Dental Insurance Benefits & Alternative Benefits
Dental insurance can sometimes be confusing, especially when your Denver dentist recommends one treatment, but your dental insurance plan calculates its benefits based on a different procedure.
If you have ever looked at an insurance estimate and wondered, "Why is my insurance covering a filling when my dentist recommended a crown?", you are not alone.
One reason this can happen is something called an alternative benefit, also known as a Least Expensive Alternative Treatment, or LEAT.
Understanding how alternative benefits work can make it easier to understand your dental insurance benefits, your treatment options, and your expected out of pocket costs.
What Is a Dental Insurance Alternative Benefit?
An alternative benefit is a way that some dental insurance plans determine how much they will contribute toward treatment when there is more than one professionally acceptable treatment option.
For example, your dentist may recommend a crown to protect a tooth that has significant structural damage. Your insurance plan may calculate its benefit based on the cost of a large filling instead.
This can be confusing, but it is important to understand that the insurance benefit determination does not change your diagnosis or your dentist's treatment recommendation.
Your dental insurance plan determines how much it will contribute according to the terms of your plan. Your dentist evaluates your tooth, your oral health, and your individual needs to determine which treatment is appropriate.
In other words, insurance coverage and clinical treatment recommendations are two different things.
Why Do Dental Insurance Plans Use Alternative Benefits?
Dental insurance plans have their own benefit structures and guidelines. When multiple
treatment options are considered acceptable within a plan, an alternative benefit may be used to determine the amount the insurance company will contribute.
This does not necessarily mean that the less expensive treatment is the best option for every patient.
When recommending treatment, a dentist considers much more than cost. Factors can include the amount of remaining tooth structure, the strength of the tooth, how the tooth functions, the materials being used, aesthetics, and the patient's individual oral health needs.
These clinical considerations are separate from the way a dental insurance plan calculates benefits.
Dental Insurance and Crowns
Crowns are one of the most common areas where patients may encounter an alternative benefit.
A dental crown may be recommended when a tooth has experienced significant structural damage and needs additional protection. Depending on the insurance plan, the plan may calculate its benefit as though a large filling were being placed instead.
This can result in a higher out of pocket cost for the patient, even though the dentist has determined that a crown is the more appropriate treatment.
Insurance requirements may also include specific documentation related to the amount of tooth structure that has been lost, cusp involvement, or other criteria.
The important thing to remember is that an insurance benefit calculation is not the same thing as a dental treatment recommendation.
What About Dental Implants and Bridges?
Alternative benefits can also apply when replacing missing teeth.
A dentist may recommend a dental implant or fixed bridge based on a patient's oral health, function, long term goals, and preferences. However, some dental insurance plans may calculate their benefit based on a removable partial denture if the plan considers that to be the least costly covered option.
This can make an insurance estimate look very different from the treatment your dentist has discussed with you.
It does not mean that your insurance company is telling you which treatment you should
choose. It means the plan is determining its financial contribution based on the benefits included in your policy.
Understanding Your Dental Insurance Benefits
Dental insurance can be helpful, but it is important to remember that insurance benefits are not designed to replace a personalized dental treatment plan.
Your insurance plan may have:
- Coverage limitations
- Waiting periods
- Annual maximums
- Alternative benefit provisions
- Frequency limitations
- Specific requirements for certain procedures
Because every plan is different, two patients receiving the same dental treatment can have very different insurance benefits.
At Wynkoop Dentistry, we are happy to help patients better understand their insurance estimates and expected costs. We believe you should feel comfortable asking questions about both your treatment and your benefits.
Your Dentist and Your Insurance Company Have Different Roles
Navigating dental insurance does not have to mean choosing between your insurance benefits and the treatment your dentist recommends.
Your insurance company determines what your plan will contribute based on the benefits you have purchased. Your dentist evaluates your oral health and recommends treatment based on your individual clinical needs.
Sometimes those two things align perfectly. Sometimes they do not.
When they do not, it is helpful to understand why.
At Wynkoop Dentistry, our goal is to give you the information you need to make confident decisions about your dental care. We will explain your treatment options, help you understand your estimated insurance benefits, and make sure you have an opportunity to ask questions before moving forward.
Your insurance plan helps determine your financial responsibility. Your dentist helps determine your dental care. Understanding the difference can make navigating dental treatment a whole lot easier.
