If your teeth need plenty of work, full coverage dental insurance without an annual maximum benefit might seem like the best choice – at least on the surface.

Insurance traditionally protects members from unexpected, extraordinarily high expenses. However, most dental plans work in the opposite fashion.

They cover routine work but cap what they pay in any calendar year. A dental plan with a very high or no annual maximum either costs much more or takes away something of value. Look under the hood of these options before making a purchase.

Avoid running out of benefits in a given year if you can. The alternatives are costly.

Annual Maximum Meaning for Dental Insurance

Make sure that you understand the annual maximum meaning for dental insurance to avoid surprises. The annual maximum is the yearly limit that any plan will pay in “allowed charges.” Allowed charges are the pre-negotiated fees for specific services rendered by participating providers.

The company stops honoring claims once you reach the annual limit. You must pay for oral care 100% out-of-pocket from that point forward – at least until the new contract year begins.

Runs Out

What do you do when you max out your dental insurance? People have three possible options.

  1. Dental financing programs can pay for any treatment needed right away
  2. Delay non-emergency treatment until the contract year starts anew
  3. Buy coverage without waiting periods before benefits begin
  4. Private health insurance could cover some related treatments
  5. Financial assistance programs could help a lucky few

Actually, people run out of benefits in two ways – not just one. Forecast your expenses based on your treatment plan to avoid running short of money to fix your teeth.

  • Annual maximum limits what the policy pays in any contract year. These limits are temporary but apply across a broad spectrum of services.
  • Lifetime maximum caps the money paid over the lifetime of a member. These limits are permanent but usually only apply to certain services such as orthodontia.

Supplemental Insurance

Supplemental insurance is an option for patients who max out their primary plan in any given year. Some people have a second policy that covers oral care. This can happen when a husband and wife both have employer-based coverage. However, be careful to get your definitions right.

  • Secondary insurance is a second plan that coordinates benefits with the first. It might pick up where the first one left off after hitting the yearly limit.
  • Supplemental insurance is a second plan that does not coordinate benefits with the first. It pays a fixed amount per service and may have a high annual limit of its own.

Per Person

The dental insurance annual maximum can be per person, for the entire family, or both. Read your policy language carefully. Each plan from the same company can handle the issue differently. Also, your choice of coverage can affect how this feature works.

  • Single
  • Husband/Wife
  • Parent/Children
  • Family

The distinction between per person vs family could be important. For example, consider a family with many children. Two people in the family could hit both hit the per person annual maximum. The remaining family members could also reach the limit – even though that had expenses that are more modest in one year.

Dental Insurance with No Annual Maximum Benefit

Full coverage dental insurance plans do exist with no annual maximum benefit limits. You cannot find anything higher than unlimited. If your dentist is recommending a significant treatment protocol, this may sound appealing – until you discover the caveats.

The carriers are in business to make money. They want to offer plans with affordable premiums that exceed what they must pay in claims. How do they do it? They limit networks or introduce disincentives such as copayments, or offer discounts rather than true insurance.

Limited Networks

A Dental Maintenance Organization (DMO) is an example of a limited network plan. The good news with a DMO is that you enjoy full coverage with no annual maximum benefit. The DMO will not limit the amount of oral care performed in a single year.

In addition, a DMO often has no deductible along with the unlimited yearly benefits. However, you will find tradeoffs that could affect your care.

  • You may have to change providers, as the networks are often very small
  • Pays nothing when you go out-of-network
  • The primary-care dentist must issue a referral to specialists

Large Copayments

Select PPO dental insurance plans feature full coverage and no annual maximum without a waiting period before benefits begin. However, the companies design in extremely large copayments to make the numbers work. A copayment is a cost-sharing feature that requires the patient to pay a set amount for each procedure.

For example, the Delta Dental Clear plan follows this model. It has no yearly limit or waiting period but does impose hefty copayments to discourage excess claims. Below is a summary of quoted charges for select services that patients must pay.

CopaymentServices
$65Exam and Cleaning
$115Fillings
$230Surgical Extractions
$535Root Canal Therapy
$740Dentures and Crowns
$2,600Surgical Installation of Implants

Do some simple math before choosing this type of design. Use your treatment plan to forecast the premium costs and copayment expense totals for the year. Make sure you can afford the entire amount.

Discount Savings

Dental discount savings programs feature full coverage and no annual maximum benefit. However, discount plans are not insurance. A third party company will not pay claims after the completion of any covered oral care service.

Discount plans charge a small monthly fee. In exchange, participating providers agree to treat card-carrying members at a lower price. The savings can vary by region and procedure. However, be prepared to pay most of the dental work charges out-of-pocket.

Sources:

  1. Dental Maintenance Organization
  2. Clear Plan
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