An alternative benefit is a dental contract provision that allows an insurance company to reimburse a dental service at the cost of the least expensive procedure that is effective for the dental patient’s need.
Alternative benefit payments, when part of a dental plan, only apply when there are multiple clinically legitimate treatments for the same dental condition. In there are multiple treatment options for an enrollee’s dental condition, the insurance company will pay its portion of costs assuming that the lowest cost option was used even if the enrollee selected a more expensive procedure.
To illustrate an alternative benefit scenario, imagine that the enrollee has a cavity. A traditional filling for the cavity costs $200 while a white filling costs $350. The enrollee chooses to have a white filling. A dental plan with an alternative benefit clause would pay only its portion of the $200 cost even though the enrollee received a $350 white filling. The enrollee would be responsible to pay cost sharing on the $200 (e.g. a $50 copayment) plus the difference between the $350 expense and the $200 baseline as the least expensive procedure. This means the enrollee would pay $200 for the white filling ($50 for the copayment and $150 more for the difference between the $350 white filling expense and the $200 traditional filling expense).
An alternative benefit is also referred to as the “least expensive alternate treatment.”
Our knowledgeable customer service team will assist you with any questions you may have prior to enrolling in a dental plan. They can guide you through the process of choosing coverage that matches your needs as well as your budget.
