Life of Bryan

Open Enrollment Hell

After several months of asking questions, trying to understand the coordination of benefits between my dental plan and my wife’s in preparation for some orthodontia, here’s the email I finally received from Delta Dental. 🦷


I have an employee under Redacted who wrote in asking how COB works when a married couple both have family coverage through separate employers under Delta and the family is about to initiate an Orthodontal claim. The spouse is an employee of Redacted hospital ($2K ortho limit is the plan they are considering). The husband read his policy documents and then called into Delta to confirm his understanding. He feels he has become more confused. Can you confirm:   · The primary (which plan will process the claim first when there is dual coverage) is determined by the birthday rule: the parent whose birthday falls first in the calendar year has the primary plan (note it’s not who is oldest but who celebrates first in any given calendar year). This is correct.

· Orthodontia has its own limit and under your policy that limit is $1500 and separate from the overall deductible. Correct, though I think you meant “and separate from the overall annual maximum”.

The $1500 is lifetime per insured. True and they will check to see if there have been any orthodontia treatments under previous plans, Delta or otherwise. 

We would only consider if the lifetime maximum has been used under the Redacted plan. 

So dual coverage for Dental would only be beneficial for Orthodontia if the 2nd policy had higher limits. 

The lifetime maximum is per plan. For example, if they use their lifetime maximum through Redacted, and move to another Delta Dental employer plan with ortho coverage, they will have a new lifetime maximum through that new plan.

· I’m not sure what Delta meant when they said “that they would not double cover” unless they were trying to make the point that a $1500 claim under policy one can’t be filed as a $1500 claim under policy two ($3000 of payment).  

Some employer plans do not allow coordination of benefits. Without knowing any information on the other plan, I am unable to review this. (note: they are the same provider and know the other plan number provided on day 1).

· If you are currently enrolled under both plans, perhaps the best plan of action would be to have the provider submit a letter of predetermination referencing coverage under both plans. 

Correct, we always recommend a pre-determination. (WTF so they think I’m doing now?)

· If you have dual coverage and file a claim you want the primary plan to have the poorer coverage. Whatever that plan doesn’t pay can be processed against the second richer coverage.  

The Redacted plan has standard coordination of benefits rules, so if it is the primary coverage, it will pay according to the schedule of benefits. If the Redacted plan falls as the secondary insurance, it will pay up to the higher allowable amount (but will not exceed). Again, I don’t know the details of the spouse’s plan, so I can’t really provide any additional information.

Here are two very high-level ortho examples. These are very general, as I do not know all the details of the other plan.

With Redacted as primary, and the other plan as secondary (if both plans have standard COB)

· $6000 orthodontia claim

· $1500 à Redacted (as primary) will pay 50% up to $1500

· $4500 à remaining charges will be sent to secondary insurance

· Secondary insurance could pay, but will not exceed what the primary allowable is, in this case $1500. Even though they may have a $2000 lifetime maximum, secondary would pay up to $1500 (based on the primary allowable).

With Spouse’s plan as primary, and Redacted plan as secondary (if both plans have standard COB)

· $6000 orthodontia claim

· $2000 à likely 50% up to $2000

· $4000 à remaining charges will be sent to secondary insurance

· Secondary insurance could pay, but will not exceed what the primary allowable is, in this case $2000. But, the Redacted plan pays 50% up to $1500, so in this case, $1500 could be paid.   Also in the event the primary plan’s non-ortho limit is exhausted, does the secondary plan become primary for the remainder of the plan year with the full limits of that plan minus whatever it has paid out already as secondary?

In the event that the annual maximum on the member’s primary plan is exhausted, then the member’s secondary will continue as secondary because we will still need the $0 payment EOB from Primary to process as secondary. But the secondary COB rules will still apply.

Please let us know if you have any additional questions!

All the best,

Halfway through The Death and Life of Great American Cities for the second time in my life (for a book club) and have come to the conclusion that it’s unreadable nonsense. Amazing how 20 years of professional experience can change one’s perspective so much.

Remembering a time in my 20s and early 30s when all I wanted was an out from where I was living in the Midwest. It felt like a prison.

It you’re in a similar situation, don’t give up hope. There’s someplace out there for you.

The job hopping in the tech space is so much different than government. As someone who has sat on many hiring panels, if I were to receive a resume with 10 jobs in as many years, that person is not even getting an interview.

Not sure why it bothers me so much that Las Vegas will get true HSR before the Northwest or Midwest, but it does.

I moved away from Lansing about 10 years ago. Lived there for almost a decade. I didn’t live there when developers tore down this block on Michigan Ave, but I still can’t believe they took out an entire historic, fine grained commercial block.

maps.app.goo.gl/T85Ea1yXJ…

My public university degrees (in-state undergrad and grad) cost $106k in tuition, not including community college costs or interest (2010). Thank god for the Public Service Loan Forgiveness (PSLF) Program. Hopefully it survives.

Made the mistake of getting back on Facebook right before the election. Just deactivated again, but seriously considering permanent deletion. What I always miss most are the groups. There are some great communities on there, I hate to admit.

I posted yesterday about needing more indoor play places for kids with adult amenities more like an airport lounge. Biggest concern to me would be sight lines. How would Foucault feel if we used the panopticon as a model? 😉

A large, circular prison interior with multiple cells and a central watchtower from which a beam of light projects.

The Achilles Heel of the YIMBY movement is the common thought that this isn’t built because it’s illegal. It’s legal in enough places to know that developers don’t build much of this. People have so much faith in the landlord and investment class. Such weird bed fellows for the movement.

Having one of those weekends with the kids where I’m ready to go back to work. I think we all need a vacation.

Making my homemade mac and cheese tonight. Feeling like I need some comfort food. Might not fill the void, but it will get me through!

We need indoor play places for kids where the parent areas are more like airport lounges. When we’re going through long stretches of bad weather, these places are lifesavers for people with young kids, but I think there’s an untapped opportunity here to provide better amenities for parents.

Went looking for a binaural sleep frequencies app and ended up self-administering EMDR. Have you tried turning your trauma off and back on again?

Currently: Old Fashioneds and a pretty competitive game of Rummikub while the kids watch a Christmas movie.

So many worries about the Fed’s direction in the coming years—beyond the usual. Transit funding, affordable housing, education… it all feels so precarious right now. Trying to stay optimistic, but it’s tough not to feel the weight of it.

As a staunch urbanist, I love the idea of the 15-minute city, but that lifestyle seems out of touch from most people’s reality. Allowing nearby amenities is easy from a land use perspective, but work, school choice, and childcare are other matters entirely. How do advocates reconcile the problem of most working households needing to commute to wherever they can find work, or needing to drive their children to consolidated schools outside their neighborhood? This is our traffic problem.