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Buyer's Guide


Buyer’s Guide for Dental Insurance and Discount Dental Plans


Browse Common Concerns:

Annual Maximum

The yearly maximum is the total amount of money that a preferred provider organization or indemnity type of plan will contribute toward your care in a year (a “year” can either be based on your anniversary date when you joined the plan or the calendar year, depending on the insurance company). This means that, typically, on a minor or major procedure, after you meet the deductible, you will contribute part of the cost of the procedure and the insurance company will cover the remainder. The yearly maximum is the total amount the plan will contribute toward your care in a year, typically somewhere between $750 and $1,500.

Here’s a quick example of how this system works: Let’s assume you have already met your deductible for the year and:

  • During a 12-month period of your insurance you undergo a dental procedure that costs $100 and—according to your plan—your share of the cost is $50. The plan will be responsible for $50.
  • And, let’s say that the yearly maximum on the plan you have is $750. As a result of the plan’s $50 contribution toward your first procedure, the plan will now contribute no more than $700 toward your dental bills for the remainder of that 12- month period.
  • Now, let’s say—for the sake of an example—that six months later you need a more expensive procedure done, say its cost is $1,000 and your share is $500. That leaves the plan to pay $500.
  • So far, in this example, the plan has paid $50+$500=$550 toward your care in that year. Because the yearly plan maximum was $750, the plan is now only responsible for contributing another $200 during the remainder of that 12-month period, and so on.

Where yearly maximums become a problem is when you have to have a lot of expensive work done within that 12-month period.

Using the example above, let’s say you have to have another $1,000 procedure done in that same year. Because the plan has paid $550 dollars to date, they will now only contribute $200 toward your care, leaving you with the balance, $800, to pay out of your own pocket.

It is therefore important to think about the condition of your teeth when deciding whether to opt for the plan with the higher, and more expensive, yearly maximum.

After the 12-month period is over, the amount the plan will pay moves back up to $750 again.

Keep in mind that the yearly maximum normally does NOT include preventive care. So, if your dentist charges $60 for a cleaning, most plans normally pay the entire amount of that charge (unless you go to an out-of-network dentist in the case of a preferred provider organization) and the cleaning will not affect your yearly maximum.

If you’re interested in purchasing a dental health maintenance organization or discount plan, there are no yearly limits, simply use your plan as much as you need.

Always read the details of the plan you’re interested in before you buy.

If you’re shopping for a preferred provider organization or indemnity plan should you purchase one with a higher yearly maximum?

If you want the flexibility of a preferred provider organization or indemnity plan and you anticipate the need for a lot of expensive dental work, then yes, choose a plan with a higher yearly maximum. But keep in mind that even if you have an unexpected, expensive procedure, a $750 yearly maximum buys you a lot of dental care. If you normally just have one major procedure done a year it should fall under that smaller yearly maximum amount—in other words, the less expensive preferred provider organization or indemnity plan, with a lower yearly plan maximum, would pay off.

When does it pay to buy the plan with the higher yearly plan maximum? It pays when you must us an out-of-network dentist for a lot of dental work done in a very short period of time.

Here’s an example:

Let’s say you live in a rural area of the country and you’re going to have to use an out-of-network dentist for your care.

  • You’ve narrowed your plan choices down to two. One plan is $30 a month and the other plan is $40 a month. The only difference is in the yearly plan maximums.

So the question is, is it worth it to pay the extra $120 a year in premium?

  • Let’s say that you’ve been in the plan awhile and you’ve been seeing your dentist twice a year for preventive care and check-ups. Because you’re using an out of network dentist, the plan pays 80% of those costs.
  • Then, let’s say for the sake of example, lots of problems suddenly pop up with your teeth—all in the same year:
    • First, early in the year you need a simple filling,
    • then your wisdom teeth need to come out but two of them are impacted,
    • finally, you damage a tooth and need a root canal and a crown.
    • Below is an item-by-item breakdown of what you would have to pay for each of those procedures under two different plans.

Notice that by the time you get your crown, under Option A, you’ve completely exceeded your plan maximum and you would have to pay for the crown completely out of your own pocket. While under Option B, you are still under the plan maximum amount and your crown will cost you much less.

(Keep in mind these prices are representative of the industry as a whole—your costs will vary.):

   


Preferred Provider Organization

Option A

Preferred Provider Organization

Option B

Plan Maximum

$750

$1,500

Monthly Premium/

12-month total

$30

$360

$40

$480

Two cleanings/checkups

Avg. Cost = $180


You Pay: $36  Plan Pays: $144


You Pay: $36   Plan Pays: $144

One filling:

Avg. Cost = $150


You Pay: $90  Plan Pays: $60


You Pay: $90  Plan Pays: $60

Two, Simple Wisdom teeth

extractions.

Avg. Cost = $300



You Pay: $180  Plan Pays: $120



You Pay: $180  Plan Pays: $120

Two Impacted

Wisdom teeth extractions

Avg. cost = $820



You Pay: $490  Plan Pays: $330



You Pay: $490  Plan Pays: $330

One Root Canal:

Avg. Cost $1,100


You Pay: $860  Plan Pays: $240


You Pay: $660  Plan Pays: $440

One Crown:

Avg. Cost = $1160


You Pay: $1,160  Plan Pays: $0


You Pay: $700  Plan Pays: $460

Your total

out-of-pocket costs


$3,176


$2,636

Savings


$540

 

As you can see, it takes a lot of dental work in one year and some fairly specific circumstances before the more expensive preferred provider organization saves you a significant amount of money. The decision comes down to your tolerance for risk. If you don’t want to use your savings, and if you can foresee a scenario in which you might need a lot of dental work in the same year, you may be more comfortable purchasing a plan that has a higher yearly maximum.

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