How Does Having 2 Dental Insurances Work?

Having more than one dental insurance plan can offer distinct advantages for managing oral health expenses. This situation, often referred to as dual coverage, typically arises when an individual is covered by their own employer-sponsored plan and also by a spouse’s plan, or when someone holds two jobs that both provide dental benefits. While it might seem like double benefits, plans coordinate to cover costs.

Understanding Coordination of Benefits

When an individual is covered by two dental insurance plans, a process known as Coordination of Benefits (COB) comes into play. COB is a set of rules established by insurance companies to determine the order in which multiple plans pay for dental services, ensuring that the total reimbursement from all plans does not exceed the actual cost of the treatment.

The COB process designates one plan as the “primary” insurer and the other as the “secondary” insurer. The primary plan is responsible for paying its benefits first, based on its policy provisions. Once the primary plan has processed the claim and paid its portion, any remaining balance for covered services can then be submitted to the secondary plan for consideration. The secondary plan will then review the claim and the payment from the primary plan, potentially covering some or all of the outstanding amount, depending on its own terms and conditions.

Several common rules are used to determine which plan is primary. For adults, the plan provided through one’s own employment is generally considered primary, with a spouse’s plan typically acting as secondary coverage. If an individual has two jobs that both offer dental benefits, the plan they enrolled in first or that has been active for the longest duration is usually designated as primary.

For children covered by both parents’ plans, the “Birthday Rule” is commonly applied: the plan of the parent whose birthday falls earlier in the calendar year (month and day) is typically primary, regardless of the birth year. In situations involving divorced or separated parents, a court decree regarding healthcare expenses can override the Birthday Rule. An active employee’s plan is generally primary over a retired or COBRA plan.

How Dual Coverage Affects Your Costs

Dual dental coverage can significantly influence out-of-pocket expenses by leveraging the benefits of two separate plans. After the primary plan processes a claim, the secondary plan can help cover amounts not paid by the first, leading to reduced financial responsibility for the patient.

Regarding deductibles, the primary plan’s deductible must typically be met before it begins paying for services. The secondary plan may then help cover costs that would have gone towards the primary’s deductible or co-payments, depending on its specific provisions. For instance, if a procedure costs $100 and the primary plan covers 80% after a deductible, paying $80, the secondary plan might then cover a portion of the remaining $20, potentially reducing the patient’s out-of-pocket cost to a minimal amount, such as $2.

Co-payments and co-insurance, which are portions of the service cost typically paid by the patient, can also be reduced with dual coverage. The secondary plan often steps in to pay some or all of these remaining amounts after the primary plan has contributed its share.

Annual maximums, which are the total dollar amounts an insurance plan will pay for covered services within a benefit year, function independently for each plan. While having two plans does not double the annual maximum for a single service, the secondary plan’s maximum can provide additional coverage once the primary plan’s limit has been reached. This can be particularly beneficial for extensive dental work, such as implants or crowns, that might otherwise exceed a single plan’s annual limit. Waiting periods, which some plans impose before certain services are covered, might be mitigated if one of the plans does not have the same waiting period for a specific procedure, allowing for earlier access to care.

Submitting Claims with Multiple Plans

The process of submitting claims with dual dental insurance involves a systematic approach to ensure proper benefit coordination. Initially, the claim for dental services is submitted to the primary insurance plan. This first submission should include all necessary details about the patient, the dental provider, and the procedures performed, utilizing the standard ADA dental claim form.

Once the primary insurer processes the claim, they issue an Explanation of Benefits (EOB) document. This EOB details what services were covered, the amount the primary plan paid, and any remaining balance or patient responsibility. The EOB serves as proof of payment and benefit application from the primary plan.

After receiving the EOB from the primary insurer, the claim for any remaining balance is then submitted to the secondary insurance plan. This submission to the secondary plan must typically include a copy of the primary plan’s EOB.

Most dental offices are accustomed to handling dual coverage situations and often manage the entire claim submission process on behalf of the patient. They possess the expertise to identify the primary and secondary plans, gather all required information such as subscriber IDs, group numbers, and procedure codes, and submit claims electronically. Patients may also have the option to submit claims manually via mail or through online portals provided by their insurance carriers, though dental office assistance can simplify this administrative task. After both plans have processed the claim, the patient will receive EOBs from both insurers, outlining the final payment distribution and any remaining balance still owed.