Coordination of Dental/Orthodontic Benefits If you are covered by two dental plans

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Coordination of Dental/Orthodontic Benefits

If you are covered by two dental plans……..

When you are covered by two dental plans this is called "dual coverage." This does not "double" your coverage. However, it may reduce your out-of-pocket costs.

Dual coverage works the same way whether you are covered by two plans offered by the same insurance company or by your carrier and another insurance company. Your dental carrier simply works with the other insurance company to coordinate your benefits.

Which plan pays first

The plans set forth rules to determine which plan pays first, ("primary") and which plan pays afterwards ("secondary"). The general rule is that the plan that covers you as an enrollee is the primary plan and the plan which covers you as a dependent is the secondary plan.

For your children's coverage, generally the primary insurance company is determined by the birthday rule (i.e., coverage of the parent whose birthday —month and day, not year — comes first in the year is considered to be your children's primary coverage). A divorce agreement or other court ruling may supersede the birthday rule.

Birthday Rule: When a dependent child's parents both have dental coverage, this rule states that the "primary" program (the one which pays first) is the one covering the parent whose month and day of birth falls first in the calendar year. The birthday rule is the most common rule for determining primary vs. secondary coverage, but it may be superseded by a court order such as a divorce agreement.

How dual coverage works

Dual Coverage: When you have coverage under more than one benefit program. The primary and secondary carriers coordinate the two programs, so that the primary carrier pays its portion first and the secondary carrier usually pays the remainder. See "Non-duplication of benefits" and "birthday rule."

For example, if both of your plans provide 50 percent coverage, then:

  • The primary plan pays its benefit as if there is no other insurance

  • The secondary plan will act as a supplement to the primary plan with its payments limited to the lesser of its normal benefit or the patient’s out-of-pocket costs under the primary plan.

Non-duplication of benefits clause

Some dental/orthodontic benefit plans have "non-duplication of benefits" provisions. This means that the secondary plan will not pay any benefits if the primary plan paid the same or more than what the secondary plan allows for that orthodontist.

For example, if both the primary and secondary carrier pay for the service at 50 percent level but the primary allows $1000 and the secondary carrier normally allows $800 for the same treatment, the secondary carrier would not make any additional payment. For example, if the primary carrier only pays 40 percent of the orthodontist’s allowed fee, then the secondary carrier would reduce its payment by the amount paid by the primary plan and pay the difference. In this case, the secondary carrier would pay $0 ($800 x 50 percent - $400 = $0).

Dual coverage saves money for you and your group by sharing the total cost of dental benefits between two carriers. Containing costs is an important part of Delta Dental's plan to keep you smiling.

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