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,