A simple guide to understand how to coordinate dental insurance benefits plans (with examples)
Are you covered under two dental insurance benefits and not use which one to use? In many households, both partners may have access to dental plans. These plans can differ in what they cover and how much they pay.
By coordinating your benefits, you can use both plans and potentially get back up to 100% of your dental expenses. In this article, we will explain how to use and coordinate 2 dental insurance plans.
Some people think they can save money by sticking with just one plan. But before you do that, check both plans carefully. One plan might cover services the other doesn’t, like orthodontics or extra dental cleanings. It might be worth staying on both plans.
If you are looking for full detailed explanation about dental insurances, click here.
First off, let’s start with some dental insurance industry rules
1. If you and your spouse each have a workplace benefits plan
- Submit claims to your own plan first.
- Submit any remaining balance to your spouse’s plan.
- Similarly, your spouse should submit their claims to their own plan first.
Example: Sarah’s Dental Claim
Sarah is covered under her employer’s health plan and as a dependant under her husband’s plan. When she goes to the dentist, she submits the claim to her own plan first, as her employer’s plan is considered her primary coverage. If there are any leftover costs, such as co-pays or portions not covered, she submits those remaining amounts to her husband’s plan, which acts as the secondary coverage.
Example: Emily’s Dental Check-Up
Emily and her husband both have dental insurance through their respective employers. When Emily goes for a dental check-up, she first submits the claim to her own plan. If there are any remaining out-of-pocket costs, such as co-insurance, she then submits the claim to her husband’s plan to cover the difference.
2. If you’re submitting a claim for your child
- Submit to the plan of the parent whose birthday (just the month and day, not the year) is earlier in the calendar year.
- Submit any remaining amount to the other parent’s plan.
Example: Jake’s Orthodontist Bill
John and his wife both have health plans that cover their son, Jake. Since John’s birthday falls earlier in the calendar year, his plan is considered primary. When Jake gets braces, they submit the orthodontist bill to John’s plan first. After John’s plan processes the claim and pays its portion, any remaining amount is then submitted to his wife’s plan for additional reimbursement.
3. If you have joint custody of your children, and both you and your ex have new partners
- Submit to the plan of the parent whose birthday comes first in the year.
- Then, submit to the other parent’s plan.
- If needed, submit to the plan of the spouse of the first parent.
- Lastly, submit to the plan of the spouse of the second parent.
Example: Lily’s Cavity Filling in Joint Custody
Mary and her ex-husband share joint custody of their daughter, Lily. Since Mary’s birthday is earlier in the year, her plan is primary. When Lily needs a cavity filled, they submit the dental claim to Mary’s plan first. After Mary’s plan pays its portion, the remaining balance is sent to her ex-husband’s plan for additional reimbursement.
4. If you have sole custody of your children, and both you and your ex have new partners
- Submit to the plan of the parent with sole custody.
- Then, submit to the plan of the spouse of the parent with sole custody.
- If applicable, submit to the plan of the other parent.
- Finally, submit to the plan of the other parent’s spouse.
Example: Jessica’s Son’s Braces in Sole Custody
Jessica, who has sole custody of her son, is remarried. Both she and her new husband have dental insurance. When her son needs braces, Jessica first submits the claim to her own dental plan. Any remaining costs not covered by her plan are then submitted to her new husband’s plan for secondary coverage.
5. If you’re a full-time university student with coverage through your university and job, and you’re also a dependant under your parent’s plan
- Submit to the student or work plan you were covered by first.
- Then, submit to the student or work plan you obtained second.
- Finally, submit to your parent’s plan.
- Exception: If you’re a Quebec resident submitting a drug claim, submit to your student plan last.
Example: Paul’s Dental Crowns as a University Student
Paul, a university student, is covered by his school’s dental plan, his part-time job’s dental plan, and his parent’s plan. After needing dental crowns, Paul submits the claim first to his part-time job’s plan. Any remaining balance goes to his university plan, and finally, the leftover amount is submitted to his parent’s plan.
6. If you have two jobs and coverage under both
- Submit to the plan of your full-time job first.
- Then, submit to the plan of your part-time job.
- Note: If you work the same hours at both jobs or have two part-time jobs, submit to the plan for the job you started first.
Example: Michael’s Root Canal with Two Jobs
Michael has two jobs, each offering dental benefits. When he needs a root canal, he submits the claim to the dental plan provided by his full-time job first. After the full-time job plan processes the claim, any remaining amount is sent to the dental plan from his part-time job.
7. If you have a retiree plan and coverage at a new job
- Submit to the plan of your new job first.
- Then, submit to your retiree plan.
How Are Coordination of Benefits Claims Reimbursed?
Start by submitting your claim to the plan designated as the primary payor. The plan will pay out according to its coverage limits.
After you receive a statement of benefits (or an explanation of benefits) from the primary plan, submit any remaining amount to the secondary plan. The secondary plan will then cover the remaining eligible costs, based on its own coverage.
However, the combined reimbursement from both plans will not exceed 100% of the total claim amount. For example, if you had a $200 claim and your primary plan covered $150, the secondary plan would only cover up to the remaining $50.
