More dental patients, providers baffled by lack of consistency in national plan's coverage

Cameron robert brown knows how of import number one impressions ar when trenchant for a job.

So when he got a letter on his 65th birthday saying he qualified for the Canadian Dental Care Plan (CDCP) last year, he was thrilled.

Brown had two teeth that needed to be replaced.

But when his dentist submitted the pre-authorization request for dentures, it was turned down.

“First of all, they said it wasn’t essential,” said Brown.

“I remember my sister saying well, ‘He’s an unemployed senior, how do they expect him to get work with two missing front teeth off to the side?’”

His sister ended up fronting the bill, to the tune of $1,000.

Brown’s dentist appealed the insurance provider’s decision, but that request was also rejected.

“I never got a penny from them,” said Cameron, who lives in Toronto.

The CDCP was rolled out by the federal government in 2024 to help improve access to dental care for uninsured Canadians with a household income under $90,000 a year. 

But questions around eligibility and a lack of clarity about why some patients are denied coverage remain major barriers.

More than 6.5 million Canadians are eligible for care under the CDCP. 

As of April 2026, more than 4.3 million people have already received care, totalling over $6 billion in claims, according to Health Canada.

It’s a lot of money, but the federal government has assured the Canadian Dental Association the long-term sustainability of the program is not at risk, said the association's president, Dr. Kirk Preston.

But consistency and predictability around what is and isn't covered continue to be problems, said Preston.

Some people have cancelled treatment because they don’t have the time or energy to go through a lengthy appeals process if their pre-authorization request is rejected, he added.

“When treatment is postponed or denied, the consequences can lead to irreversible tooth loss, often leading to more complex dental issues,” said Preston.

Dr. Melvin Lee runs a dental clinic in downtown Ottawa.

His office has run into similar challenges trying to get pre-approval for crowns. More complex procedures, such as crowns or dentures, need to be pre-authorized before treatment can proceed.

Out of dozens of requests, all but one was denied by insurance provider Sun Life, which administers the CDCP and processes claims. 

“It’s tremendously frustrating when we’re receiving rejection after rejection after rejection without any details or instructions, recommendations, action items as to why such a pre-determination was rejected,” said Lee.

He thinks Health Canada should consult with front-line dentists more frequently about the challenges they are having with the program to figure out what needs to be improved.

The government also needs to clear up how much coverage patients receive for basic, preventive care, said Kathryn Taylor, a dental administrator with 40 years of experience.

“The periodontal part of the plan is woefully inadequate,” said Taylor, who works at a dental office in Victoria, B.C. 

Periodontal care includes cleaning, scaling, root planing, polishing and fluoride. These treatments can help prevent gum disease as well as tooth and bone loss.

Dental plans that are privately or employee funded usually have a set amount of cleaning that’s covered in a calendar year, said Taylor. But some patients need to go more often, so many plans have an annual maximum.

But the CDCP’s fee guide does not mirror anything Taylor has seen provincially.

Even cases she thought would be a slam dunk to qualify for more coverage were denied, with no justification other than they do not meet the criteria.

“So we’re having to educate patients about what they’re going to have to pay because there will always be a balance,” said Taylor.

She thinks the CDCP should set an annual limit. That makes it clearer for patients and may also help avoid any potential abuse.

“You don’t have carte blanche to do everything,” said Taylor. “There are practitioners out there that will over treat.”

She also says Sun Life needs to ensure only procedures that are medically necessary are approved.

Sharon Cameron is worried some dentists may be exploiting the program.

Like Brown, Cameron, who is in her 70s, was relieved to get coverage under the CDCP. She’d been cautious with her teeth, but was grateful to have a cleaning and X-rays done.

But after her exam, she was told she needed some fillings replaced and was given options for an action plan.

“One of them, total, after seven appointments, would have been $11,411,” said Cameron, who lives in Mont-Saint-Hilaire, Que.

She felt the action plan was a money grab.

“Is there anyone really monitoring the dentist and what they’re doing here?” said Cameron, who fears the CDCP will be scrapped if it's abused.

“I don’t want to lose it. It’s very important to people, but it has to not be misused.”

A spokesperson for Health Canada said there is a “robust” verification process to make sure that only procedures that meet the plan's criteria are covered.

There are also safeguards in place, including audits, to avoid abuse.

Health Canada says CDCP members and dental care providers can review the benefits guide online. There are videos and checklists available.

The federal government meets with national and provincial-territorial associations regularly to share information, gather their feedback and improve the plan’s administration and processes, said Karine LeBlanc, a spokesperson for Health Canada.

Brown hopes the government can sort out the confusion.

“I know there are people out there who need these kinds of services," he said.

“They need someone to go in there and make it work.”

Journalist

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