Are your clients aware of dual coverage and how it works? If not, they could be missing out on substantial savings on their dental care.
Dual coverage (or coordination of benefits), as the name implies, is when a person is covered under two dental plans. This doesn’t mean double coverage, however. Both plans won’t fully cover each approved procedure. In a dual coverage scenario, the primary carrier (or primary plan) will pay a larger portion of the benefits, while the secondary carrier (or secondary plan) pays a smaller amount.
Why would my clients have dual coverage?
There are several scenarios in which a client may have dual coverage:
- A client and his or her spouse both have employer-sponsored coverage
- A client has two benefits-eligible jobs
That’s good to know! How do my clients know which is their primary carrier?
Your clients and their dependent children may be eligible for dual coverage. Which insurance carrier is the primary depends on several factors.
For clients, the primary carrier depends on whether the client also has dental coverage through a spouse or domestic partner:
- If the client does, the primary carrier is the one provided by his or her employer.
- ·If the client doesn’t, but currently has two jobs that provide dental coverage, the primary carrier comes from whichever employer has provided coverage for the longest time. If the client has coverage through a current and former employer, the current employer’s plan is primary.
For dependent children, the primary carrier depends on whether the child’s parents are married and live together.
- If they are (or have joint custody), the primary carrier is through the parent whose birthday falls earlier in the year. (If both parents have the same birthday, the primary carrier is the one that’s provided coverage for the longest time.)
- If they aren’t and don’t have joint custody, the primary carrier is through the parent who has legal custody of the child.
Is there anything else my clients should know about dual coverage?
Yes. For starters, dual coverage applies only to group plans, not individual plans. Group plans can coordinate benefits only with another group plan.
If one of the plans covering the claim is an individual dental plan, that plan will always pay coverage as primary. Individual plans can’t coordinate benefits with other individual plans, either. In that situation, all plans will pay as primary.
Also, if employees have dual coverage, they must inform their dental office of both plans before they receive treatment. (Failure to do so could be considered insurance fraud!) Once they do, we’ll coordinate the cost sharing with the employee’s other plan.
An important caveat is whether the client’s secondary policy has a non-duplication of benefits clause. While this clause won’t negate their dual coverage, it means the coverage will provide less benefit than standard dual coverage would.
For example, if a client has dual coverage in which the primary carrier covers 50% of a procedure and the secondary carrier covers 80%, then 100% of the cost of the procedure would be covered. However, if the secondary carrier has a non-duplication clause, then only that carrier’s 80% would be covered.
Clients should also be aware that they’re still responsible for amounts that exceed maximums, charges above the allowed amount if using an out of network provider and charges for non-covered services.
Finally, dual coverage involving an HMO-type plan such as DeltaCare® USA can be complicated. Clients can contact Delta Dental Customer Service for details if they have dual coverage involving two HMO-type plans or a PPO and HMO-type plan.
Does Delta Dental have dual coverage resources for my clients?
Yes. Your clients can refer to the dual coverage information available on their Delta Dental member site.
Dual coverage at first may seem confusing, but with some guidance and our resources, your clients can enjoy maximum saving with minimum hassle.
