When an employee is covered by more than one dental plan, such as their own and their spouse's plan, the employee can coordinate their benefits, as long as both plans accommodate this arrangement.
Here's a practical example of a benefit coordination arrangement:Employee A has both a primary and a secondary dental plan. The primary plan covers up to 50 percent of the cost of a crown and the secondary covers up to 80 percent. If the cost of the crown is $500, then the primary will cover $250. The secondary covers up to 80 percent of $500 ($400) minus what has already been covered by the primary ($250), which comes to $150. ($400-250=$150). In some arrangements, up to 100 percent of the total dental bill will be covered. Coordination of benefits under dual coverage is a smart choice, as long as both plans specify that they allow coordination, and both plan administrators are aware of the dual coverage.
Here are four common types of coordination arrangements identified by the American Dental Association:
This method is the most straightforward and allows plan members to combine their plans to cover up to 100 percent of their costs.
The secondary carrier does not have to cover any of the costs as long as the primary carrier has covered what the secondary would have been
responsible for if they had been primary.
3. Maintenance of Benefits
This covers a bit less than a traditional arrangement because the amount that the primary plan has paid is subtracted before the plan deductible and co-insurance levels are determined.
4. Carve out
This arrangement, like the example listed above, calculates primary plan benefits, then reduces this coverage of the secondary by the amount provided by the primary.
Each individual plan will specify percentages, cost caps for the year and how coordination of benefits will apply in each case. Dual coverage limitations will be a part of any arrangement, so it's important to make sure before any procedures are scheduled what will be covered at what rate. The ultimate goal is to provide the widest amount of coverage for procedures to the largest number of plan members.
The Scripps Research Institute's Information on Coordination of Benefits - The Scripps Research Institute's information on how some carriers arrange coordination of benefits.