Primary and Secondary Insurance

[tammy8]

What is the name of your state? NC

I realize that each and every medical and dental insurance company operates different however as a general rule, how does the primary and secondary insurance usually handle claims? I am mainly speaking of dental right now.

Again I realize every company/state/etc is different but just the generals...

Thanks in advance.

 

[Beth3]

In general, most insurance companies follow the "birthday rule." If both parents work and have family coverage (which is seldom a cost-effective choice), then whatever parent's birthday falls earlier in the year is primary for the dependents with dual coverage. If dad's birthday is in January and Mom's is in May, dad's plan is primary. (You'll need to check with the specific carriers involved however.)

Now here's the other issue. When there is duplicate coverage, many plans these days follow a "maintenance of benefits" rule, rather than a coordination of benefits rule. Maintenance of benefits means that if dad's plan covered that cavity or medical procedure at 80% and mom's would have covered it at 80% had her plan been primary, the level of coverage has been "maintained" and therefore mom's plan pays nothing. If dad's plan covered it at 70% and mom's plan would have paid 80%, then mom's plan will only pay the 10% difference. Again, you will need to check the specific provisions of the medical and dental plans involved.

FYI for future reference - because of these maintenance of benefits provisions and when you factor any premiums the parents are both making for family coverage, having duplicate coverage for dependents is often not a cost-effective choice.