Dental Plans - Coordination of Benefits

One area of dental benefits that can cause some confusion is coordination of benefits (COB). COB takes place when a patient has more than one dental plan and is able to use both of them to cover their dental procedures. When this occurs, the two plans work together to coordinate benefits to eliminate over-billing or duplication of benefits.

What happens when both plans have COB provisions?

• The primary plan is the one in which the patient is enrolled as an employee or as the main policyholder.
• The secondary plan is the one in which the patient is enrolled as a dependent.
• State laws and regulations often mandate coordination of benefits, but plan sponsors should be certain that the selected plan specifies its method of coordination.

How does COB work with dependents?

• The policy that pays first for dependents depends on the rules of the insurance company or state laws.
• The typical protocol for dependents whose parents have overlapping coverage is to follow the birthday rule: The parent whose birthday is earlier in the calendar year is primary.
• In the case of divorced/separated parents, the court’s decree would take precedence.

When does the secondary policy pay?

• Usually, the secondary policy will not accept a claim until after the primary claim is paid, and then the secondary policy will often require a copy of that payment information (referred to as an explanation of benefits, or EOB).
• In addition, state laws and regulations often mandate coordination of benefits.
• Plan sponsors should be certain that the plan they select specifies its method for coordinating benefits with other plans.

ADA Guidance on Coordination of Benefits (PDF) can be downloaded online. The ADA recommends that patients impacted by these policies consult with their human resources department to determine their entitled level of benefit prior to treatment.

You may download the entire publication, Dental Benefits: An Introduction, which also includes information about understanding different types of dental plans, communicating with third-party payers and more.

If you are not an ADA member, you can purchase this whitepaper in the ADA Store.