How Does Dual Dental Insurance Work?

Dual dental insurance involves having coverage from two different dental plans simultaneously. This often arises when an individual is covered by their own employer’s plan and a spouse’s employer’s plan, or through two different jobs. Understanding how these plans interact helps policyholders manage costs and utilize benefits effectively.

Coordination of Benefits Explained

Coordination of Benefits (COB) is the process insurance companies use when an individual has more than one dental plan. Its purpose is to determine which plan pays first and prevent total payments from exceeding 100% of the service cost. COB ensures individuals do not receive more in benefits than the actual treatment cost.

This process distributes care costs between multiple insurers, reducing the policyholder’s out-of-pocket expenses. When COB applies, one dental plan is designated as primary and the other as secondary. The primary plan pays first, and the secondary plan then considers the remaining balance.

Rules for Identifying Primary and Secondary Plans

Determining which dental insurance plan is primary and secondary is guided by common rules. The primary plan pays first, and its designation significantly impacts the claims process.

The plan covering the patient as an employee or main policyholder is primary over a plan where they are covered as a dependent. For dependent children covered by both parents’ plans, the “Birthday Rule” applies: the plan of the parent whose birthday falls earlier in the calendar year (month and day, not year) is primary. For example, if one parent’s birthday is in March and the other’s is in July, the March birthday parent’s plan is primary.

For divorced or separated parents, a court decree assigning responsibility for a child’s healthcare expenses takes precedence over the Birthday Rule. If a patient has coverage through an active employer and also through COBRA or a retiree plan, the active employment plan is primary. While these rules provide a framework, specific plan contracts or state regulations can introduce variations.

Navigating Claim Submissions

When an individual has dual dental insurance, the claim submission process follows a specific sequence. First, submit the dental claim to the primary insurance carrier. This carrier processes the claim according to its benefits and contractual agreements.

After the primary plan processes the claim, it issues an Explanation of Benefits (EOB) document. This EOB details the services received, the amount charged, the amount the primary insurance covered, and the remaining balance. Next, submit the claim to the secondary insurance carrier, along with the EOB from the primary plan. The secondary plan then reviews the remaining balance and pays according to its own benefits and COB rules, up to its limits, often without exceeding the total charge. Dental offices assist patients with this multi-step process, and understanding the sequence is beneficial.

Impact on Out-of-Pocket Expenses

Dual dental insurance can significantly reduce a policyholder’s out-of-pocket expenses for dental care. The Coordination of Benefits process helps ensure that a larger portion of the dental bill is covered, reducing the patient’s financial responsibility.

Regarding deductibles, the primary plan’s deductible must be met before it pays. The secondary plan may apply its own deductible, or waive it if the primary plan’s deductible is met, depending on its COB rules. Each dental plan maintains its own annual maximum, which is the total dollar amount the plan will pay for covered services within a benefit period. Dual coverage does not combine these maximums. Instead, the secondary plan pays up to its annual limit after the primary has paid, which further reduces the amount the individual pays out of pocket. While dual coverage does not mean receiving double benefits, it results in lower out-of-pocket costs for dental services.