A “maximum benefit” is one of the trickiest concepts in dental insurance and if you don’t understand it, you might pay very high out-of-pocket costs. This resource will give you a quick tutorial on maximum benefits and demonstrate how this feature affects the financial protections represented by your insurance. The article includes:
A maximum benefit is a feature typically associated with dental PPO insurance and dental indemnity plans. The maximum benefit is a dollar value that represents the most an insurance plan will pay for your dental care in a year. If a plan has a maximum benefit of $1,500 than any dental costs above $1,500 during the plan year is paid completely by the patient even if the dental service is covered by the insurance plan. The dental costs that count toward the maximum benefit reset each year, so if your policy begins on January 1st, you start with $0 spent by the insurance company toward your maximum limit.
A dental plan may refer to a maximum benefit by other terms such as:
HMO dental plans and dental discount plans lack a maximum benefit but they come with trade-offs such as a narrow dental provider network.
Yes, a maximum benefit is legal spending cap in the dental insurance industry. In other types of medical coverage, such as Medicare Advantage plans and Affordable Care Act plans, there is no limit on an insurance company’s annual spending for covered care (though there are conditions on that care related to network, prior authorization, etc.). Moreover, both Medicare Advantage plans and Affordable Care Act plans also have a MOOP, which is a yearly limit on out-of-pocket costs paid by the patient for covered treatments.
DentalInsurance.com has observed maximum benefits as low as $500 a year. A single crown or dental implant could exceed this amount and leave a patient with substantially more to pay out-of-pocket. Thankfully, there are many options with more generous limits including dental insurance plans with very high maximum benefits.
If you are enrolled in a PPO or indemnity dental plan that has a maximum benefit, you need to monitor that amount from year. Why? Inflation. As the cost of dental treatment increases annually, a static maximum benefit means your plan covers less now than it did when you first enrolled in the coverage. Some dental plans increase the maximum benefit over a three-year period as a loyalty reward for continuous enrollment. Other plans do not adjust their maximum benefit. If you are enrolled in a plan with a low maximum benefit (e.g. $1,000 annually), it would be wise on an annual basis to explore the cost other plans with higher maximum benefits (or plans that lack these caps altogether). A single dental implant can cost, in some cases, $2,000 and a patient with a $1,000 annual maximum would have to pay $1,000 out of pocket on top of his monthly insurance premiums in this scenario.
Another important issue related to a maximum benefit is if a dental plan has multiple maximum benefits that apply to different categories of dental care. Dental care is normally divided into three major groupings: preventive, basic, and major. Preventive care includes annual dental exams, x-rays, and cleanings. Basic care covers fillings, whether traditional or cosmetic white fillings. Teeth extractions, crowns, root canals, and implants are considered major dental care. While it is uncommon, a dental plan may have a lower maximum benefit for certain dental procedures than others so review the plan’s information regarding the conditions that apply to the maximum benefit. You can find these details easily:
Procedures outside of traditional dentistry, such as braces, may also be covered by a separate maximum benefit if covered at all. Consumers should be aware that a high maximum benefit is of reduced value if the maximum excludes expensive types of major care (e.g. crowns, root canals, implants) or has a reduced maximum benefit for one of the three categories of dental care (preventive, basic, and major).
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There are a variety of dental insurance options on the market. Importantly, these options for foster competition regarding benefits, networks, and costs. With respect to a maximum benefit, generally the larger the maximum benefit, the higher the premium. However, there are a variety of exceptions. Consider the two dental plans below. You’ll notice our plan comparisons include a column labeled “Plan Maximum” which lists a plan’s maximum benefit.
You’ll notice that the first plan has a slightly lower monthly premium than the second but, despite the lower premium, the first plan has a maximum benefit that is $250 higher annually.
The example below is even more striking. The first plan has a premium quote 14 percent less expensive than the premium of the second plan but its maximum benefit is $1,000 more generous each year.
The lesson from these examples is that it pays to comparison shop.
When evaluating the maximum benefits of dental plans, dig into the detailed coverage conditions that apply to the maximum benefit. As mentioned earlier, some plans have a general maximum for most services but a lower maximum for procedures like implants or braces. For example, a plan may have a $2,000 maximum benefit for preventive and basic dental care but a $1,500 maximum major care. Get into a thorough review of a plan’s benefits to see if there are any waiting periods on dental service coverage or a reduced maximum benefit for major services.
Our agents can:
There are two easy ways to find a dental plan with a high maximum. The first is to go to our dental insurance quote page and see what plans are available in your local area. As mentioned earlier in this article, our plan comparisons have a column labeled “Plan Max” that lists an insurance product’s maximum benefit.
The second option is to read our article “Dental Plans with the Best Maximum Benefits." This article contains a list of nine dental plans with maximum benefits ranging from $2,500 to $10,000.
To make your shopping easier, DentalInsurance.com has compiled a brief list of dental plans with very high maximum benefits. While many dental plans have maximum benefits below $2,000 annually, the plans below have limits significantly more generous to their enrollees. Please review an individual product’s plan details for additional information.
| Waiting Periods Before Some Dental Services Covered? | Annual Maximum Benefit (single enrollee) | Limitations on Maximum Benefit | |
| NCD Complete by MetLife | None | $10,000 | The maximum limit on dental implants is $3,000 per calendar year |
| Humana Extend 5000 | Preventive care has no waiting period, basic care has a 90-day coverage delay, and major care has a 6-month coverage delay | $5,000 | The annual maximum benefit for dental implants is $2,000, and there is an additional $4,000 lifetime limit on implant costs |
| NCD Elite 5000 by MetLife | Preventive and basic care have no waiting periods. Most major care has no waiting periods except for dental implants, which have a 24-month delay before coverage begins | $5,000 | Dental implants have a $2,500 maximum benefit each year of coverage |
| Delta Dental Immediate Coverage Plan | None for traditional dental care. Orthodontia has a 12-month coverage delay | $3,000 | Orthodontia has a $300 calendar year cap and a $1500 lifetime maximum |
| Cigna Dental Vision Hearing 3500 | Preventive and basic care have no waiting periods. Most major care has a 6-month coverage delay. Dental implant coverage has a 12-month delay | $3,500 | Dental implants have a $2000 lifetime maximum |
| Waiting periods may vary by state. Not all plans available in all areas. | |||
Our knowledgeable customer service team will assist you with any questions you may have prior to enrolling in a dental plan. They can guide you through the process of choosing coverage that matches your needs as well as your budget.
