How Does It Work If You Have 2 Dental Insurances?

Having two dental insurance plans is a common situation that can lead to questions about how benefits are applied. Individuals often find themselves with dual coverage through various circumstances, such as having their own employer-sponsored plan while also being covered as a dependent under a spouse’s plan, or holding two jobs that each offer dental benefits.

Understanding Coordination of Benefits

When an individual has more than one dental insurance policy, a process known as Coordination of Benefits (COB) determines how these plans work together. COB is an industry standard designed to prevent overpayment and ensure a fair distribution of costs among insurers. It dictates the order in which each plan pays for dental services.

In a COB scenario, one plan is designated as the “primary insurance,” and the other as the “secondary insurance.” The primary plan is responsible for paying its benefits first. After the primary plan has processed the claim, the secondary plan then considers the remaining balance. The purpose of COB is to ensure that the combined payments from all plans do not exceed the total cost of the dental services received. State laws and carrier policies can influence how COB is handled. Only group (employer) plans are generally required to coordinate benefits, while individual policies may not.

Determining Primary and Secondary Coverage

Establishing which dental insurance plan is primary and which is secondary typically follows a set of industry-standard rules. The plan that covers an individual as an employee or main policyholder is generally considered primary. Conversely, a plan where the individual is enrolled as a dependent would be secondary.

For dependent children covered by both parents’ plans, the “Birthday Rule” is commonly applied. This rule dictates that the plan of the parent whose birthday falls earlier in the calendar year (month and day, not year) is usually primary. For instance, if one parent’s birthday is in March and the other’s is in July, the March birthday parent’s plan would be primary.

In situations involving divorced or separated parents, a court decree specifying responsibility for the child’s healthcare expenses takes precedence over the Birthday Rule. If no court order exists, the Birthday Rule may still apply, or the plan of the custodial parent might be primary. When an employed patient has coverage through their employer, that plan is primary over a COBRA or retiree plan.

Processing Claims with Two Plans

When a patient has two dental insurance plans, the claims submission process involves a specific sequence. The dental office typically submits the claim to the primary insurance plan first, detailing the services rendered and associated costs.

After the primary plan processes the claim, it pays its portion of the covered services. The primary insurer then issues an Explanation of Benefits (EOB) to both the patient and, often, the secondary insurer. This EOB outlines what was covered, what was paid, and any remaining balance.

The secondary plan then uses the primary EOB to process the remaining balance. The secondary plan will pay up to its own coverage limits for the service, often covering a portion that the primary plan did not. Any remaining balance after both plans have paid is the patient’s responsibility.

Financial Implications

Having two dental insurance plans can significantly affect a patient’s out-of-pocket costs, often leading to reduced expenses. The secondary plan can cover amounts not paid by the primary plan. This can lower, or in some cases eliminate, the patient’s financial responsibility for covered services.

Each dental plan typically has its own deductible and annual maximum. The deductible is usually met with the primary plan. For example, a common annual maximum ranges from $1,000 to $2,000 per person, though some plans may offer higher limits. The secondary plan may or may not have its own deductible that needs to be met, depending on its terms.

The annual maximum of each plan operates independently. The secondary plan will only pay up to its own maximum, and these limits do not combine. For instance, if both plans have a $1,500 annual maximum, the patient does not have a combined $3,000 maximum. Services not covered by either plan remain the patient’s responsibility.