The Alternate Benefit Clause: What You Need to Know

Suppose you just found out from your dentist that you need to have a bridge placed. You feel confident your plan will cover most of the proposed amount and your out-of-pocket expenses will be minimal. Then you find out your insurance provider will pay less than you thought. They explain that due to a clause in your coverage, they will consider a different procedure instead. How did this happen?

Most plans are meant to cover core and restorative services, with limited coverage for extensive and costly major dental services. Should you assume that if your dentist recommends a treatment, it’s automatically eligible for reimbursement? Submitting an estimate or pre-determination form to your dental insurance provider is the best way to find out. Sometimes a clause is included that you weren’t aware existed, and this can affect your claim in a serious way. One such provision commonly found in dental plans is known as the Alternate Benefit Clause, affectionately named “the ABC.”

What is the Alternate Benefit Clause?

The Alternate Benefit Clause is a stipulation in many dental plans stating that certain dental procedures must convert to a less expensive treatment. The patient can still receive the more expensive treatment, but is reimbursed for the amount of a procedure that 1) is less expensive and 2) serves the same function.

For example, you have a missing molar. Your dentist thinks an implant would be ideal, so he sends an estimate to your dental insurance provider. Contrary to what you might expect, your provider reverts to the ABC and doesn’t approve the implant. Rather, they decide to pay for the equivalent partial denture instead. You can still get an implant, but you will be reimbursed for a denture.

The ABC isn’t limited to major dental services. Tooth-coloured fillings on molar teeth may convert to the equivalent metal. Again, you don’t need to have the metal fillings placed; but you will only be paid their equivalent cost.

Why Does My Plan Have This Clause?

While many dental procedures are innovative and more efficient than their predecessors, they almost always cost significantly more. When a person has extensive dental work done, their premiums may not cover the entire procedure. In an effort to keep costs down, many plans have the ABC.

The ABC isn’t meant to stand in your way from getting the treatment you need. It is a provision in your plan that is intended to provide coverage for the most cost-effective option. It is a financial limitation that allows you to go ahead with the desired treatment but only covers a certain amount.

Which Dental Procedures Are Most Likely to Fall Under this Clause?

The ABC differs from plan to plan. Some plans don’t cover implants, others may pay for a bridge or denture instead of the implant, and others might convert a bridge to the less expensive denture. Most insurance providers require an estimate or “predetermination of benefits” that lists the proposed treatment, the proper codes, the costs, the teeth involved and a panoramic x-ray of the patient’s entire mouth. The insurance provider reviews the estimate and x-ray and determines what procedure is eligible for reimbursement.

How Will My Insurance Plan Determine the Total Amount Reimbursed?

Suppose the total cost of a bridge is $1,830.00 but the procedure is converted to a partial denture through the ABC. According to the applicable fee guide, the acceptable amount for a partial denture is $710.00. Your plan pays major dental services at 50%. You are therefore eligible to receive roughly $355.00. You end up paying much more out of pocket than you had anticipated which is why estimates are always encouraged.

How Does This Tie In With My Yearly Maximum?

“We offer some dental plans that run by the calendar year and replenish every January 1”, while other programs may run for 12 consecutive months (a benefit year). Your plan likely has a maximum amount per year (consecutive or annually) and will most certainly impact your claim. If your plan covers $1,000 annually for major dental services, you will likely receive that amount for a bridge converted from an implant, depending on the cost. Keep in mind that most major dental coverage pays at the rate of 50%, but be sure to double check your plan parameters. Also, your maximum does not carry over to the next year if you do not use any of the major coverage.

What If My Plan Doesn’t Cover Implants?

If your plan explicitly states that it excludes implants, it will automatically reject any implant claims or estimates. The ABC does not apply to excluded services. Even if the dentist sends an estimate stating that implants are the optimal or only solution, they would not be eligible, and you would thereby be responsible for any costs.

If My Plan Won’t Cover Implants, Can I Send My Claim to My Spouse’s Plan?

Coordinating benefits with a spouse requires that you first submit your request or estimate to your plan first. Whether your plan will pay an amount or outright reject it, your partner’s plan will need proof in the form of an Explanation of Benefits.

If the other plan excludes implants, the claim will not be eligible for reimbursement. If your spouse’s plan provides coverage for bridges and dentures, your application can be assessed and possibly reimbursed for the remaining amount up to the yearly maximum.

Your spouse’s plan may be significantly different from your own, so when sending an estimate to your plan, you should send one to your spouse’s as well.

What if My Dentist Disagrees With the Decision?

Your dental plan dictates your coverage. Your dentist likely has your best interest at heart and wants to fix the dental issue, but ultimately, the decision on what route to take is yours. Talk to your dentist and see what other options there are. If you decide to go ahead with the treatment, you must realize that you will be absorbing the costs that are not eligible or covered under your plan. The ABC is not meant to dictate your choices, but to limit coverage.

What Are My Options if I Decide Against That Treatment Due to the Clause?

If the provision is enabled and the plan only pays a certain amount, this may leave you significantly out of pocket, and you may decide against the original procedure.

Alternatively, some patients opt for the less expensive method. With the Alternate Benefit Clause, it’s a difficult choice, but it IS better than an outright rejection of a proposed procedure.

The predetermination process helps you make an informed decision on your next steps. Some people do opt for the less expensive treatment to avoid paying larger amounts out of pocket, but that’s a decision you have to make yourself.

Understanding your plan is critical as you make important choices that have a direct impact on your dental health. Be sure to look for clauses such as the ABC and talk to your dentist about your options.