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Direct Answer — Why Am I Paying Out of Pocket with CDCP?
The Canadian Dental Care Plan (CDCP) is not free dental care. Even with 100% income‑tier coverage, you may still have some out‑of‑pocket costs for a few reasons.
The CDCP follows its own fee schedule, which may differ from the Ontario Dental Association (ODA) fee guide that many dental offices use. In some cases, this difference may result in a small amount for patients to cover. Depending on household income, a co‑payment may also apply, and some treatments may not be covered or may require preauthorization.
Overall, the CDCP helps cover a portion of eligible dental services based on plan guidelines, rather than covering all dental costs at every dental office.
≠ Free The CDCP is a benefit plan, not free dental care | 52% Of preauth requests denied Nov 2024 – Jun 2025 (Health Canada) | 92% Of Canadian dentists balance bill always or sometimes (Oral Health, 2026) | 56% Of Canadians still delayed dental care due to cost in 2025 (PolicyMe / Angus Reid) |
Sources: Health Canada CDCP Coverage Page; Oral Health Group, March 2026.
The Core Problem: A Partial-Payment Plan Sold as Free Care
The most consistent frustration patients express about the CDCP comes down to one thing: it was described publicly in ways that created expectations the plan was never designed to meet. As Bernard Dolansky, a senior dental industry consultant, put it plainly in the Oral Health Group’s December 2025 survey analysis: “The CDCP was presented like Medicare, as if patients wouldn’t have to pay anything, and that misunderstanding has never really been corrected.”
The reality is that the CDCP is a partial-payment benefit with four distinct mechanisms that can leave you with a bill even when you’re enrolled and eligible. Understanding each one separately is the fastest way to stop being surprised by your dental invoice.
1. Balance Billing: The CDCP follows its own fee schedule, which may differ from the fee guide used by some dental offices. When this occurs, patients may be responsible for covering the difference, regardless of income.
2. Income-Based Co-Payments: Households earning $70K–$89,999 pay 40–60% of the CDCP fee, even on covered services.
3. Non-Covered Services: Implants, veneers, whitening, bridges, and cosmetic work are not covered, you pay 100%.
4. Preauthorization Denials: Complex treatments require prior approval. If denied, you will be responsible for the full cost if you proceed.
Reason 1: Balance Billing — The Gap Nobody Warned You About
This is the most widespread source of unexpected CDCP costs and the least understood. The CDCP reimburses services using its own national fee grid, a set of dollar amounts the federal government determines for each procedure code. Most dentists in Ontario set their fees using the Ontario Dental Association (ODA) fee guide, which is typically 15-20% higher than the CDCP grid.
Balance billing is the difference between what your dentist charges and what the CDCP will pay. It is permitted under the program’s rules, and according to a March 2026 survey by Oral Health Group, only 8% of Canadian dentists report that they never balance bill. The other 92% always or sometimes do.
REAL-WORLD EXAMPLE — CLEANING + EXAM, INCOME UNDER $70,000
Your dentist’s fee for cleaning $220.00 CDCP established fee for same cleaning $175.00 CDCP covers (100% of established fee) $175.00 You owe (balance billing) $45.00
Note: Even at the “100% coverage” income tier, you still owe $45 because the CDCP only pays up to its own grid, not your dentist’s actual fee. This applies to every eligible service where your provider charges above the CDCP rate. |
The key takeaway: “100% coverage” in the CDCP context means 100% of the CDCP-established fee, not 100% of what your dentist charges. These are often two very different numbers.
Reason 2: Income-Based Co-Payments
If your adjusted family net income is between $70,000 and $89,999, you owe a mandatory co-payment on every covered service, before balance billing is even calculated. Co-payments are a percentage of the CDCP established fee, not a percentage of your dentist’s actual fee. This means co-payments and balance billing stack on top of each other.
Adjusted Family Net Income | CDCP Pays | Your Co-Payment | Plus Balance Billing? |
Under $70,000 | 100% of CDCP fee | 0% | Yes, the difference between the ODA fee guide and the CDCP established fee |
$70,000–$79,999 | 60% of CDCP fee | 40% co-pay | Yes, the difference between the ODA fee guide and the CDCP established fee |
$80,000–$89,999 | 40% of CDCP fee | 60% co-pay | Yes, the difference between the ODA fee guide and the CDCP established fee |
$90,000+ | Not eligible for CDCP | ||
STACKED COST EXAMPLE — CROWN, INCOME $75,000 (40% CO-PAYMENT TIER) CDCP established fee for crown $900.00 Your dentist’s fee for crown $1,200.00 CDCP pays 60% of established fee $540.00 Your 40% co-pay of CDCP fee $360.00 Balance billing (dentist fee minus CDCP fee) $300.00 Total out-of-pocket $660.00 Source for fee structure: Health Canada CDCP co-payment examples. Note: Crown also requires preauthorization before coverage applies. |
Disclosure: Dollar amounts shown are illustrative only and provided for educational purposes. Actual fees, coverage, and out‑of‑pocket costs may vary based on provider, location, and current CDCP rules.
Reason 3: Your Treatment May Simply Not Be Covered
The CDCP covers a defined list of services, and anything outside that list is 100% your responsibility. The procedures that most commonly surprise patients are those they expect to be covered but are not:
- Dental implants — not covered at any income level. The CDCP covers dentures as an alternative tooth-replacement option.
- Fixed bridges — not covered. The plan covers removable dentures, not fixed restorations.
- Veneers and cosmetic bonding — not covered, as these are considered cosmetic, not therapeutic.
- Teeth whitening — not covered under any circumstances.
- Orthodontics — not yet available for most patients. Coverage for medically necessary cases is planned, but the confirmed launch date remains pending as of March 2026.
- Services beyond frequency limits — if you’ve had a cleaning within the past 12 months and want another, it is not covered without preauthorization based on clinical need.
Implants Are the Most Common Surprise Gap Patients who delay dental care for years often need implants when they finally see a dentist, exactly the population CDCP was designed for. Yet implants are explicitly excluded. If you need tooth replacement, discuss whether dentures (which CDCP does cover) or implants (which CDCP does not) are appropriate for your situation. Our team at Costello Family Dentistry can walk you through both options and their costs transparently. |
Certain higher-complexity services, including crowns, partial dentures, complete immediate dentures, root canal retreatments, and general anesthesia, require the CDCP to pre-approve them before treatment begins. If you receive this treatment without preauthorization, or if your preauthorization request is denied, the CDCP will not pay, and you bear the full cost.
This is not a minor administrative issue. Between November 2024 and June 2025, Health Canada reported that 52% of preauthorization requests for complex dental work were denied. CBC and Oral Health Group confirmed these figures, noting that even excluding incomplete submissions, the denial rate dropped only to 38%.
“The CDCP uses its own national fee grid, which differs from the ODA fee guide used by most dental offices. Balance billing is permitted, meaning patients are responsible for any amount not covered by the plan, including both co-payments and the difference between fee guides. — MEK Dental, London, Ontario (citing CDCP program rules, 2025) |
Common reasons for preauthorization denials include incomplete clinical documentation submitted by the provider, the patient not meeting the clinical criteria for that specific procedure, the request being a duplicate, or the procedure having already exceeded its lifetime or annual frequency limit. If your preauth is denied, your dentist can appeal with additional supporting documentation, such as X-rays, treatment notes, and clinical photos, but this takes time and is not guaranteed to succeed.
Never Proceed With Preauth-Required Work Until Approved
If your dentist recommends a crown, partial denture, or other preauthorization-required treatment, do not schedule the procedure until you have written approval from Sun Life confirming CDCP coverage. Beginning treatment before approval means the CDCP will not pay, regardless of eligibility. Processing now typically takes 7 days for straightforward cases, but complex cases can take considerably longer.
How to Protect Yourself From CDCP Surprise Bills
Every one of these out-of-pocket cost sources is avoidable or at least predictable, if you ask the right questions before treatment starts. Here is a practical protocol:
- Request a pre-treatment EDI estimate: Before any procedure, ask your dental provider to submit a pre-estimate to Sun Life. This document shows the CDCP’s established fee, what the plan will pay, your co-payment amount, and any balance billing, before you’ve committed to treatment.
- Confirm your dentist’s balance billing policy: Ask directly: “Do you charge your standard ODA fee or the CDCP fee grid for CDCP patients?” Some offices waive balance billing as a patient access policy; others always charge their standard rate. Know which you’re dealing with.
- Verify your co-payment tier: Your co-payment level is based on your most recently assessed adjusted family net income. If your income changed at renewal, your tier may have changed. Bring your CDCP determination letter to every appointment.
- Do not pay for covered services upfront: The CDCP does not allow patient reimbursement. If your provider asks you to pay the covered portion and get reimbursed, that is not permitted under the program. Only the dental office bills Sun Life.
- For preauth-required work, get written confirmation: Before scheduling a crown, partial denture, or complex procedure, ensure your provider has submitted and received preauthorization approval, not just submitted the request.
- Ask about financing for non-covered services: For treatments the CDCP doesn’t cover, like implants, ask about payment plan options. At Costello Family Dentistry, we offer flexible financing to help manage the costs of treatment outside the CDCP’s scope.
Using Your CDCP at Costello Family Dentistry
At Costello Family Dentistry in Carleton Place, we accept CDCP patients and direct-bill Sun Life on your behalf. We believe transparency about costs is non-negotiable, which is why we review your coverage, run a pre-treatment estimate, and explain every expected cost before any work begins.
If you need teeth cleaning, root canal treatment, dentures, or any other covered service, bring your CDCP member card or eligibility letter, and we’ll handle the billing process. For services outside the CDCP, including dental implants, we’ll discuss your options clearly and without pressure.
You can also visit our CDCP information page for a summary of how we work with the plan, or contact us directly if you have questions before booking.
Related Articles
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What Are the Risks and Benefits of Dental Implants?
What Are the Different Types of Dentures — and Which Is Right for You?
Frequently Asked Questions
1. Why do I still have to pay out-of-pocket costs with CDCP if I make under $70,000?
Even at the 100% coverage tier, the CDCP only covers up to its own established fee grid, which may differ from the Ontario Dental Association (ODA) fee guide used by many dental offices. If the ODA‑based fee is higher than the CDCP rate, patients are responsible for covering the difference. This is known as balance billing and is permitted under the program. Always ask for a pre‑treatment estimate before any procedure to understand any potential out‑of‑pocket costs.
2. What is balance billing under the CDCP?
Balance billing is the difference between your dentist’s standard fee and the CDCP’s established fee grid for the same service. You are responsible for paying this difference directly to your provider. For example, if a cleaning costs $220 at your dentist but the CDCP grid rate is $175, you owe $45, plus any income-based co-payment on top. According to a March 2026 Oral Health Group survey, 92% of Canadian dentists always or sometimes balance bill.
3. Why was my CDCP preauthorization denied?
Between November 2024 and June 2025, Health Canada reported that 52% of preauthorization requests for complex dental work were denied. Common reasons include incomplete documentation from the provider, the procedure not meeting CDCP clinical criteria, a duplicate submission, or exceeding frequency limits. If denied, your dentist can appeal or resubmit with additional supporting clinical evidence, such as X-rays and treatment notes.
4. Does the CDCP cover dental implants?
No, dental implants are not covered under the CDCP at any income level. The plan covers removable dentures (complete and partial, some with preauthorization) as a tooth-replacement alternative, but does not cover implant placement, implant crowns, or implant-supported restorations. If you need tooth replacement, speak with your dentist about which option is clinically appropriate and ask about financing for implants if that is your preference.
5. Can I get a pre-treatment estimate before committing to CDCP-covered work?
Yes, and you should always ask for one before any procedure. Your dental provider can submit an EDI pre-estimate to Sun Life showing exactly what the CDCP will cover, your co-payment, and any balance billing, all before treatment begins. This gives you the full cost picture upfront and prevents unexpected bills.
Accuracy Notice: This article reflects CDCP rules and statistics as published by Health Canada, the Ontario Dental Association, CBC, and Oral Health Group as of March 2026. The CDCP is an evolving program; fee grids, preauthorization criteria, and program rules can change. Always verify your current coverage with your dental provider or Service Canada (1-833-537-4342) before proceeding with treatment.
