What Is a Dental Maximum and How Does It Work?
Demystify the dental maximum: understand this key insurance limit and its impact on your oral health costs.
Dental insurance helps manage oral healthcare costs. Understanding the “dental maximum” allows policyholders to maximize their benefits. This financial limit is a core component of most dental plans.
Understanding Your Dental Maximum
A dental maximum is the highest dollar amount a dental insurance plan will pay for covered dental care within a specific benefit period. This period is usually 12 months, often aligning with a calendar year, though some plans may operate on a policy year or a rolling year. Most dental plans feature an annual maximum, which resets each benefit period. This differs from a lifetime maximum, less common for general dental services, but applicable to specialized treatments like orthodontics where the total benefit does not renew.
Annual dental maximums typically range from $1,000 to $2,000, though some plans offer higher limits. Services counting towards this maximum include basic and major restorative procedures like fillings, root canals, crowns, extractions, and oral surgeries. Many plans do not count preventive and diagnostic treatments, such as routine cleanings, exams, and X-rays, towards the annual maximum. Policyholders can determine their specific dental maximum by reviewing plan documents or contacting their insurance provider.
How Your Dental Maximum Works
The maximum typically resets after a defined benefit period. This reset commonly occurs on January 1st for calendar year plans, making a new full maximum available at the start of each new year. Other plans might reset on the policy’s start date anniversary or on a rolling basis, one year after the first claim is submitted. Unused benefits from the previous period do not carry over.
When a policyholder receives covered dental services, the amount the insurance company pays is subtracted from their annual maximum. For example, if a plan has a $1,500 maximum and the insurer pays $500 for a procedure, $1,000 of the maximum remains. Once the total amount paid by the insurance company reaches the annual maximum within a benefit period, the insurer will no longer contribute to the cost of further covered services.
Once the maximum is reached, the policyholder becomes responsible for all subsequent costs for covered dental services for the remainder of that benefit period. A dental maximum differs from deductibles and co-insurance. A deductible is the amount a policyholder pays before the insurance plan covers costs, and copays are fixed amounts paid per service. Neither directly reduces the maximum. However, the percentage of costs covered by the insurer after the deductible and co-insurance are applied counts towards the maximum.
Impact on Your Dental Treatment Costs
Understanding the dental maximum directly influences out-of-pocket expenses, especially for extensive or multiple dental procedures. If a patient requires significant dental work, such as several crowns, root canals, or implants, costs can rapidly accumulate. A single crown, for instance, can range from $750 to $2,000, and a root canal can cost between $750 and over $1,000 per tooth. Such procedures can quickly cause a policyholder to reach their annual maximum.
Once the maximum is reached, the policyholder becomes responsible for the entire cost of any additional covered services. Even if the maximum is exhausted, the patient may still benefit from negotiated rates between the dentist and the insurance provider, which offer a discount compared to the dentist’s full fee. Planning dental treatments, possibly spreading them across two benefit periods, can help utilize benefits from both years and manage expenses more effectively.