Government Dental Insurance Programs in Ontario

Government Dental Insurance Programs in Ontario

There are three major government funded dental programs in Ontario:

  1. Ontario Disability Support Program (ODSP): provides coverage for patients with physical or mental disabilities
  2. Ontario Works: provides coverage individuals 18-64 years of age who meet income requirements (generally low income)
  3. Healthy Smiles Ontario: children and youth aged 17 and under who meet income requirements (generally low income) see separate blog post for more information

 

Other government funded insurance programs include: First Canadian Health (First Nation/Inuits), Veterans Affairs, and Interim Federal Health (refugee and refugee claimants)

 

What is covered?

In general the following BASIC services are covered:

ODSP:

  • Recall (01202), Specific (01204) and Emergency (01205) exams
  • Radiographs (4 films every 12 months)
  • Scaling (1111#) every 12 months
  • Restorations
  • Extractions, biopsies, excision, management of trauma and fractures
  • Endodontic treatment (up to 3 canals), apicoectomy/retrofilling (maxillary and mandibular anterior teeth)
  • Non-surgical management of oral diseases (codes 41211, 41231, 41232, 41233)
  • Gingivectomy when related to cases involving gingival induced hyperplasia (42311)
  • Dentures/relines/repairs (complete/partial) are considered a discretionary benefit and must be pre-determined by provider prior to treatment and approved
  • Anesthesia (nitrous oxide) general, deep, etc)
  • Topical application of Chemotherapeutic/antimicrobial agents (43511)

 

Ontario Works, varies by region but in general includes the following as they relate to pain relief/emergency treatment:

  • Emergency (01205) and Specific (01204) exams (max of 3 per 12 months per dentist)
  • Extractions (71109 etc.)
  • Nitrous oxide (92412) when performed with extractions
  • Endodontic treatment (up to 3 canals) are considered a discretionary benefit -often for the anterior twelve teeth (canine to canine) which are symptomatic, periodontally stable, can be maintained without crowns and have an overall good prognosis. Services must be predetermined by the provider and approved. Pulpectomy/pulotomy are gernally approved as emergency procedure given that the tooth is restorable with a conventional restoration
  • Dentures/relines/repairs (complete/partial) are considered a discretionary benefit and must be pre-determined by provider prior to treatment

** Please note that there are frequency limitations associated with all programs. A predetermination is recommended prior to all treatment if the provider is unsure of remaining coverage

What is not covered?

Cosmetic treatments and fixed prosthodontic services are not covered for ODSP and Ontario Works patients

 

Ontario Works:

  • Preventive services
  • Endodontic treatment of premolars and posterior teeth, crowns and fixed prosthodontics are not covered expenses.

 

More information on coverage can be found at https://www.mcss.gov.on.ca/en/mcss/programs/social/odsp/income_support/odsp_dental.asp

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