Quick Answer
You can schedule a dental visit by locating a nearby dentist through an online search or dedicated dental directories. Gather your dental history and insurance details to prepare for the booking. Most clinics can be contacted via phone, online form, or email—whichever suits your schedule. When booking, confirm the appointment's time, date, and location and understand any cancellation policies to avoid fees.
What is meant by the coordination of benefits in insurance policies?
Coordination of benefits is an extended health, drug, and dental insurance term that refers to a situation when someone has dual coverage with two or more group plans. When this situation arises, coordination of benefits refers to the process in which the insurance company determines which plan or coverage will pay first toward the insurance claim. The secondary plan(s) may then provide additional coverage.
Whether you're a university student on your parents' plan or part of a married couple with full-time jobs, coordinating your extended health, drug, and dental insurance is crucial. This approach ensures you fully leverage all available coverage options, enhancing overall benefits and reducing out-of-pocket expenses.
Why is coordinating benefits important?
Coordinating benefits is key for minimizing out-of-pocket expenses when using your extended health, drug, and dental benefits. For example, suppose your plan covers 80% of dental costs up to a specific limit. In that case, you can use additional coverage from a spouse's plan to pay the remaining 20%, potentially reducing your direct costs to zero. This strategy maximizes your available benefits and helps you manage healthcare expenses more effectively.
How do I set up the coordination of benefits?
To set up coordination of benefits in Canada, follow these steps:
- Inform Each Insurer: Contact all your insurance providers and let them know you have coverage under multiple plans
- Determine Your Primary Plan: Your employer's plan is typically the primary plan. For children, the primary plan is usually determined by the parent whose birthday falls earlier in the year.
- Submit Claims Accordingly: Always submit your claims to the primary plan first. Once processed, submit the remaining amount along with the Explanation of Benefits (EOB) from the primary plan to the secondary insurer.
This process helps ensure that you maximize your coverage across all plans.
Which policy pays first?
The coordination of benefits in Canada is a structured process managed by insurance companies and governed by the Canadian Life and Health Insurance Association. This regulated system determines the order in which plans pay for claims, ensuring clarity and consistency for dental and health costs coverage, with minimal guesswork involved.
Below, we detail several scenarios where coordination of benefits is applicable and explain how insurers determine which plan pays for specific services.
| Situation | Who pays first? | Who pays second? | Example |
|---|---|---|---|
| Persons A and B have group coverage and are listed as dependents on each other's plan. | Your employer plan pays your claim first | Your partner's plan pays your claim second | John has a dental claim. John has group benefits. Jane has group benefits. John's plan pays first, and Jane's plan pays second. |
| Person A has group coverage, and Person B has individual dental insurance but is named as a dependent on Person A's plan. | Person A's plan with group benefits pays first. | Person B's plan with individual benefits pays second. | George has a dental claim. George has individual dental insurance and is listed as a dependent on Beth's plan. Beth has group benefits. George's insurance pays first, and Beth's group benefits pay second. |
| Person A works two jobs, both with benefits. | Full-time job benefits will pay first. | Part-time job benefits will pay second. | Rachelle works full-time for the government and has a weekend retail job, carrying insurance from both employers. For her dental claim, the sequence is:
|
| Person A and Person B have a dependent child. Person A is born in December. Person B is born in May of the same year. | Person B's insurance will pay first as they have an earlier birthday. | Person A's insurance will pay second. | Johnny has a dental claim and is a dependent on both Jennifer's and Robert's group benefits. Jennifer's birthday is May 2. Robert's birthday is December 21. Jennifer's plan pays first, and Robert's second. |
| Person A and Person B have separated and have new partners but have joint custody of a child. Person A is born in February Person B is born in October of the same year | Person A's insurance will pay first when their child needs coverage as they have an earlier birthday. | Person A's new spouse's plan will pay next Person B's insurance will pay next Finally, Person B's spouse will pay. | John and Pam, who are separated and have remarried, share custody of their child, Bailey. For Bailey's dental claim, the sequence is:
|
| Person A and Person B have a child dependent on their plan who is in full-time university and under 25. Person A was born in December. Person B was born in September. The child is on a student insurance plan. | The child's student insurance plan pays first. | Person B's plan will pay second. Person A's insurance will pay third. | John and Jim have a child named James. John was born in February. Jim was born in November. James has a university insurance plan but is also listed as dependent on his parents' plans. James has a dental claim. James's university plan will pay first. Then John's and then Jim's plan. |
Getting the most out of your dental benefits
Beyond the primary and secondary payer rules, here are a few additional points to consider:
- Annual Maximums: Knowing the annual limits of both plans can help you use further coverage once one plan's maximum is reached.
- Specific Exclusions and Claim Deadlines: Be aware of what each plan does not cover and the deadlines for submitting claims to ensure you don't miss out on available benefits.
- Public Plans Coordination: In places with public dental programs, these typically cover costs only after private plans are exhausted. Understanding their specifics can maximize your coverage.
- Keep Records and Seek Help: If needed, seek advice from your benefits administrator or insurance provider's customer service to navigate the coordination process efficiently.
By understanding how to coordinate your dental benefits, you can more effectively manage and plan dental care for you and your family. Knowing the ins and outs of your primary and secondary insurance plans allows you to strategically schedule treatments, making the most of the coverage limits. A proactive approach helps keep costs down and supports regular access to dental care, contributing to better oral health over time.
Frequently Asked Questions
How do you coordinate benefits?
Coordinating benefits is a straightforward process with any Canadian benefits company. You can usually update your benefits through your plan's member account online. If necessary, you can also contact your insurance company directly.
What information will you need to coordinate benefits?
To coordinate benefits, you will need each insurance company's policy numbers and contact details, member IDs for all participants, coverage details and effective dates, and the necessary claim forms and receipts for all related expenses.
When can I add a partner to my benefits plan?
You can add a partner for most plans when they become legally married or enter a common-law relationship. The details will depend on the province or territory in which you live.
Who can I list as dependents?
The definition of dependents will depend on the specific group benefit plan and insurance company. In most cases, dependents are limited to partners and underage dependent children.
When can I add a dependent?
You can enroll dependents in the plan during the initial enrollment period, the annual open enrollment, or within 30 days following a qualifying life event, such as marriage, entering a common-law relationship, or the birth or adoption of a child.
Can I coordinate benefits between private insurance and the CDCP (Canadian Dental Care Plan)?
No. Canadians with access to private dental insurance are not eligible for CDCP coverage.
Can I coordinate benefits between provincial programs and private insurance?
This depends on the specific provincial program. Please refer to your provincial program's website to understand whether it allows coordination of benefits.
*The content provided in this article, including text, graphics, and referenced material, is intended for informational purposes only and is not a substitute for professional dental advice, diagnosis, or treatment. Always consult with your dentist or another qualified oral health professional for questions regarding your dental condition. Never disregard professional dental advice or delay seeking it based on information from this article. If you believe you have a dental emergency, contact your dentist, or seek immediate assistance from an oral healthcare professional.