Coordination of Benefits

Coordination of Benefits is a procedure for paying health care expenses when people are covered by more than one benefits plan. The goal of coordinating benefits is to make sure the cost of the dental procedure is covered within the scope of the plans, without exceeding the amount of the actual bill.

If you are covered by two or more dental plans—usually because both you and your spouse receive coverage through work—your coverage will be coordinated. The primary plan must pay its full benefits as if you had no other coverage. The secondary plan will then pay benefits according to the state coordination rules described in your certificate of coverage.

To decide which plan is primary, Delta Dental will consider both the coordination provisions of the other plan and which member of your family is involved in a claim. The primary plan will be determined by the first of the following rules that applies:

• Non-coordinating Plan—If you have another group plan that does not coordinate benefits, it will always be primary.
• Employee—The plan that covers you as an employee (neither laid off nor retired) is always primary.
• Children (Parents Divorced or Separated)
  • If a court decree makes one parent responsible for health care expenses, that parent's plan is primary.
  • If a court decree gives joint custody and does not mention health care, Delta Dental follows the birthday rule. The plan that covers the parent or guardian whose birthday comes first in the calendar year will be considered the primary carrier.
  • If neither of those rules applies, the order will be determined in accordance with the Kentucky Department of Insurance rule on Coordination of Benefits (See 806 KAR 18:030).
• For all other situations, the plan that has covered the person for the longer period of time is primary as determined in accordance with the Kentucky Department of Insurance rules on coordination of benefits.