Your dentist just presented your treatment plan – the dental treatment you urgently need will cost a few thousand dollars. Thankfully, you have dental insurance. But wait – you’ve already hit your annual cap! What does that even mean?
It means you exceeded the annual maximum coverage provided by your dental insurance. You must pay out of pocket for your dental care until your coverage resets at the beginning of the next benefit period.
Understanding Dental Insurance’s Annual Maximum Limit
Dental insurance policies generally limit coverage to $1,000 -$1,500 within a twelve-month benefit period. So, if your plan has an annual maximum (sometimes called an “annual cap”) of $1,500, your dental benefits provider pays their portion of your dental work until they have paid out that $1,500. You then pay out of pocket for your dental care until your plan resets.
A typical dental insurance plan offers what is known as "100-80-50" coverage. This means the insurance will pay 100% of the cost of routine preventive and diagnostic care – typically two checkups with cleanings annually. After you meet your deductible, (typically $50-$100) most dental insurance providers pay 80% of the cost of basic services such as fillings or root canals, and 50% of the cost of major procedures such as crowns and bridges. You would then pay the rest of the money owed – a process that’s known as “co-payments” or “coinsurance”.
The part that you pay does not apply to your annual limit. For example, if you have a $300 cost for repairing a cracked tooth, and your insurance pays 80% ($240) of the cost, you have $1,260 left before you hit your annual limit.
If your oral health is excellent, you may not max out your dental insurance. However, that said, one major procedure can easily bring you past your dental insurance cap. For example, the average *cost for a crown these days is $750-$2,000 per tooth, and the cost of a root canal is $750-$1,000+ per tooth (that price can soar if you need a complex root canal). Even though one procedure can max out your insurance, you would still need to pay your monthly premiums (unless your employer picks up the whole cost) and you also have to pay for whatever other dental care you need until your plan resets. For many people, that can be a significant financial burden.
Save on Dental Costs by Going to the Dentist
One of the best ways to keep your dental costs low is by seeing your dentist regularly. Consistent dental care is essential for oral – and overall – health, and it can significantly reduce your dental costs.
“For every dollar spent in preventive services like the ones provided through the Virtual Dental Home demonstration project an estimated $50 is saved on more expensive, complicated procedures,” said Dr. James Stephens, president of the California Dental Association, in a PBS interview.
Regular dental checkups also allow you and your dentist to plan ahead for expensive treatments so you can make the best use of your dental insurance and prepare for any uncovered costs.
Emergency Dental Care After you Max out Insurance
Sometimes no matter how carefully you plan for the future, a sudden emergency can put a huge stress on your budget. For example, just biting down on a crunchier-than-expected treat can leave you with a cracked, chipped, loose, or even broken tooth, and repairing it may cost more than your dental insurance’s annual cap. You need it fixed but may be unsure about how to afford it – delaying, however, can actually cost you more in the long run and may impact the chances that the tooth can be saved with processes such as a dental splint.
A badly damaged tooth can also be at risk of infection. These are the symptoms to watch for, according to the Mayo Clinic:
- Severe, persistent toothache
- Fever
- Swelling in your face or cheek
- Red gums
- Foul-smelling/tasting discharge
- Difficulty breathing or swallowing
If you are experiencing any of the above symptoms, you need to see a dentist or other medical professional immediately. If you have no other options, go to the nearest urgent care or emergency room.
Bottom line – you need your tooth fixed. So how can you fit it into your budget?
Affordable Dental Care Options
If you need to fill in a coverage gap after maxing out your insurance, there are a few ways to handle the situation without having to delay care:
Ask Your Dentist About Payment Plans
Your dentist may have a solution that allows you to budget your payments rather than pay all at once.
Consider Health Care Credit Cards
These credit lines are specifically designed to help you pay off the cost of medical care. Your dentist may have information on this option, so you can ask for their advice.
Review Short-Term Loan Options
Your bank, credit union, retirement savings plan or employer may offer loans or lines of credit for health care or other emergencies.
Purchase Supplemental Insurance
This type of insurance can help with one-time costs for treatments such as orthodontics but check to make sure there is no waiting period before the coverage activates and that the specific procedure you need is covered. Here again, your dentist can guide you.
Join a Dental Savings Plan
Dental savings plans are an affordable alternative to traditional dental insurance that enable you to save 10-60% on most dental procedures, from braces and dentures to crowns, root canals and more. There are no annual spending caps, waiting periods, approval process or restrictions on pre-existing conditions. These plans activate immediately so you can get your care right away. Talk to your dentist to find out which plans they accept and recommend for your needs.
You can also use the DentalPlans.com search tool to compare the dental savings plans that are accepted by your current dentist, or choose to sort by the best overall savings in your area, the biggest savings on specific procedures you need, or the lowest cost plan. And you’ll also want to ask your dentist for guidance on how to best coordinate the use of your insurance and your dental savings plan.
Navigate Dental Care Beyond the Insurance Limit
Maxing out your dental insurance may make it feel like you can’t afford the care you require to maintain your health. But with the recommendations above, you can find the option that fits your budget, preferences, and oral health needs, so you can get the care you need and deserve.
Don’t delay dental care due to financial concerns – poor oral health has been linked to cardiovascular disease, certain types of cancer, respiratory infections, dementia, and raises the risk of complications in pregnancies. Untreated gum disease can make it more difficult to manage conditions such as diabetes. Seeing your dentist regularly is one of the best investments you can make in your health and happiness.
Frequently Asked Questions
Can I still receive dental treatment if I have maxed out my insurance?
Yes, you can still receive dental treatment even if you have maxed out your insurance coverage. You will just need to be prepared to cover the costs out of pocket or explore alternative payment options as mentioned earlier.
Will my insurance coverage reset after a certain period?
Many dental insurance plans reset their coverage limits annually, typically at the beginning of the calendar year. However, it’s important to check with your insurance provider to confirm when your benefits reset and what your new coverage limits will be.
Can I appeal to my insurance provider for additional coverage if I have maxed out my benefits?
It may be possible to appeal to your insurance provider for additional coverage in certain circumstances, especially if you require essential dental treatment. However, approval is not guaranteed, and you will need to provide a valid reason for the request.
*Cost averages obtained from DentalPlans.com procedure search tool.
Dental Insurance Methodology
To determine the best dental insurance providers, we pored through all United States carriers. We winnowed the list by only including companies that have a wide coverage area and product offering. To further break down the list to the true best dental insurance providers, we gave weight to carriers that offer discounts, are available in all states and have multiple payment plan options.
Dental Plans Promo
Get 10% off any dental savings plan at DentalPlans.com. You can reduce your dental care costs by saving 10-60% off at the dentist!