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Dental Definitions Decoded: Navigating Your Annual Maximum

Posted on December 9, 2014 in Dental benefit information



Man with computerMost dental plans have an annual dollar maximum. This doesn't refer to a cap on the amount you will pay out of pocket. Instead, this is the maximum dollar amount a dental benefit plan will pay toward the cost of dental care within your annual benefit period.
Once you reach your annual maximum, you are responsible for paying any costs for services above the maximum. However, if you use a network dentist for procedures covered under your plan, the dentist cannot charge you more than the allowed network amount. Consult your plan booklet for specific information about your plan's annual maximum.

To further clarify what an annual maximum actually is, here's a quick example:

Let's say you have a plan with an annual maximum of $1,000.

You get your preventive care (cleanings, xrays). The total cost is $200. Your plan covers preventive care at 100%. The $200 is deducted from your annual maximum, leaving your annual maximum balance at $800.

Then, you need a new crown that will cost $800. Your plan covers crowns at 50% so you will pay $400 and your plan will pay $400. The $400 is deducted from your annual maximum, leaving your annual maximum balance at 200.

You will have $200 left of your annual maximum for future eligible dental costs for your remaining plan year. Worried about exceeding your annual maximum?

Delta Dental of Illinois offers a few ways you can help manage your expenses:

1. Predetermination of benefits. Delta Dental of Illinois recommends that you get a predetermination of benefits for any service over $200. If your dentist recommends a certain procedure that will cost over $200, ask him or her to determine what the fee will be in advance of performing the procedure so you have a clear understanding of what you may owe.

2. Flexible Spending Account (FSA) Your employer may have an FSA, which is a plan that lets you set aside a certain amount of your paycheck into an account for qualified healthcare expenses before paying income taxes. With an FSA, you can reduce your taxable income and use the income reduction to pay for healthcare expenses that otherwise would have been paid with after-tax dollars.

When you use tax-free dollars to pay for these expenses, you have more take home pay, significant tax savings and more control over your family budget.

You can put a certain amount in your healthcare FSA each year. This means you can budget for expected expenses, like dental work you know you'll need in the coming year.

3. Delta Dental of Illinois' To Go Feature

Delta Dental of Illinois offer the To Go℠ feature for group clients as an option for Delta Dental PPO℠ and Delta Dental Premier® programs.

In traditional PPO plans, the annual maximum is a “use it or lose it” benefit. The To Go feature gives members (in groups with plans that include this feature) the ability to carryover any qualified, unused portion of their annual maximum in a given year and apply it to their To Go Bank, increasing their total dollars for dental treatment.

Learn more about the To Go feature.*

*Brokers and groups, contact your account manager or sales executive for more information; this feature is not available for individual and family (non-group) plans.

Do you have a better understanding of annual maximums now? Leave us your questions and comments below!