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Coordination of Benefits
This feature is for those patients who are covered by two insurance
plans. The term coordination of benefits refers to the way the insurance
companies determine their benefit. This used to be pretty simple. The
primary plan pays based on its plan provisions, then the secondary plan
pays based on its provisions. The only limit was that the total benefits
of both plans not exceed the fee actually charged. Most times, patients
with dual coverage could expect minimal, if any, out of pocket expense.
Things aren't so simple today.
Some insurance companies, in an effort to manage costs (meaning pay
less in benefits to you), have been implementing different policies
called non-duplication, carve-out, maintenance of benefits, limited
coordination, non-dual, and integration of benefits, to name a few.
The effect of these clauses is to reduce or eliminate payment as the
secondary coverage.
As an example, let's take a crown with a fee of $700, and two plans.
The primary pays $340 towards the fee. The secondary plan was predetermined
to pay 50%. Because of a 'carve-out' or 'non-duplication' clause, carves
out the $350 benefit from the primary and pays only the remaining $10.
That leaves the patient owing $350 even with two insurance plans. This
is not always obvious, even with written pre-determination by the plan.
There is always fine print on the form stating the benefit may be affected
by coordination of benefits.
Another, and perhaps worse scenario is 'integration of benefits'. This
means that the sum of the total benefits paid by either carrier may
satisfy the annual maximum of the secondary carrier. For example, a
patient has a bridge made with a fee of $3000. The primary plan pays
$1500. The secondary plan has an annual maximum of $1500. The secondary
plan then states its maximum is satisfied for the entire plan year even
though it's the primary plan which paid the $1500.
These examples illustrate the importance of understanding the specifics
of your dental insurance. We agree these plan provisions don't seem
fair. Your premiums aren't reduced if you have dual coverage. Our only
suggestion is to make you feelings known to those in your company who
have input into the nature of the insurance plan that is selected. Decisions
are often made by considering what is included in coverage and not giving
sufficient consideration to the exclusions.
We will do everything we can in assuring you receive the full benefits
of your insurance plan, but we have no control over what those benefits
are. If you have any questions regarding the plan provisions pertaining
to coordination of benefits or any other plan provisions, you should
direct them to your employer. If you have a description of your dental
insurance plan, we will be happy to review it with you. As always, we
strive to be accurate with our estimates. Thank you for your understanding.
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