, that is the Dental Association of Ontario. All dental offices in the province base their fees on this guide -- it is standardized across the province. That means almost all dental offices in Ontario charge the exact same fees.

This is a good thing. It means:

1. There are no surpise upcharges and;

2. No one is receiving specialized or discriminatory pricing. That means no one should be paying less than someone else and no one should be paying more.

The CDCP has it's own fee guide which it considers as it's 100% (the maximum amount it will pay for a service). In reality, that 100% coverage of dental fees is more like 80%. As you go down the tier list, it becomes:

100% = 80%

60% = 40%

40% = 20%

If your income is between 80 000 to 90 000, I would consider your 40% CDCP coverage as more like a rebate than a full dental plan.

Hey, I'm not comlaining. This is the first time in history that dental treatments are being treated like universal healthcare. It's not perfect, but it's a good start. Rather than being upset there are still some out of pocket expenses, it's better to consider the alternative -- no coverage at all.

Please don't get mad at your dentist. They aren't any happier about this and I'll explain why in another article for dental professionals.

What services are covered and what services are not covered?

The CDCP has one really great feature. It has no maximum. What is a maximum? That is the amout of money a plan member is entitled to utilize per benefit period. For most dental plans, that can look like $1000 per calendar year up to $3000.

For employee-based dental plans, the maximum amount is determined by your employer when they decide which plans to purchase for their employees. Every dental plan has a different maximum. It is important to know your plan maximum to make sure you don't exceed your plan coverage.

Now, back to the CDCP!

The CDCP covers all basic dental services (sometimes called preventative services). Let's quickly go through what these terms mean.

Basic = your standard dental care. That includes:

• Dental exams (complete oral exams (aka. new patient exam), specific area exam, and emergency exam

• X-rays ------> NOTE: Only 8 x-rays of any type are covered per 12 rollings months

PS: What are "rolling months"? Rolling months mean it's not calendar year (Jan-Dec). The coverage does not automatically reset every January like many employer dental plans. Rollings months begin on the date you receive a service. So, if you have 8 x-rays on May 14th 2024, you won't be eligible for coverage again until May 14th 2025.

• Fillings/Restorations

  • There is NO MAXIMUM for restorations with CDCP. You can have as many fillings as you need. The only exception is they will not pay again for the same tooth + same tooth surface unless more than 2 years has passed.

• Extractions

  • No maximum for extractions. You could theoretically take out all of your teeth. In fact, once we get to the Major Restorative section, you'll see why they cover extractions so readily.

• Cleanings

PAUSE.

We've hit a snag. Although cleanings are a "basic dental service", the CDCP only covers 1 cleaning every 12 rolling months.

Q&A: How are dental hygiene services billed?

Dental cleanings are billed based on time. They are billed as someting called scaling units. A scaling unit is anywhere from 7-15 minutes of time that a hygienist has spent:

• Removing calculus from your teeth with hand instruments or a cavitron

• Performing other hygiene services such as flossing or oral hygiene instruction

• Setting up your dental operatory, reviewing your medical history, and making clinical notes during or after your visit

• Odontogram or periodontal charting

  • Periodontal charting involves checking the gum pocket depths around the outside and inside of your teeth along your gumline. They also mark areas of recession, bleeding, and other This is important information! Not just for your dental care team to get a clear picture of your periodontal status but for CDCP coverage it is required. I will get into that more later in the post.

The CDCP covers 4 scaling units per 12 months. For most adult cleanings, that is 1 appointment only as a standard adult hygiene therapy appointment is 1 hour. Although some offices only bill 3 units per cleaning, so roughly only 45 minutes of th 1 hour only is actually charges, the CDCP still only effectively covers 1 cleaning per 12 months.

1 unit of cleaning is around $56-66.00 dollars. So out of your $200, 3 unit cleaning appointment, ony a small portion would be covered if you decided to have your cleanings every 6 months under CDCP.

I have to say, no one is very impressed with this arbitrary limitation. Would it kill the CDCP to cover the standard 2 cleanings a year?! So everyone should just walk around will build up on their teeth instead?! I digress.

Cleaning adjunct services:

• Fluoride is covered, 1 unit, every 12 rolling months

• Polish is covered, 1 half unit, every 12 rollings months

Major Restorative

What is major coverage? That includes things like:

• Dental crowns

• Partial and Complete Dentures

• Bridges

When the CDCP was first introduced, they did not cover any major treatment.

SPECIAL CONSIDERATIONS

• Root canals = covered

  • An offshoot of root canals is also covered, known as a pulpotomy or pulpectomy. That is where your dentist or endodontist either treats the pulp or only removes some of it. This takes the pain away from a tooth but it is not a complete root canal which requires that the roots be filled and sealed.

  • A dentist may perform a partial root canal like a pulpectomy for a patient during emergency treatment and then refer to an endodontic specialist to finish

  • If the roots are oddly shaped or they cannot access the full roots. Your dentist may attempt a root canal and have to refer you to a specilist to complete it.

PS: Why does this happen?

A general dentist office only has 2D x-rays. The standard x-rays you get at your regular office. The roots of the tooth may not be adequately shown on an x-ray and they won't know until they open up the tooth.

A specialist office has special imaging called a CBCT which stands for Cone Beam Computed Tomography. It allows a radiologist or specialist to see all structures inside your anatomy. The CDCP and specialist services like CBCT I may cover in another article. Quick tip: CBCT scans are not currently covered by CBCT.

Simple, uncomplicated root canals are covered by CDCP. They will not cover all types of root canals. Calcified canals, exceptional anatomy, and difficult access root canals are not covered.

We start to get into why the CBCT covers extractions...

Going back to Major Restorative, it is now covered by CDCP. But there are MAJOR exceptions.

I may or may not have posted my article yet for dental professionals and CDCP major coverage. At this time, getting approved for a dental crown, bridge, partial denture or denture is very very difficult.

It requires exceptionally specific criteria that 99% of patients will not qualify for. Please understand, the CDCP is not your dentist. Your dentist will make recommendations to benefit the longevity of your dentition.

The CDCP would prefer to pay for a simple extraction at $200-500 than pay $1500 for a dental crown to prevent a patient from fracturing a weak tooth. Risk of cracks, fractures, chronic sensitivity or pain, and even root canals are not enough of a reason for the CDCP to approve a crown.

Now, we all know, molars need a dental crown after a root canal. Why? The tooth is hollow. A molar is very susceptible to breaking from the pressure of your bite after a root canal and your dentist will often recommend a crown. Please be cautious when using CDCP coverage to determine your dental treatment. Just because someting isn't covered, doesn't mean you don't need it.

What is NOT covered by CDCP.

• Orthodontic treatment

  • It's not covered yet. It may become available in 2026 or beyond. The intial rollout was supposed to take place in 2025 but it has not happened yet.

• Veneers/cosmetic crowns or any treatment that might be considered aesthetic

• Whitening

• Implants

  • and treatments related to implants such as bone grafts and ridge augmentation (socket grafts post extraction)

• Periodontic services

  • Gum graft surgeries

    • Gum grafts, flap surgery (peeling back the gums to clean/contour below your gumline to remove bacteria and subgingival calculus)

    • Most other specialized procedures

• Night Guards

• Sleep apnea devices like snoreguards

• Sedation

  • NOTE: Nitrous oxide is covered

  • Conscious IV sedation, oral sedation, and general anesthesia (performed outside of hospital) is not covered

• TMJ treatments

Let me know if anyone would like more detailed breakdowns of coverage.

Thanks,

Your Dental Receptionist