What is a dental insurance annual maximum?

what is an out of pocket maximum


Annual maximums are the most feared and misunderstood of all dental insurance costs. They sound scary, but they aren’t actually.

Sometimes referred to as a plan maximum, or maximum amount - a dental annual maximum is the total your dental plan will pay toward your care during any one plan year. Annual maximums usually range between $1,000 and $2,000.

Nobody wants to max out on their dental benefits. But in reality, most people never reach their dental insurance annual maximum. According to the National Association of Dental Plans, only 2.8% of people on a PPO plan reach their dental annual maximum each year.

Let’s look closer at the concept and reality of dental annual maximums.

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How dental annual maximums work

It’s pretty simple, really. At the start of each benefit period (usually a year) the maximum is set to pay for your dental care. Your annual maximum only applies to the portion your dental insurance plan pays on your behalf.

  • • Your deductible doesn’t apply to the annual maximum.
  • • Any copays on your plan don’t apply to the annual maximum.
  • • Costs that accumulate after your deductible and copy are satisfied are applied to your annual maximum.
  • • Most treatments have a coinsurance level; i.e., we pay XX% and you pay the rest. The original “XX%” is applied to your annual maximum.

Each time you visit the dentist, a dental claim is submitted. We pay the claim and subtract the cost of the service from your maximum. When the maximum is reached, the plan stops paying for care and you are responsible for out-of-pocket costs. The amount of any maximum not reached or spent in a benefit period is not carried over to the next benefit period. At the beginning of the next benefit period, you get a new annual maximum.

Some plans get very creative and stretch the annual maximum for families with children. An example of this is our Family Advantage Plan. If you have a family and a tight budget, it may be the right one for you.

In the end, if you are concerned about your annual maximum, it’s always a good idea to talk to your dentist about costs when scheduling dental treatments. Be upfront about wanting to stay within your dental annual maximum. Working in partnership with your dentist, you may be able to set up a treatment plan that spreads out out-of-pocket costs while still meeting your dental needs.