If You Have Two Dental Insurances, Which One Is Primary?

Having two dental insurance plans can offer enhanced coverage and potentially reduce out-of-pocket costs for dental care. Navigating which plan pays first and how benefits are applied can seem complicated. Understanding the rules governing multiple dental policies helps ensure claims are processed efficiently and benefits are maximized.

Understanding Coordination of Benefits

When an individual has coverage under two or more dental insurance plans, a process known as Coordination of Benefits (COB) comes into play. COB is a standard industry practice designed to ensure that the combined payments from all plans do not exceed the total cost of the dental services received. This mechanism prevents “over-insurance” or the duplication of benefits, meaning an individual cannot be reimbursed more than the actual cost of treatment.

Within the COB framework, one dental plan is designated as the “primary” plan, and the other as the “secondary” plan. The primary plan is responsible for paying its benefits first, according to its own terms and conditions. After the primary plan has processed the claim, the secondary plan then considers the remaining balance. The secondary plan may cover additional costs, up to its own allowed amount, ensuring that the patient receives the maximum allowable benefit from both plans.

Rules for Determining Primary Coverage

Determining which dental plan is primary involves specific rules that insurance companies commonly follow. For an individual, the dental plan they are enrolled in as an employee or the main policyholder is primary. A plan where they are covered as a dependent, such as through a spouse’s employer, is secondary.

A widely applied guideline for dependent children is the “Birthday Rule.” This rule dictates that the plan of the parent whose birthday (month and day, not year) occurs earlier in the calendar year is primary for the child. In cases where parents share the same birthday, the plan that has covered the individual longer typically becomes primary.

If one dental plan is from current employment and another is from a former employer, such as COBRA or retiree benefits, the plan associated with active employment is primary. In situations where an individual has coverage from two different employers, the plan that has covered the individual for the longest duration is primary. Furthermore, if a court order, such as a divorce decree, specifies which parent is responsible for a child’s dental coverage, that legal document takes precedence over other COB rules like the Birthday Rule.

Processing Claims with Two Plans

When a patient has two dental insurance plans, the claims processing follows a specific sequence to coordinate benefits effectively. The dental office typically submits the claim first to the primary insurance provider, detailing the services rendered and associated costs, allowing the primary insurer to apply its benefits, deductibles, and co-payments as per the policy terms.

Once the primary insurance processes the claim, it issues an Explanation of Benefits (EOB) document. This EOB outlines what the primary plan paid, any amounts applied to deductibles, and the remaining balance. The dental office then submits the claim, along with a copy of the primary EOB, to the secondary insurance provider. The secondary insurer uses this information to determine its payment, covering a portion of the remaining balance up to its own allowed amount. This sequential process ensures that both plans contribute appropriately, and the combined payment does not exceed the dentist’s total charges for the services.

Tips for Dual Coverage

Individuals with dual dental coverage can take steps to manage their benefits effectively. It is always important to inform your dental office about both insurance plans at the time of service. Providing complete and accurate insurance details helps ensure that claims are submitted correctly and benefits are coordinated without delays.

Understanding that having two plans does not guarantee 100% coverage is important, as benefits are coordinated up to the allowed amount for services. After receiving dental care, carefully review the Explanation of Benefits (EOB) documents from both insurers. This review helps verify that claims were processed accurately and provides clarity on any remaining financial responsibility. If questions arise about specific claim payments or the coordination of benefits rules for your plans, contacting your insurance companies directly is advisable for clarification.