Can Dental Insurance Affect Medicare, Medi-Cal, or Share of Cost?
One of the most common questions we hear is:
“If I buy a dental insurance plan, will it interfere with my Medicare, Medicare Advantage plan, Part D drug coverage, Medi-Cal, or Medi-Cal Share of Cost?”
In most situations, the answer is no. Dental insurance is usually separate from your medical insurance and coordinates benefits independently. Many people successfully carry dental insurance alongside:
- Medicare Part A & Part B
- Medicare Advantage plans
- Part D Prescription Drug Plans
- Medi-Cal
- Medi-Cal Share of Cost
- Employer health insurance
- Retiree coverage
Routine dental care is generally not covered by Original Medicare, which is why many people purchase a separate dental insurance policy or enroll in a Medicare Advantage plan that includes dental benefits.
Important: If you have Medi-Cal or Medi-Cal Share of Cost, you may be required to report other insurance coverage, including dental insurance. In many cases, the dental plan pays first and Medi-Cal may pay second if applicable.
Can Dental Insurance Help Lower Medi-Cal Share of Cost?
Sometimes, yes. Certain health insurance premiums — including some dental insurance premiums — may potentially help reduce Medi-Cal Share of Cost calculations depending on your situation. This is one reason many California consumers ask about standalone dental coverage.
You can also review our pages on:
- Dual Coverage & Medi-Cal Coordination
- Medi-Cal Share of Cost
- Working Disabled Program
- Medicare Coverage Information
- Medicare Part D Drug Coverage
What Is Coordination of Benefits (COB)?
Coordination of Benefits means insurance companies determine which plan pays first and which plan pays second. This prevents duplicate payment of claims.
For example:
- Your dental insurance may pay first
- A secondary dental plan may help with remaining costs
- Medi-Cal may pay after other insurance if the provider accepts Medi-Cal
Having two plans does not usually mean you get paid twice. Instead, the plans coordinate benefits under insurance rules. Learn More
Already Have Dental Through Medicare Advantage?
Many Medicare Advantage plans already include limited dental benefits. However, some people still purchase separate dental insurance because:
- The Medicare Advantage dental maximum may be too low
- They need crowns, implants, dentures, or oral surgery
- The network may be limited
- They want additional coverage for major dental work
Every plan is different, so it is important to verify how your coverage coordinates before enrolling.
Need Help Understanding Dental & Medicare Coordination?
We help California consumers understand how dental insurance may work with Medicare, Medicare Advantage, Medi-Cal, Share of Cost, and other coverage.
#Dentala Co Ordination of Benefits
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Coordination of Benefits (COB) Non-Duplication of Benefits Delta Flyer
- Delta Dental – COB Co-Ordination of Benefits only on Group Policies
- Denti Cal Member Handbook
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- Such clauses means that the secondary plan will not pay any benefits if the primary plan paid the same or more than what the secondary plan allows for that dentist.
- For example, if both the primary and secondary carrier pay for the service at 80 percent level but the primary allows $100 and the secondary carrier normally allows $80 for the same treatment, the secondary carrier would not make any additional payment. However, if the primary carrier only pays 50 percent of the dentist’s allowed fee, then the secondary carrier would reduce its payment by the amount paid by the primary plan and pay the difference. In this case, the secondary carrier would pay $14 ($80 x 80 percent – $50 = $14).
- Dual coverage saves money for you and your group by sharing the total cost of dental benefits between two carriers. Containing costs is an important part of Delta Dental’s plan to keep you smiling.
- understanding non duplication
- Nonduplication COB – In the case of nonduplication COB, if the primary carrier paid the same or more than what the secondary carrier would have paid if it had been primary, then the secondary carrier is not responsible for any payment at all. ADA.org
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How does dual coverage and COB work?
- With non-duplication of benefits, the primary carrier pays its portion first and the secondary carrier, instead of paying the remainder, calculates what it would have paid if it were the primary carrier and subtracts what the other plan paid.
- For example, if the primary carrier paid 80 percent, and the secondary carrier normally covers 80 percent as well, the secondary carrier would not make any additional payment. However, in the same scenario, if the primary carrier paid 50 percent, the secondary carrier would pay up to 30 percent. Dental Dental
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(a) This section shall only apply to a health care service plan covering dental services or a specialized health care service plan contract covering dental service pursuant to this chapter.
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(b) For purposes of this section, the following terms have the following meanings:
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(1) “Coordination of benefits” means the method by which a health care service plan covering dental services or a specialized health care service plan contract, covering dental services, and one or more other health care service plans, specialized health care service plans, or disability insurers, covering dental services, pay their respective reimbursements for dental benefits when an enrollee is covered by multiple health care service plans or specialized health care services plan contracts, or a combination thereof, or a combination of health care service plans or specialized health care service plan contracts and disability insurers.
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Please note, I’m not an attorney nor an authorized claims representative for any Insurance Carrier.
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