What Happens When You Reach Your Dental Insurance Maximum?

When you need expensive work done on your teeth, you may ask yourself what happens when you reach the maximum annual benefit on your dental insurance.

The policy stops making claim payments temporarily, resuming at the beginning of the new plan year, which could be just one month or twelve.

You must delay treatment until the limit resets in the next plan year or find another way to pay the dentist.

Of course, with an average maximum of only $1,500 per year, people needing the most expensive services will quickly reach the limit again. Therefore, most people should investigate alternatives.

Maxed-Out Dental Insurance Options

There are many things that patients can do to minimize costs or get emergency treatment after they max out the annual benefit limit on their dental insurance.

Dental insurance promotes wellness rather than reducing your exposure to unaffordable treatments, hence the tiny annual maximum benefits. Therefore, patients needing pricey implants, dentures, gum surgery, root canals, or crowns should find other means to manage expenses.

Financial Assistance

Financial assistance for dental work can lower treatment costs after reaching your dental insurance annual maximum. Charity care, local clinics, dental schools, pro bono care, and grant programs might make a dent in your expenses.

Plus, dentists sometimes offer free exams and cleanings to attract new patients. Typically, they covet those with insurance who can pay for treatment years into the future.

Dental Financing

Dental loans for bad credit can help you pay for urgent treatment when you max out your insurance for the year. Monthly payment plans spread the costs over time, and your dentist gets an upfront payment and can begin treating you immediately.

Patients with poor borrowing credentials face steeper odds but still have alternatives. Subprime lenders specialize in working with consumers with spotty records, and Flexible Spending Accounts offer guaranteed approval, zero interest, and up to four different tax savings.

Two Dental Plans

You can have two dental plans to avoid maxing out your annual benefits yearly. Patients with dual coverage might double the allowed amount paid with multiple policies.

However, buying a second or third plan will have several caveats

  • Supplemental dental insurance could double your yearly limit, but only after meeting a long waiting period for major services
  • Dental insurance with no waiting period might boost your yearly limit gradually, as these plans typically reduce benefits early on
  • Dental insurance with no annual maximum often includes hefty copayments well above the usual 50% for major services

Delay Treatment

Delaying treatment is a viable coping strategy to explore when your dental insurance is maxed out. Sometimes, we can afford to wait for the yearly limit to reset when the plan resumes making claim payments.

Schedule any non-urgent oral care for the beginning of the new plan year.

Paying for emergency dental care without insurance is the only alternative when the pain is too intense, and you cannot wait for the annual limit to reset. Sometimes, delaying treatment makes the problems worse and more expensive to treat.

Medicaid Coverage

Medicaid covers dental work for adults in many states, but not all. Low-income patients reaching their annual maximum should research the rules in their region to see if they qualify based on their household size and earnings.

This publically-funded program might help if you live in a state that supports the type of oral care needed.

  • Preventative dentistry (exams, cleanings, fluoride): 31
  • Restorative care (root canals, dentures, crowns): 33
  • Oral surgery (wisdom teeth extraction, corrective jaw surgery): 33
  • Periodontal treatment (deep cleaning, gum flap surgery): 26
  • Cosmetic services (teeth whitening, labial veneers): 0

Annual Maximum Meaning

The annual maximum benefit for dental insurance is the yearly limit that the plan will pay towards the “allowed amount” for all covered family members. The number resets at the beginning of the specified period, and the claim payments resume. 

In-network dentists cannot charge more than the allowed amount by contract. A plan with a 50% copayment for major services and a $1,500 yearly cap might calculate the patient’s financial responsibility as follows for an $8,000 set of dentures.

  • Provider charges: $8,000
  • Allowed amount: $6,000
  • 50% copayment: $1,500 (would be $3,000 without limit)
  • Patient responsibility: $4,500

Out-of-Pocket Maximum

The annual out-of-pocket maximum for dental insurance means something completely unexpected. Dental plans do not include this feature, but health insurance does when it pays for oral care in rare circumstances.

The dental procedures covered by medical insurance are numerous when medically necessary:  care arising from non-biting accidents, certain diseases, and treatments considered integral to other services included in the plan.

The out-of-pocket maximum for your health insurance could apply to your dental work, meaning the plan will pay 100% of allowed charges above the specified threshold.

Lifetime Maximum

The maximum lifetime benefit in dental insurance means the plan will stop making claim payments after the approved allowed charges reach a specific threshold spanning multiple years.

Lifetime maximums are typical with dental plans that include benefits for orthodontia, as the treatments often span three years or more.

Switching insurance during treatment for braces can sometimes work to get around the orthodontic lifetime maximum. Be careful to ask whether the limit resets or carries over and whether new waiting periods might apply when changing plans.

Per Person Maximum

The dental insurance annual benefit maximum per person means the plan stops paying claims after a specific family member reaches the lower yearly limit for approved allowed charges.

Some plans contain a lower per-person and higher family cap, similar to this example.

  • Per-person: $1,500
  • Family: $2,500

With this configuration, a family of four could have one individual hit the yearly per-person limit of $1,500, leaving only $1,000 of benefits for the remaining three people.