Understanding the Ins and Outs of Dual Coverage

Posted on August 7, 2018 in Dental benefit information

It's not uncommon to be covered by two dental benefits plans, which means that you have “dual coverage.” If this applies to you or your family members, take a moment to learn how dual coverage works with these four key points.

Understand your coordination of benefits (COB).

Your COB is the way your two plans work together when you have dual coverage. The plan that pays first is called the “primary plan,” while the one that pays second is called the “secondary plan.” The two plans are coordinated so that no more than 100 percent of the total covered expense of any treatment is paid. When your dental office sends a bill, they will address it to the primary plan provider. After the primary plan provider has paid, the remainder of the bill will be sent to your secondary plan provider. In some cases, the secondary plan may cover the rest of the bill.

Dual coverage works the same way whether you are covered by two Delta Dental of Illinois plans or by Delta Dental and another carrier. Delta Dental of Illinois simply works with the other dental carrier to coordinate your benefits.

Figure out which plan pays first.

One plan is identified as the primary carrier, the plan that pays first, and the other is identified as the secondary carrier, the one who pays second.

For kids, the primary plan provider can be determined in a couple of ways:

  • If you're currently married and your kids have dual coverage, their primary plan will be based on your and your spouse's birthdays. The parent whose birthday comes first in the year (regardless of birth year) will have the primary plan. For example, if your birthday is June 15th and your spouse's birthday is December 1st, yours would be the primary plan. If                  both parents have the same birthday, then the plan that has been effective for a longer period of time will be the primary plan.
  • If the parents are separated or divorced, and two or more carriers cover the same child as a dependent, the order of benefit determination is as follows (unless a court decree states differently; please see your certificate of coverage or benefits booklet for specific details):
    1. First, the plan of the parent with custody of the child;
    2. Second, the plan of the spouse of the parent with custody of the child.
    3. Third, the plan of the parent not having custody of the child.

If you have dual coverage because you're married, the coverage you receive under your employer is your primary plan, as opposed to the coverage you receive from your spouse. Alternatively, you might have dual coverage because you have two jobs. In this case, the plan you've had for the longest will be your primary plan. The primary and secondary plans can vary in some cases.  For example, plans for a retired employee may pay differently. For specific details regarding your primary or secondary plan, please review your certificate of coverage or benefits booklet.

Don't expect double coverage.

Dual coverage means your two benefits providers share costs in a pre-determined way – not that you receive double benefits. For instance, both plans may cover two cleanings a year, but having dual coverage doesn't mean that you're now covered for four.

As an example, both of your plans may provide two cleanings a year, each with 80 percent coverage. The primary carrier pays 80 percent, and the secondary carrier usually covers up to the remaining 20 percent that you would have had to pay out-of-pocket if covered by only one plan.

Know if your plan has a non-duplication of benefits clause.

Some plans have a rule that prevents secondary plan coverage when the primary plan already paid as much or more than the secondary plan would have covered if it had been the primary plan. Check your plan information to see if your secondary plan has this rule before using your benefits.

With some quick research, you can handle dual coverage with ease and know what to expect after you visit the dentist.