All dental insurance plans refer to an “Annual Benefit Maximum” in their summary of benefits.  Sometimes this is also called “Annual Plan Maximum,” or “Annual Maximum.”  What does this mean.

The Annual Benefit Maximum of a dental insurance plan is the most benefit in terms of dollar amount you will receive (the dental insurance company will pay out towards your claims) in the policy year of your policy.  The majority of dental insurance plans offer a $1,000 Annual Benefit Maximum.  Thus, $1,000 is the most benefit you could hope to receive from the dental insurance plan.

The Annual Benefit Maximum is not based on the total amount of the dental services you receive, but on the total amount of benefit the dental insurance company pays out on those services.  Let’s use a simple example to make this point clear:

I visit the dentist in 2009 three times,

Visit 1, an exam and cleaning, total bill, $150. (My dental insurance plan pays 100% of this visit type)

Visit 2, a root canal, total bill, $850. (My dental insurance plan pays 50% of this visit type)

Visit 3, an exam and cleaning, total bill, $150. (My dental insurance plan pays 100% of this visit type)

Did the dental insurance plan only pay claims on the first two visits, since they total $1,000 in total costs?  No!  My dental insurance plan paid on all three claims, since the total paid out, $150 for the first claim, $425 for the second claim (50% of $850) and $150 for the third claim totals $725, under the $1,000 Annual Benefit Maximum.  In this example, I actually have $275 remaining in possible benefit for the remainder of the plan year.

Many people I speak with about dental insurance wonder if the Annual Benefit Maximum is going to be enough.  The maximum seems a bit low at first glance.  I answer this with claims data from the dental insurance companies I work with.  Each insurer has a slightly different number (from researching their claims), but on average, 93% of the time, this $1,000 Annual Benefit Maximum was enough to cover one’s dental costs for the year!

Of course, there is that other 7% you could fall into one year, the year your dentist tells you she recommends 3 root canals!  But, I have found, through personal experience, and from hearing my customers’ experiences, that your biggest advocate in keeping under the maximum is your dentist.  They and their staff are familiar with your plan, and will usually try to maximize your benefits. 

Here’s an example of what I mean.  I went to see my dentist a few years back, sometime just before Thanksgiving.  After the exam, she explained I had two cavities that needed a filling.  But, with where my dental insurance plan’s Annual Benefit Maximum was sitting, only one cavity would be covered before the Annual Benefit Maximum would be met.  So, she scheduled one filling for December (the cavity that needed immediate attention), and the second filling for January (the Annual Benefit Maximum for my dental insurance plan started over January 1)!