Confusion over reimbursements and eligibility slows claims under Canada Dental Care Plan rollout
Over half of all pre-authorized dental treatment requests under the Canada Dental Care Plan (CDCP) have been rejected, according to Health Canada — a figure raising concern among providers and stakeholders managing benefits plans.
As reported by CBC, 52 percent of pre-authorization requests between November 2024 and June 2025 were denied.
While most basic services such as cleanings and fillings don’t require pre-approval, complex procedures like crowns and partial dentures do.
These require detailed documentation, including X-rays and dental charts, which many clinics have submitted only to face delays or denials.
Bruce Ward, president of the Canadian Dental Association, said, “There’s been a lot of confusion for dentists who send in what we would normally send in to a private plan, and it comes back rejected.”
Ward added, “It’s a much, much, much higher rejection rate than private plans.”
Clinics must send these submissions through Sun Life, the government-contracted insurer for the program. According to Ward, providers often wait weeks or months for responses, only to be told more paperwork is needed.
Health Canada attributed these delays to incomplete applications and an unexpectedly high volume of submissions, though it said 80 percent are now processed within seven business days.
Despite over 5.2 million Canadians being approved under the plan, only 2.2 million have received care as of June 2025, as per CBC.
Ward pointed out that patients are arriving with years of untreated dental issues due to previous financial barriers, further straining providers.
In Atlantic Canada, for instance, clinics are already booking appointments into spring 2026, according to Natalie Marsh, vice-president of the Canadian Dental Assistants Association.
Beyond logistical hurdles, gaps in preventive care have also emerged.
Donna Wells, manager of professional practice at the Canadian Dental Hygienists Association, noted that adults only receive one hour of dental scaling per year, while teenagers are limited to 15 minutes.
She said requests for additional scaling are being “rejected en masse.”
Further issues have surfaced around the CDCP’s reimbursement rates.
As reported by Benefits and Pensions Monitor, clinics are permitted to charge patients the difference between their rates and what the plan covers, since the government’s reimbursement often falls below provincial fee guides.
Ward said some patients remain unaware of this structure, expecting procedures to be “100 percent covered.” He recalled a recent patient who was upset after learning they would have to pay out of pocket.
Andrew Ostro, CEO and co-founder of PolicyMe, argued the plan design discourages work and penalizes modest-income earners. “Between 70 and 80 [thousand], you have a 40 percent co-pay, and above that, you have 60 percent,” Ostro said. “At those levels, it doesn't do a whole lot.”
He also noted that many working-class households may find themselves disqualified despite low per-person earnings.
Ostro pointed to other design flaws as well — namely, the CDCP’s incompatibility with private insurance.
Unlike other public health plans, the CDCP does not complement existing workplace benefits but replaces them.
He warned that employers might wrongly assume workers are now covered and cancel dental benefits, exposing employees to higher out-of-pocket costs. “What you end up left with is a lot of people now in way worse shape than they were before this rolled out,” he said.
The plan also excludes some major procedures altogether, including dentures, and offers reimbursement rates that Ostro called “quite low” relative to market rates and dental association fee schedules.
This could discourage providers from accepting CDCP-covered patients, especially when those patients face partial reimbursements and dentists remain under no obligation to discount their fees.
“From a pure economic standpoint, you'd probably rather cover a patient who's fully covered by a plan versus one who's partially covered,” Ostro said.
He added that the government should publicly acknowledge the plan’s flaws, pause the rollout, and restructure the program with clear messaging that encourages people to retain their existing coverage.
Still, Ward said the program has given millions access to dental services they could not otherwise afford.
“It’s been a huge boon to a lot of people who frankly would never have been able to afford to have their mouths taken care of,” he said. “It’s remarkable. And yes, there’s going to be some growing pains.”
