Navigating dental insurance can feel overwhelming, especially when dealing with primary and secondary insurance, major and basic procedures, deductibles, and maximum eligible amounts. At Toothcrew Family Dental, we want to make it easy for you to understand how your coverage works so you can make informed decisions about your oral health.
Let’s break it all down so you know exactly what to expect when using your dental insurance at the dental office.
1. Understanding Primary and Secondary Dental Insurance
If you have two dental insurance plans, you have what’s called dual coverage. This usually happens when:
You have dental insurance through your employer, and your spouse’s plan covers you as well.
Your child is covered by both parents’ plans.
Here’s how it works:
Primary Insurance – The plan that pays first. This is typically the insurance provided by your employer or the parent whose birthday comes first in the calendar year (known as the Birthday Rule).
Secondary Insurance – The plan that pays after the primary insurance, covering additional costs not fully paid by the primary plan.
How Does Primary and Secondary Coverage Work at the Dental Office?
• Your primary dental insurance processes the claim first and pays its portion.
• The remaining balance is sent to your secondary insurance for further coverage.
• Depending on your plan, secondary insurance may cover some or all of the remaining balance.
Important Note: Having secondary insurance does not mean 100% coverage for everything. Each plan has its own rules, maximums, and limitations.
2. Major vs. Basic Dental Procedures: What’s Covered?
Most dental insurance plans categorize procedures into three main groups:
Preventive Procedures (Usually 100% Covered)
Preventive care is essential for maintaining good oral health and preventing costly dental issues. Most dental insurance plans cover:
Routine dental exams (typically twice a year)
Dental cleanings
X-rays (as needed)
Fluoride treatments (usually for children)
Sealants (for children’s molars)
Basic Procedures (Usually 70-80% Covered)
Basic dental services typically require the patient to pay a portion of the cost. These include:
Fillings for cavities
Simple tooth extractions
Periodontal (gum) treatments
Root planing and scaling (deep cleanings)
Major Procedures (Usually 50% Covered)
Major dental work often has higher out-of-pocket costs and may require pre-approval from insurance. These include:
Crowns
Bridges
Dentures (full or partial)
Dental implants
Root canals
Pro Tip: Even though major procedures are covered at a lower percentage, having both primary and secondary insurance can significantly reduce your out-of-pocket expenses.
3. Understanding Maximum Eligible Amounts: Combined vs. Separate Maximums
Every dental insurance plan has an annual maximum—the total amount your plan will pay for dental care within a year. This amount resets annually.
Combined Maximum: If you have both primary and secondary insurance, some plans combine their annual maximums, meaning they share a total coverage limit.
Separate Maximums: In other cases, both insurance plans have their own separate maximums. This means you can get more coverage since each plan will contribute up to its own limit.
Example:
• Primary Insurance Maximum: $1,500
• Secondary Insurance Maximum: $1,000
• If they have separate maximums, you may receive up to $2,500 in total dental benefits for the year.
How This Affects You at the Dental Office:
• If your treatment exceeds your primary insurance maximum, your secondary insurance may cover the remaining costs (if the plan allows).
• Once you reach your maximum on both plans, you are responsible for the remaining costs out-of-pocket.
4. Understanding Deductibles in Dental Insurance
A deductible is the amount you must pay out-of-pocket before insurance starts covering costs. Deductibles apply differently depending on the procedure type.
Typical Deductible Structure in a Dental Plan:
Preventive procedures – Often no deductible
Basic procedures – Deductible may apply (usually around $50-$100 per year)
Major procedures – Deductible almost always applies
Primary and Secondary Deductibles: How Do They Work?
If you have two dental insurance plans, you may have to meet the deductible for both. However:
If your primary plan pays in full, your secondary insurance may not require an additional deductible.
Some secondary plans waive the deductible if the primary plan has already met its own deductible.
Example:
• Your primary dental insurance has a $50 deductible, and your secondary insurance has a $75 deductible.
• If your primary insurance covers the full cost after meeting the $50 deductible, your secondary insurance may not charge the additional $75 deductible.
Key Takeaway: Always check with your dental office and insurance providers to understand how your deductibles apply.
5. Coordination of Benefits: How Do Two Insurances Work Together?
When you have primary and secondary dental insurance, the process of who pays what is called Coordination of Benefits (COB).
Your primary insurance processes the claim first and pays its portion.
Your secondary insurance then processes the remaining balance (up to its limits).
What If the Secondary Insurance Doesn’t Cover the Full Balance?
If your primary insurance and secondary insurance do not cover the entire cost, the remaining balance is your responsibility.
Example:
• You need a $1,200 crown.
• Your primary insurance covers 50%, paying $600.
• Your secondary insurance covers another 30%, paying $360.
• Your remaining balance is $240 out-of-pocket.
Does Having Two Dental Insurances Mean No Out-of-Pocket Costs?
Not always. Each insurance plan has rules, maximums, and limitations. Always check your coverage with your dental office before starting major treatment.
6. Key Questions to Ask Your Dental Office About Insurance
Before your appointment, call your dental office and ask:
What is my annual maximum for primary and secondary insurance?
Does my plan have separate or combined maximums?
What is my deductible, and does it apply to basic and major procedures?
What percentage is covered for basic and major procedures?
Does my secondary insurance cover any costs my primary doesn’t?
At Toothcrew Family Dental, our team is happy to help you navigate your dental insurance benefits so you can get the most out of your coverage!
Final Thoughts: Get the Most Out of Your Dental Insurance-Every insurance is different, get to know your insurance.
Understanding your dental insurance can save you money and stress when visiting the dental office. Whether you have one plan or two, knowing your coverage for basic and major procedures, maximum limits, deductibles, and coordination of benefits can help you plan for your dental care without surprises.
Need help figuring out your insurance? Contact Toothcrew Family Dental today—we’ll be happy to explain your benefits and help you maximize your coverage! 
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