What is an Annual Maximum?

This refers to the maximum amount of money that the insurance company will pay for covered dental expenses within a policy year. Once the dental expenses incurred by an insured individual reach this annual maximum, the individual will be responsible for covering any additional dental costs for the remainder of the policy year.

What is a Deductible?

A deductible is the amount of money that you, as the insured individual, must pay out of your own pocket before your dental insurance coverage begins to contribute to the cost of your dental expenses.

The deductible may or may not apply to preventive services like check ups and cleanings.

Let's say you're due for your 6 month checkup and cleaning, your plan benefits are:

Annual Maximum $1,500

Deductible $50 (does not apply to preventive services) For this visit you will not have a copay, but the cost of the visit (let's say $200) will be discounted from your annual maximum. So your remaining available benefits are $1,300.

Or,

Annual Maximum $1,500

Deductible $50 (Applies to preventive services) For this visit you will have a $50 copay, and the remaining cost of the visit $150 ($200-$50) will be discounted from your annual maximum. So your remaining available benefits are $1,350.

Generally speaking, all plans have frequency limitations

A set amount of exams, cleanings and x-rays per year. So if you need more that the allowed services per year, you will be responsible for paying for those services. Common occurrence with patients who require more than 2 cleanings per year.

A limit on how often they will pay for specific services

* Fillings, Crowns, Deep cleanings, Implants

For example, if you had a crown placed 3 years ago and it fails, it most likely will not be a covered benefit since they're usually covered every 5-7 years. You will be responsible for the full payment of that new crown.

The most common non-covered services are

* Bone Graft, Orthodontic treatment for adults & Implants.

Some plans will "cover" some services but will downgrade them giving you a higher copay. The most common are:

* White fillings on molar teeth. Insurance will only cover the cost of a silver filling.
* Porcelain, ceramic, or zirconia crowns on molar teeth. Insurance will only cover the cost of a metal crown.

Coinsurance is a percentage of the total cost that you are responsible for (e.g., 20% for a root canal).

It is common for insurances to cover:

* 100% of preventive services
* 90-80% of basic services
* 50-60% of major services

Knowing your plan's percentages will help you plan for your expenses accordingly. Remember that all of these percentage payments get deducted from your annual maximums and that most services will have a frequency limitation.