Folks who are lucky enough to have two dental insurance policies should generally expect greater benefits. But, while this is often the case, you want to know what is covered before you agree to costly dental procedures rather than just assuming both insurers will pay. Read the fine print on both of your dental policies to see which services each one covers, if there are any waiting periods and how the benefits will be coordinated. This way you know how much your smile is going to cost, out-of-pocket.
Primary Versus Secondary
The primary plan is the one that pays claims first, as if there were no other insurance. The secondary plan pays claims second and takes into consideration what the primary plan has already paid. The purpose of establishing an order of benefits is to avoid processing delays and prevent overpayment. Unless a plan has a no-coordination-of-benefits clause, meaning it does not coordinate benefits and is automatically primary, special rules are used to designate the order.
Which policy is primary is determined by the order-of-benefits determination rules or coordination-of-benefits provision. This information can be found in your plan contract, or you can ask each insurer what criteria it uses to make the determination. Generally, the plan that covers the insured directly is primary, and the plan you're a dependent on is secondary. The birthday rule is used if you're a dependent on both plans -- the policy of the subscriber with the earlier birth date is primary.
Coordination of Benefits
Generally, dental plans coordinate benefits so that eligible claims are paid up to 100 percent between the two plans. The primary plan pays the claim as it normally would, and the secondary plan pays what's left based on its coverage limits and up to 100 percent of the total claim. However, a secondary plan with a maintenance-of-benefits, a non-duplication-of-benefits or carve-out provision reduces what it otherwise would have paid by what the primary plan has already paid -- leaving some out-of-pocket expense.
State coordination-of-benefits laws play a role in how insurance companies pay claims and coordinate plans. Medicaid, Medicare and worker's-compensation policies have their own provisions. Medicare Secondary Payer provisions were enacted in 1980 to make Medicare secondary to most primary plans. Similarly, Medicaid typically pays as the last option, when all other payer or liability options have been exhausted. Worker's compensation becomes the first payer, despite individual coverage, if the claim was caused by employment.
- Delta Dental: If You Are Covered by Two Dental Plans
- American Dental Association: Coordination of Benefits
- Blue Cross and Blue Shield of Minnesota and Blue Plus: Coordination of Benefits Types
- Ark-La Tex Health Network: Coordination of Benefits
- Wisconsin Chiropractic Association: Coordination Of Benefits Rules
- State of New Jersey: Sample of Coordination of Benefits Contract Language
- Centers for Medicare & Medicaid Services: Medicare Secondary Payer Manual
- Colorado Department of Health: Coordination of Benefits
- Care Source: Coordination of Benefits
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