Maximums and Dental Insurance Plans

With health insurance, after a deductible is met the insurance company will pay the remainder of the treatment. Dental insurance can be thought of as a partial benefit. It is designed to cover part of your dental expenses, so you may not be covered for every need. Dental benefit plans have are what is known as maximums. Once the maximum is reached the company will not pay anymore toward treatment. You are not insured against loss, it’s more of a potential partial payment by the insurance company. Aside from routine cleanings, dental benefit plans cover a percentage of your treatment, which ranges from 50% to 80%. The portion that is covered is what is applied to your maximum.

What does it mean to max-out your dental insurance? The maximum is the most that a company will pay toward your treatment within a 12-month benefit period. Maximums usually range from 1,000 to 2,000 per year. When the maximum is reached, the company will not pay anymore toward treatment for the remainder of the benefit period. That is true even in the case of emergencies and trauma. The remainder of what is owed is known as the out-of-pocket or patient’s portion.

But You Still Receive Contracted Rates

A big benefit is that the negotiated insurance rate for treatment still applies even after you reach your yearly maximum. Some negotiated rates are 10 to 30% less than the dentist’s full service fee. So even though your dental insurance company may not be paying any more toward treatment, your bill is still less than it would be without your dental benefit. For example, a dentist may charge $160 for a service. The approved amount from your insurance company is $120. Therefore, you save $40 by simply having the dental plan. Cavities (decay), cracks and infection get worse over time and it is not always possible to delay treatment when you have reached your maximum. If you have coverage it is beneficial to complete your treatment while you have the negotiated rate before problems and expenses increase. Utilizing a health savings account (HAS) is a way to use pre-tax dollars to help towards the out-of-pocket expenses.

Do your Math

Some dental plans may not be worth the money paid by you or your employer. If a plan cost $550 a year and has a $50 deductible and only has a $1000 maximum, you are only receiving $400 of benefit aside from the lower negotiated rates. Two cleanings a year do not cost $600 dollars. People with infrequent dental needs may be better off without insurance. So, if your dental needs are infrequent, you would be better off to set aside money in a health savings account to cover costs for dental work if they arise.

The Bottom Line

At Martin Dentistry we will help you understand the particulars of your plan. We can also look at your individual needs to see if dental insurance would be of benefit to you or suggest plans that have better coverage. Dental insurance (benefit plans) can be confusing and their support is limited at times. We are here to help.