How Does Secondary Dental Insurance Work?

Secondary dental insurance provides an additional layer of coverage for individuals already enrolled in a primary dental plan. This type of coverage can be acquired through various avenues, including a spouse’s employer-sponsored plan, a second job that offers benefits, or by purchasing a private policy. Having secondary dental insurance can help manage out-of-pocket expenses for dental treatments, especially for more extensive procedures. This article clarifies how these multiple plans interact to provide more comprehensive dental benefits.

Defining Primary and Secondary Dental Coverage

Understanding how dental plans are designated as “primary” or “secondary” is foundational to navigating dual coverage. Generally, the dental plan through an individual’s own employer is considered primary. If a person is covered by a spouse’s plan, that plan typically serves as the secondary coverage. For children with coverage under both parents’ plans, the “birthday rule” often applies. This rule designates the plan of the parent whose birthday falls earlier in the calendar year as primary.

Before delving into how two plans interact, it is useful to define common dental insurance terms. A “deductible” is the amount an individual must pay out-of-pocket before their insurance coverage begins to pay for services. The “annual maximum” represents the highest dollar amount a dental plan will pay for covered dental services within a benefit year. “Coinsurance” refers to the percentage of the cost for a covered service that the patient is responsible for after meeting their deductible. A “copayment” is a fixed amount an insured person pays for a covered service, typically at the time of service.

How Coordination of Benefits Works

When an individual has more than one dental plan, a process called Coordination of Benefits (COB) determines how the plans work together to pay for services. COB rules are designed to prevent overpayment or duplication of benefits, ensuring that combined payments from all plans do not exceed 100% of the total charges for a procedure. These rules dictate which plan pays first (primary) and how much the subsequent plan (secondary) will contribute.

There are different types of COB provisions that can affect how benefits are calculated. Under a “traditional” COB model, the secondary plan typically pays the remaining portion of the cost after the primary plan has paid its share. For example, if a procedure costs $100 and the primary plan pays $80, a traditional secondary plan might cover the remaining $20. Another common method is “carve-out” COB, where the secondary plan calculates its normal benefit amount and then reduces that amount by what the primary plan paid.

Some plans may include a “non-duplication of benefits” clause. With this clause, if the primary plan pays an amount equal to or greater than what the secondary plan would have paid if it were primary, the secondary plan may not make any payment. This means the patient could have higher out-of-pocket costs compared to a traditional COB scenario.

Navigating Claims with Multiple Plans

The practical process of submitting and processing claims when you have both primary and secondary dental insurance follows a general sequence. The dental provider’s office typically initiates the claim process by submitting the bill for services directly to the primary insurance carrier first. The primary insurer then processes the claim according to its policy terms, applying deductibles, coinsurance, and annual maximums. After processing, the primary insurance company issues an Explanation of Benefits (EOB) statement.

This EOB details the services provided, the total charges, the amount paid by the primary plan, and any remaining balance for which the patient is responsible. Once the primary EOB is received, the claim, along with a copy of the primary EOB, is then submitted to the secondary insurance carrier for consideration. Most secondary plans require the primary EOB to process their portion of the claim.

The secondary insurer will then process the claim based on its own COB rules and policy provisions, potentially covering a portion of the remaining balance. In many cases, the dental office handles both submissions on behalf of the patient, streamlining the process. It is advisable to keep thorough records of all EOBs and communications with both insurance companies.

Practical Tips for Dual Coverage

To maximize the benefits of dual dental coverage, it is advisable to understand the specifics of both your primary and secondary plans. This includes knowing each plan’s annual maximums, deductibles, coinsurance percentages, and any waiting periods for specific dental procedures. Many plans have waiting periods, typically ranging from a few months for basic procedures to 6-12 months or more for major services.

Before undergoing significant dental work, it is beneficial to verify coverage with both insurers. This proactive step can help clarify how each plan will contribute to the cost and prevent unexpected out-of-pocket expenses. Discussing your dual coverage with the dental office staff is also recommended, as they often have experience navigating claims with multiple plans and can assist in understanding potential costs.

Dual coverage can significantly reduce out-of-pocket expenses for dental care. While it rarely results in 100% coverage of all costs, it can substantially lower the amount you are responsible for compared to having only one plan. However, having two plans does not mean double benefits, as COB rules prevent overpayment. For instance, if both plans cover the same procedure at a high percentage, the secondary plan might pay little or nothing if a non-duplication clause applies.