Why am I having to pay for fillings that should be free for a pensioner?

I am 71, have a full medical card and full PRSI contributions for optical and dental treatment. My query is this. My dentist told me that I need a filling on a back tooth. She said it will be €100. I thought that I was entitled to two free fillings a year.

Today the hygienist and the exam with the dentist cost €25.

Could you please advise if I should be entitled to free fillings?

Mr SM, email

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Dental care for medical card holders is becoming an increasingly tricky situation. The bottom line is that there is a growing gulf between what you should be entitled to and what you can actually get.

The rules on dental services for medical card holders – which includes most older people – are pretty straightforward. As outlined by the HSE, every medical card holder is entitled to a free dental examination every year. As your recent visit was likely to have been your first one this year, it should have been free.

As far as I understand, free teeth-cleaning is available only to people with certain specific conditions. According to a recent report on State-funded dental care, the routine “scale and polish” service that used to be available under the medical card scheme is suspended, as are X-rays.

However, the Department of Social Protection says that pensioners who met the PRSI coverage rules in the year before they retired (which you say you do) are entitled to payment of up to €42 towards the cost of a scale and polish. Dentists can, however, charge a fee of up to a further €15 for this work.

On that basis, you should have been charged no more than €15 for the hygienist’s work as far as I can see.

What are those PRSI rules? Well, you need to have paid a minimum of 260 PRSI stamps over your working life and you need to have either 39 paid or credited PRSI weekly payments in the year you turned 64 or the year before it, or you need to have 26 paid PRSI stamps in both the year you turn 64 and the one before it.

Why 64? I don’t know. It is called the “relevant tax year” in this regard by the Department of Social Protection and is defined as the second-last completed tax year before you turn 66.

Fillings

On fillings, should they be necessary, you should be entitled as you thought to two free fillings in any calendar year. If you needed any teeth pulled, that too would be covered, without limit.

There are other benefits that should be available, although they are discretionary. These include provision of dentures, for which the dentist will need to seek specific HSE approval.

The issue you appear to have run into is the gap between what you are entitled to and the number of private dentists prepared to undertake medical card work. This is becoming a serious problem, with dentists complaining that the system is close to collapse.

The problem dates back to the financial crash back in 2008. For most people, this is now hopefully a distant memory, but if you are a medical card patient seeking dental care, it certainly isn’t.

With austerity, the HSE imposed reduced pay for dentists under the Dental Treatment Services Scheme and the Treatment Benefit Scheme. More significantly, it said treatments were only available to medical card holders on an emergency basis – including fillings – according to an independently commissioned report by the Irish Dental Association published last month. That report's author, Ciaran O'Neill, who is professor of health economics at Queen's University Belfast, said nothing had changed in the 13 years since.

The problems with the medical card scheme – especially the amount paid under it – has apparently led to an exodus of private sector dentists out of the programme. The number prepared to do medical card work has fallen by more than 50 per cent in the past two years, according to the incoming president of the Irish Dental Association, Dr Caroline Robins. The association says it is estimated that only about 750 of the State's 2,000 private dentists are now accepting medical card work. The areas worst hit appear to be Dublin and Wicklow.

“A service that relies on self-employed general dental practitioners will not function if it refuses to at least cover their costs of delivery,” Prof O’Neill says in his report. “Adequate funding remains central to it or any scheme’s success.”

The dentists accuse the HSE of "arbitrary and unilateral changes" in the medical card contract and say that "explicit written promises from representatives of the Department of Health have been reneged upon to the anger and dismay of dentists and their patients".

So where does that leave you? It appears that if your dentist did offer medical card services, she no longer does so. Your choices are really either to pay as a private patient at your current practice or contact your local health centre where they will have a list of dentists doing medical card work – assuming they can take any more onto their books.

Fair notice

To be fair, if your dentist previously undertook medical card work and no longer does so, I would expect that they would inform all medical card patients to this proactively. This should be done ideally when the decision to withdraw from medical card services is made, but certainly at the point when an appointment is made.

The problem here is twofold. Firstly, people have a relationship with a dentist. They use that particular person because they feel secure in their care. People rarely move dentist unless they relocate to a different part of the country or have a poor experience in their care. And moving can be an uncertain process.

Secondly, people generally only contact their dentist at a time of need. Suddenly finding that you have to either pay up for an unexpected and unwelcome bill or scramble around for a provider who will accept medical cards even as you suffer pain is not something any of us would be happy to do. Hence the reason any reasonable practitioner should give proper advance notice.

To charge people who understood their treatment was covered under the service is not remotely reasonable.

Please send your queries to Dominic Coyle, Q&A, The Irish Times, 24-28 Tara Street, Dublin 2, or by email to dcoyle@irishtimes.com. This column is a reader service and is not intended to replace professional advice