How Does Having Two Dental Insurance Plans Work?
Navigate the complexities of dual dental insurance. Understand how multiple plans work together to cover your care and reduce out-of-pocket expenses.
Having two dental insurance plans, often referred to as dual dental coverage, is a common scenario for many individuals. This often arises when someone is covered by their employer’s plan and a spouse’s plan, or holds two jobs providing benefits. While dual coverage does not mean receiving double benefits, it can significantly reduce out-of-pocket costs for dental procedures.
Understanding Coordination of Benefits
When you have more than one dental plan, Coordination of Benefits (COB) applies. COB is a standard procedure that determines how two or more dental plans work together to pay for covered services, preventing overpayment and avoiding duplication of benefits. The fundamental principle of COB is that the combined payments from all plans should not exceed 100% of the total cost of the dental procedure. COB rules are designed to ensure that you receive the maximum allowable benefits from each plan without being reimbursed for more than the actual cost of the treatment. For instance, if a procedure costs $100, the total reimbursement from both plans will not exceed $100.
Determining Primary and Secondary Coverage
Plans establish rules to determine which one pays first, known as the primary plan, and which one pays second, the secondary plan. The primary plan processes and pays its benefits first, and then the secondary plan considers the remaining balance.
For an individual, the dental plan received through their own employer is typically primary. If an individual is also covered under a spouse’s plan, the spouse’s plan is generally secondary. If a person has dental coverage through two different employers, the plan that has covered the individual for the longest period is usually primary.
For dependent children covered by both parents’ dental plans, the “Birthday Rule” applies. This rule dictates that the plan of the parent whose birthday falls earlier in the calendar year (month and day) 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. In situations involving divorced or separated parents, a court order regarding dental coverage takes precedence over the Birthday Rule.
How Dual Coverage Works in Practice
Once the primary and secondary plans are determined, dual coverage applies to dental procedures. The dental office typically submits the claim to the primary insurance plan first. The primary plan processes the claim according to its terms and benefits, paying its portion.
After the primary plan processes the claim, it issues an Explanation of Benefits (EOB). This EOB details the services rendered, the amount charged, how much the primary plan covered, and any remaining balance. An EOB is not a bill, but an explanation of how the claim was processed.
With the primary EOB, the claim and EOB copy are submitted to the secondary dental insurance plan. The secondary plan reviews the claim and the primary plan’s payment, then considers covering some or all of the remaining balance, up to its own coverage limits. The secondary plan’s payment may reduce the patient’s out-of-pocket costs, potentially covering deductibles or co-insurance amounts left by the primary plan. Dual coverage does not mean that all costs will be covered, as each plan has its own annual maximums and limitations. For instance, if both plans cover two cleanings per year, dual coverage does not entitle you to four cleanings.