What does Annual Maximum mean when it comes to your dental insurance?
An annual maximum is the maximum dollar amount your dental insurance will pay toward the cost of dental services and/or treatment in a benefit plan year. The benefit year is typically a 12-month period. Each time a dental claim is submitted by your dentist, your dental insurance provider subtracts the cost that they have paid for the service from your maximum. Once the maximum dollar amount is reached, any further dental services you receive are 100% your responsibility to pay until the next plan year.
Annual maximums only apply to the portion your dental insurance plan pays on your behalf. Deductibles and co-pays do not count towards your annual maximum. Most diagnostic and preventive procedures do not count towards your deductible but most of these services are covered up to 100% by your dental plan.
On average, an annual maximum usually ranges between $1,000 and $2,000 and resets at the end of each benefit period, typically 12 months. Certain plans could have an even higher annual maximum, so make sure to check with your dental insurance provider.
Dental insurance annual maximums are different than medical insurance out-of-pocket maximums. Out-of-pocket maximums for health insurance is the maximum amount YOU have to pay out-of-pocket before your health insurance provider will pay 100% of health care costs for the remainder of the benefit plan year.
Does orthodontic care count towards the annual maximum?
Most dental insurance coverage renews its annual maximum each plan year, however, orthodontic benefits typically come with lifetime maximums. This means all orthodontic treatments within the same benefit plan year, or over the course of multiple years, are counted against your total available orthodontic benefit. Your total orthodontic benefit does not renew at the beginning of each benefit period and once you have reached the orthodontic maximum, there is no further orthodontic benefit for the life of your dental plan.
What counts toward an annual maximum?
Examples of dental services that may count toward your dental insurance annual maximum include:
Depending on your plan, diagnostic or preventive services, such as exams and cleanings, may not count toward your annual maximum. If you have any questions about what services will count toward your dental insurance annual maximum, we recommend speaking to your dentist or dental insurance provider who will be able to provide specific details regarding your coverage.
How can I check my annual maximum?
There are a number of ways to check the remaining balance of your annual maximum.
1. You may call your dental insurance provider’s customer service team.
2. Online services provided by your insurance provider that allow you to check your benefits 24/7.
Delta Dental of Kentucky members can log in to Member Portal and securely access their dental insurance benefits in real-time.
Below is an example of how much of the annual maximum is left for the remainder of the benefit year.
1. Your Dental Benefits: Use Them or Lose Them. (n.d.). Retrieved November 15, 2020, from https://www.mouthhealthy.org/en/dental-care-concerns/paying-for-dental-care/using-dental-benefits