Interim Administration of Mandatory Dental Benefits

for Children under Ontario Works

The Board of Health recommends the adoption of the following report (June 15, 1998) from the Medical Officer of Health:

Purpose:

To advise the Board of Health of the expanded mandate of the Municipality for the provision of children's mandatory dental benefits under the Ontario Works Act.

To describe a system to be administered by the Public Health Division for the interim management of this program.

To seek approval for the Department to acquire the resources necessary to implement the program.

Funding:

Funding for the program is available in the Social Services Division, Community and Neighbourhood Services Department, approved budget. The estimated cost of the program is $10 million ($2 million net) for dental services plus 10 percent ($1 million gross or $0.5 million net) to administer the program. The cost of providing services is reimbursed 80 percent by the Province; the cost of the administration is reimbursed 50 percent by the Province. The Social Services Division is also concurrently submitting to the Ministry of Community and Social Services a budget estimate for the program.

Recommendations:

It is recommended that:

(1)Toronto Public Health be authorized to contract with Social Services Division, Community and Neighbourhood Services Department, to administer, on an interim basis, the Ontario Works Mandatory Dental Benefit Program For Children Age (0-17) effective July 1, 1998 subject to final concurrence of the Ministry of Community & Social Services; and

(2)Toronto Public Health staff be authorized and directed to take the necessary action to implement this report.

Background:

In June 1997, the Province announced its intent to reform the social assistance system. The Ontario Works Act (OW) and the Ontario Disability Support Program Act (ODSP) replaced the General Welfare Assistance Act (GWA) and the Family Benefits Act (FBA). Municipalities and First Nations are now responsible for OW service delivery including mandatory dental care benefits. Under the new social assistance legislation, it is mandatory for municipalities to provide dental services to children under age 18 years, whose parents are receiving OW and ODSP as of May 1, 1998. Dental benefits for adults is discretionary. Program cost sharing has changed from 50/50 to 80/20 Provincial/Municipal and 50 percent of the administrative costs.

Across Ontario there have been different approaches to administering dental programs for welfare recipients. Currently in Toronto, children in receipt of social assistance receive treatment through the Children In Need of Treatment (CINOT) Program administered by Public Health. CINOT was designed to meet the needs of children up to grade 8 who had an urgent dental condition. Once in the program, the child was eligible for one complete course of dental treatment and for preventive maintenance.

Until January 1, 1998, the Ministry of Health provided 100 percent funding for the CINOT Program. At that time, responsibility for funding CINOT was downloaded to the municipalities under the provincial Who Does What process. These changes have significant impact on the provision of dental benefits by municipalities for low-income families and families on social assistance. The Community and Neighbourhood Services Committee was informed of these changes in a report Provision of Dental Services to Social Assistance Recipients, dated April 14, 1998.

On April 30, 1998, all municipalities received the schedule of the dental benefits for implementation of the program as early as May 1, but no later than August 31, 1998. On May 5, all dentists in Ontario received from the Ministry of Community and Social Services, the interim schedule of covered dental services and fees, but no instructions on procedures. Given the short time to implement this program, Public Health and Social Services management staff is recommending that the most efficient way to implement this program fully by the deadline of August 31, 1998 is to expand on the current administrative structure of the CINOT Program in the Public Health Division.

Discussion:

(1)Existing Structure and Processes

In 1990, the former Metropolitan government delegated the management of dental care the children of GWA families to municipal public health agencies. Public health departments provided preventive services and administered or provided care for children of low-income families under the provincial Children in Need of Treatment (CINOT) Program. Social service workers and Public Health CINOT staff cooperated to ensure that care was provided to these children through an effective referral system. During 1997, 12,000 children in Toronto were treated under the CINOT program, approximately 50 percent of whom were clients of GWA.

(2)CINOT Program

Since its inception in 1987, the CINOT Program has been delivered each year within its allotted budget, while ensuring that any child in urgent need of care obtains a full series of dental treatment. Public health divisions have been successful in achieving this through the practice of quality management which includes:

(a)screening to identify those in need of dental care, so that only those children who needed care received dental benefits;

(b)providing services and a frequency of services which is based upon evidence that such services have a positive impact on health;

(c)providing preventive services by public health staff, and

(d)requiring a predetermination of those services which are infrequently required and expensive.

(3)Additional Requirements under Ontario Works

The OW schedule of services and fees for children is more comprehensive than the existing CINOT schedule and includes payment for preventive services and coverage for routine dental care (not restricted, as in CINOT, to those with urgent need). Additionally, children aged 14-17 are eligible for dental benefits under Ontario Works, whereas CINOT eligibility extends only to

Grade 8.

It is estimated that the number of children in Toronto that will be eligible is 104,000. Of that number, it is further estimated that 40 percent will utilize the program.

(4)Services to be Provided by Pubic Health

Toronto Public Health will follow established CINOT procedures to administer the program. Staff will ensure that:

(a)Children will be screened to identify their needs. If they have no needs they will be invited to return for a recall screening after an appropriate period;

(b)children with identified needs will be issued a claim form to authorize care from their dentist of choice;

(c)Toronto Public Health dentists will predetermine the services which require prior approval as defined by the provincial schedule of dental benefits;

(d)claims will be submitted to Public Health offices for payment;

(e)Toronto Public Health dental staff will review claims to ensure program standards are met and will authorize payment;

(f)reimbursement to dentists for provision of services will be carried out by Toronto Public Health;

(g)Toronto Public Health will request cost recoveries, via monthly transfers from Social Services, as reimbursement for amounts spent (staff are working to establish a means to do this electronically);

(h)Toronto Public Health dental staff will conduct periodic audits using a sample of patients in order to ensure that services paid for have been provided, and

(i)for emergency patients who present in a dentist's office, Toronto Public Health staff will authorize the emergency care by phone. For the remaining care, Toronto Public Health staff will initiate the process as above. For after-hours emergencies, clients will be required to present their eligibility card to the dentist. The dentist will then confirm eligibility the following working day.

(5)Budget

Due to the short time frame given to implement the management of this program and the fact that an additional age group (15-17) has been included in the program, it is difficult to detail the resources that the Public Health Division will require to administer this program.

It is anticipated that the interim administration of the mandatory dental program for children under Ontario Works will require additional resources in the Public Health Division. These resources include staffing and information technology. Funding for these resources will be obtained from the funds reimbursed by the Social Services Division to the Public Health Division for interim administration of the program. However by incorporating the principles of need-based health care into the program there will be significant savings to the municipality.

These principles include:

(a)Public administration to ensure accountability through open reporting;

(b)needs assessment (case-finding to ensure that those who need care are identified and followed-up and that the costs of diagnostic work-up and extensive preventive care are avoided for those who have no need);

(c)quality audits of care to ensure clinical success and to detect and deter fraud;

(d)treatment and preventive service eligibility based on the current best evidence, and

(e)predetermination of infrequently needed, but often very expensive, services to ensure that the program is comprehensive, stays within the established budget, and the treatment proposed is appropriate to need.

Conclusion:

This report outlines an administrative system of mandatory dental benefits for children under Ontario Works. This system is to be administered by the Public Health Division on behalf of the Social Services Division, subject to final concurrence of the Ministry of Community & Social Services.

Contact Name:

Dr. Jack Lee, Regional Director, Toronto Office

Tel:392-7467

Fax:392-0713

Dr. Jim Leake, Dental Restructuring Project, Toronto Office

Tel:392-7454

Fax:392-7418