Understanding coordination of benefits and dual coverage

If you’re fortunate enough to be covered by two dental plans, you have what is called dual coverage. Dual coverage doesn’t mean that your benefits are doubled. What it does mean is that you will likely enjoy lower out-of-pocket costs for your dental care.

Dual coverage works the same way whether you are covered by two Delta Dental plans or by Delta Dental and another carrier. We simply work with the other dental carrier to coordinate your benefits and ensure that the combined amount paid by the plans does not exceed the total amount charged by the dentist.

Who is the primary carrier?

The first or primary carrier is the one that covers you as a primary enrollee (e.g., your employer rather than your spouse’s employer). If you have two jobs, the plan that has covered you longer is considered primary.

For your children’s coverage, the primary carrier is generally determined by the “birthday rule”: 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. For example, if the mother’s birthday is in April and the father’s birthday is in September, the mother’s plan would be the primary coverage for the children’s claims. The birthday rule may be superseded by a divorce agreement or other court ruling.

How does dual coverage work?

Suppose, for example, that both of your plans provide two cleanings a year, each with 80 percent coverage. The primary carrier pays its normal benefit. Any calculation or adjustment of benefit is done by the secondary carrier. In this instance, the primary carrier pays 80 percent, and the secondary carrier would cover up to the remaining 20 percent that you would have had to pay out-of-pocket if covered by only one plan. You would not, however, be entitled to four cleanings per year.

Many dental practices do not bill the secondary carrier until the primary carrier has paid. Once the secondary carrier receives documentation of the primary carrier’s payment, the secondary carrier can calculate and pay its portion.

Why not twice as many benefits?

Why don’t you receive double the benefits when you have two dental plans, especially if your dentist recommends that you receive more than two cleanings per year?

Dual coverage limitations, like all other plan limitations, are built into your group’s contract and into the rates your group pays for your coverage. These contracts are set up to provide affordable dental care to a maximum number of people. Given the choice between doubling one individual’s benefits or providing a greater scope of benefits to more people in the group, most group purchasers choose to spread their benefit dollars more evenly.

What if I have non-duplication of benefits?

For groups with a non-duplication of benefits rule in their plan, the secondary carrier pays only the difference between what the primary carrier actually paid and what the secondary carrier would have paid if it had been the primary carrier.

For example, if the primary carrier paid 80 percent and the secondary carrier normally covers 80 percent as well, the secondary carrier would not make any additional payment. However, if the primary carrier had only paid 50 percent, the secondary carrier would pay up to the remaining 30 percent.

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.