Who Pays First: Medicare or Spouse’s Dental Insurance?
- Victoria Tatarzewski
- Jun 9
- 2 min read
When a patient has both Medicare and dental coverage through their spouse’s employer, things can get confusing — especially when it comes to determining which insurance is primary.
This is where Medicare’s Coordination of Benefits (COB) rules come into play — and understanding them can prevent denied claims and save you (and your patients) unnecessary stress.
The Key Question:
How many employees does the spouse’s employer have?
This one factor determines whether the employer-sponsored plan (like Delta Dental) or Medicare pays first.
Here’s the Breakdown:
✅ If the spouse’s employer has
20 or more employees:
The employer group dental plan is primary.
Medicare is secondary.
❌ If the spouse’s employer has
fewer than 20 employees:
Medicare becomes primary.
The employer group dental plan is secondary.
Why Does This Matter?
These rules fall under the Medicare Secondary Payer (MSP) guidelines. The goal is to make sure Medicare doesn’t pay first when another insurer should be responsible.
Misunderstanding this order can lead to:
Denied claims
Incorrect coordination of benefits (COB)
Delays in reimbursement
Extra work for your billing team
Real-World Example:
Let’s say a male patient has Medicare and is also covered by Delta Dental through his wife’s job.
If her employer has 25 employees, then Delta Dental is primary, and Medicare is secondary.
If her employer has fewer than 20 employees, then Medicare is primary.
Final Tip:
When verifying coverage, always ask how many employees are on the group plan if the insurance is through a spouse’s employer. This one question can help you determine the correct billing order and avoid costly errors.
For a clear breakdown of how Medicare coordinates with other types of coverage, check out this official guide from Centers for Medicare & Medicaid Services :
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