What Happens If You Have Two Dental Insurance Plans?

It is common for individuals and families to have more than one dental insurance plan, such as coverage through an employer and as a dependent on a spouse’s plan, or an individual policy alongside a group plan. Understanding how these plans interact is important for managing dental care costs. This article explains the mechanisms that govern how these plans work together to cover dental expenses.

The Concept of Coordination of Benefits

When a patient has dental coverage through two or more plans, Coordination of Benefits (COB) comes into play. This mechanism determines the order in which plans pay for services and ensures the total amount paid by all plans does not exceed the dental treatment’s cost. The primary goal of COB is to prevent “double-dipping,” where a patient might receive payments totaling more than 100% of the actual cost of services.

Insurance companies utilize COB rules to manage their financial liabilities and ensure fair payment practices. Without COB, a patient could potentially profit from their dental care by having multiple insurers pay for the same service. These rules help maintain the financial integrity of the insurance system by clearly defining each plan’s responsibility. While COB rules are largely standardized, minor variations can exist based on the specific plan’s terms.

For example, if a dental procedure costs $500 and a patient has two plans, COB rules ensure the combined payment from both plans will not exceed $500. One plan pays first, and the other then considers the remaining balance. The total reimbursement will be capped at the actual expense. This process streamlines payment flow and clarifies financial responsibilities for both the patient and providers.

Rules for Primary and Secondary Plans

When multiple dental plans are active, one is designated as the “primary” payer, and the other as the “secondary” payer. The primary plan is always responsible for paying benefits first, according to its own terms and conditions, before the secondary plan considers any remaining balance. Identifying the primary plan is a crucial step in the claims process.

Several common rules dictate which plan assumes primary responsibility. For children covered under both parents’ plans, the “Birthday Rule” is a widely used guideline. Under this rule, the plan of the parent whose birthday falls earlier in the calendar year is considered primary, regardless of the birth year itself. For instance, if one parent’s birthday is in April and the other’s is in September, the plan of the parent with the April birthday would be primary.

A common scenario involves employment status. A dental plan from active employment is typically primary over a plan from a former employer, such as a retiree plan or COBRA coverage. If an individual is covered both as an employee and as a dependent on another plan, the plan where they are the direct subscriber is usually considered primary. In situations involving divorce, court decrees might specify which parent’s plan is primary for dependent children.

An employer-sponsored dental plan is generally primary over an individually purchased dental plan. It is important for individuals to consult their specific plan documents and benefit summaries, as these contain the precise rules governing primary and secondary designations for their particular coverage. Understanding these rules helps ensure claims are submitted correctly from the outset.

How Claims Are Processed

Once the primary and secondary plans have been determined, the claims processing sequence begins. Dental providers typically initiate this process by submitting the claim directly to the primary insurance company. This initial submission details the services rendered, associated costs, and the patient’s coverage information for the primary plan.

The primary plan then processes the claim according to its specific benefits, which include applying any deductibles, copayments, or annual maximums. It pays its portion of the covered charges, either directly to the dental provider if an assignment of benefits is in place, or to the patient. An Explanation of Benefits (EOB) document is then issued by the primary insurer, detailing what was covered, what was paid, and any remaining patient responsibility.

After the primary plan has processed the claim and issued its payment, the remaining balance, if any, is then submitted to the secondary insurance company. This step often requires sending the EOB from the primary plan along with the original claim details to the secondary insurer. In some cases, the dental office handles this entire coordination, while in others, the patient may need to forward the primary EOB to their secondary plan.

The secondary plan reviews the claim and the primary plan’s payment. It then applies its own benefits, deductibles, and maximums, often paying up to its allowed amount for the service, less what the primary plan already paid. The total payment from both plans, combined, will not exceed 100% of the dental provider’s fee or the maximum allowed amount by either plan, whichever is lower. Any charges not covered by either plan, such as services exceeding annual maximums or those deemed not medically necessary, remain the patient’s financial responsibility.

Patient Actions and Financial Outcomes

Patients play an active role in ensuring their multiple dental plans are utilized effectively. It is important to inform the dental office about all active dental insurance plans at the first visit. Providing comprehensive and accurate information, including policy numbers, group numbers, and subscriber details for both plans, allows the dental staff to properly coordinate benefits and submit claims in the correct order.

Patients should also carefully review the Explanation of Benefits (EOB) statements received from both their primary and secondary plans. These documents provide a detailed breakdown of how benefits were applied, what amounts were paid by each insurer, and any remaining balance that is the patient’s responsibility. Understanding these statements can help clarify billing questions and ensure proper processing. If any discrepancies or questions arise, patients should follow up promptly with their dental office or directly with their insurance companies for clarification.

Having two dental insurance plans typically results in significantly reduced out-of-pocket costs for covered services. The secondary plan can often cover a substantial portion of the expenses that the primary plan does not, thereby lowering the patient’s financial burden. However, this arrangement rarely means 100% of the billed charges will be covered. Instead, it aims to cover up to 100% of the allowed charges, which are the maximum amounts an insurer will pay for a specific service, or up to the combined maximums and limitations of the plans.

Patients remain responsible for services not covered by either plan, amounts that exceed combined annual maximums, or services not considered medically necessary by the insurers. Each dental plan maintains its own annual maximum benefit limit. Once this limit is reached for a particular plan within a benefit period, that specific plan will not pay any further benefits, regardless of any remaining balances, until the next benefit cycle begins.