Sometimes, a patient might have two dental insurance policies. There are many reasons why this might happen. For instance, a patient might have dental insurance through their employer, but also through their spouse’s employer. Or, maybe the patient is covered both through Delta and Cigna dental insurance plans. However, dual dental insurance does not at all mean “double coverage”! This can feel confusing to deal with, especially when each policy provides a different type of coverage. Properly understanding how to navigate this situation will help you to best serve your patients and find them the best deal that they can acquire.
Dental insurance plans set forth rules for this scenario in particular, and these rules will determine which plan will pay first (the “primary” plan), and which will pay afterward (the “secondary” plan).
The general rule is that the plan that covers the patient as an enrollee will be their primary dental plan, and the plan that covers the patient as a dependent will be the secondary plan.
This is where it gets a little hairy, and can get confusing — both for dental offices and the patient. So, let’s try to illustrate this with an example. Let’s say that your patient has two plans that both provide two cleanings a year, each cleaning with 80% coverage.
What does this mean and what does it not mean?
What this does NOT mean is that your patient will be entitled to four cleanings a year — no matter what they may try to argue!
What this DOES mean, is that the primary plan will pay its benefit as if there is no other insurance. In other words, the patient will receive the 2 cleanings a year with 80% coverage from their primary insurance provider.
Coordination of Benefits
When a patient has two different insurance plans, a process called a coordination of benefits (COB) will determine which insurance plan is primary, and which is secondary. While this seems like it should be clean-cut, it relies on a number of factors. Therefore, there are several different terms that are used to describe a coordination of benefits. Here are some of the most common:
Other Dual Coverage Factors
Some dental insurance plans have a “non-duplication of benefits” provision. This means that the secondary plan will not pay for any benefits if the primary plan has paid the same or more than what the secondary plan would allow. For example, if both the primary and secondary carriers pay for a service at an 80% level, but the primary allows $100 and the secondary allows $80, then the secondary carrier would not make any additional payment. However, if the primary carrier only pays 50%, then the secondary carrier would reduce its payment by the amount paid by the primary plan, and then pay the difference in order to meet its own threshold for coverage. This way, the patient is covered for the 80% that the secondary carrier allows for.
Network plan write-offs are the difference between the dentist’s full fee and the sum of the dental benefit plan payments plus the patient payments. Write-offs should not be posted until all plans have been paid accordingly. If a write-off is posted after the primary plan pays, and then posted again based on the secondary payment, the dental office may incorrectly apply a credit to the patient’s balance. Remember to always be careful when submitting write-offs so as to not make this mistake.