28 Jan The Alternate Benefits Clause
Dental insurance policies may have an alternate benefit clause, which is “a provision that helps determine how payment will be made when there are several ‘clinically accepted’ dental services that can satisfactorily correct the dental dentition” (Summerford 2013). This clause was also called the Least Expensive Alternative Treatment (LEAT) clause (“Least Expensive Alternative Treatment Clause” 2007, 1). Due to this clause, the policy would cover “‘the least expensive treatment option,’” but patients could still choose the pricier procedure (Summerford 2013). With the pricier option, they would be covered at the rate of the cheaper treatment, but pay more out-of-pocket based on the price difference of the fees, which is established by the clinic, between the cheaper and more expensive options (“Alternative Benefits (Downgrades);” Summerford 2013). The alternate benefits clause can apply to many services.
The clause can include many types of procedures that would affect the patient’s overall bill. For instance, when patients need a restoration for their bicuspids and molars, the amalgam (silver) filling is cheaper than the composite or resin (white) filling (“Alternative Benefits (Downgrades)”). The clause usually covers fillings at the rate of the amalgam option, “[reducing] the amount [the dentist’s] office is reimbursed and increases the patient’s out-of-pocket copayment,” if patients choose the resin fillings (Funk 2018). If the patient needs crowns for their molars, the policy would cover the all-metal crown as the alternate benefit instead of the all-porcelain (white) crowns and porcelain-covering base-metal crowns, both of which costs more than the all-metal crowns (“Alternative Benefits (Downgrades)”). While the alternative treatment may work just as well as the more expensive treatment, the dentist may recommend the pricier option if it benefits the patient more, “based on the clinical circumstances, needs and desires presented by the patient” (“Least Expensive Alternative Treatment Clause” 2007, 2). Sometimes, patients could benefit with the cheaper option. For instance, while resin composite fillings look more similar to the patient’s teeth than the metal fillings, patients have to replace resin fillings more often because “[resin] composite fillings last five to seven years, which is half the lifetime of an amalgam filling” (“The facts on fillings: Amalgam vs. resin composite” 2018). Patients also must go through a longer process with a resin filling than a metal filling (“The facts on fillings: Amalgam vs. resin composite” 2018). Based on these comparisons and assuming that the patients are not allergic to the metals in the amalgam, patients could choose amalgam fillings for less out-of-pocket payments under the alternate benefits clause (“The facts on fillings: Amalgam vs. resin composite” 2018).
Dentists and patients should review the clause thoroughly and get a pre-estimate before proceeding with treatment (Funk 2018; “Least Expensive Alternative Treatment Clause” 2007, 5). The clause can help direct patients to more affordable options. However, since dental conditions could differ between individual patients, some patients may have to choose the more expensive option.