What Happens If You Have 2 Dental Insurances?

Having two dental insurance plans is common for many individuals and families, such as when a person is covered by their own employer’s plan and also by a spouse’s or parent’s plan, or if they have multiple jobs offering benefits. While dual coverage does not mean receiving double the benefits, it can impact how dental services are covered and how out-of-pocket expenses are managed.

Coordination of Benefits Explained

When an individual is covered by more than one dental plan, a process called Coordination of Benefits (COB) applies. COB is a set of rules used by insurance companies to determine how two or more plans will work together to pay for dental services. Its purpose is to prevent over-insurance, ensuring combined payments from all plans do not exceed 100% of the total cost of the dental procedure.

COB establishes a clear order of responsibility among multiple insurance providers. One plan is designated as the primary payer, which pays its benefits first, as if no other coverage exists. The other plan then acts as the secondary payer, considering the remaining balance after the primary plan has paid its portion. This system prevents patients from profiting from their insurance coverage.

The most common approach allows the beneficiary to receive up to 100% of covered expenses from the combination of primary and secondary plans. This coordinated effort helps maximize benefits and reduce a patient’s out-of-pocket costs. COB provisions can vary based on individual plan rules and regulations.

Identifying Your Primary and Secondary Plans

Determining which dental insurance plan is primary and which is secondary is key to navigating dual coverage. Several rules guide this designation. Generally, the plan covering the patient as an employee or main policyholder is considered primary. A plan covering the patient as a dependent, such as through a spouse, would then be secondary.

For dependent children covered by both parents’ 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, not year) is primary. If both parents share the same birthday, the plan that has covered the patient for the longest duration becomes primary.

Other scenarios have specific rules. If an individual has two employment-based plans, the plan that has covered the individual for the longest time is considered primary. When one plan is current employment-based and another is a retiree or COBRA plan, the current employment plan takes precedence as primary. In cases of divorced or separated parents, a court decree assigning responsibility for the child’s healthcare expenses will determine the primary plan, overriding the Birthday Rule if specified.

Navigating Claims with Dual Coverage

Submitting dental claims with dual coverage involves a specific sequence. The initial step is to submit the claim to the primary insurance carrier. This insurer will process the claim based on its policy terms and then issue an Explanation of Benefits (EOB). The EOB details the services rendered, the amount charged by the dentist, the portion covered by the primary plan, and any remaining balance that is the patient’s responsibility.

After the primary plan has processed the claim and provided its EOB, the remaining balance and a copy of the primary EOB are then submitted to the secondary insurance carrier. The secondary plan will review the claim and the primary EOB to determine what, if any, additional amount it will cover, adhering to its own benefits and COB rules. The dental office often assists with this process; patients should provide both insurance details upfront.

The secondary policy will not accept a claim until the primary policy has paid for services according to its benefits. This sequential processing ensures that both plans coordinate effectively without overpaying for services. Timely submission of claims and necessary documentation helps prevent payment delays and maximizes benefits.

Understanding Your Financial Responsibility

Having two dental insurance plans can substantially reduce out-of-pocket expenses, but it rarely eliminates them entirely. Patients remain responsible for certain financial aspects, even with dual coverage. Both primary and secondary plans have their own deductibles, which are amounts a patient must pay before coverage begins. The primary plan’s deductible must be met before it pays; the secondary plan may or may not cover this deductible depending on its provisions.

Each dental plan also has an annual maximum, the total amount the plan will pay for a member’s dental care within a 12-month period. While dual coverage means two separate annual maximums exist, COB rules prevent combined payments from exceeding 100% of the total treatment cost. This arrangement benefits extensive dental work, as the secondary plan can help cover costs once the primary plan’s annual maximum is reached.

A “non-duplication of benefits” clause is found in some secondary plans. This clause means the secondary plan will not pay any benefits if the primary plan has already paid an amount equal to or greater than what the secondary plan would have paid if it were primary. In such cases, despite having two plans, the patient might still incur out-of-pocket costs that would otherwise be covered by a secondary plan without this clause.