I hit my annual maximum. What now?
The short answer
Most dental plans have a yearly spending cap. Once you reach that annual maximum, the plan stops paying until its new year begins, a bit like a gift card that refills once a year. Many plans set the cap somewhere around $1,000 to $2,000. If your dentist is in your plan's network, there's some good news: you'll usually still pay the plan's discounted fees, not full price.
When it resets
Your maximum resets at the start of your plan year. That's often January 1, but some plans run on a different schedule. Check your Summary of Benefits or call member services.
Planning around it
- Before big treatment, ask how much of your maximum is left. Other claims, including from other dentists, may have used some of it.
- Ask your dentist whether treatment can be safely split across two plan years. For example, one crown in December and another in January.
- Ask whether preventive visits count against your maximum. Some plans don't count them.
In network? You usually still get the network price
Even after you hit your maximum, a dentist in your network is usually still limited to the plan's contracted fee for covered services, not their full fee. That's one of the benefits of staying in network. This can vary from plan to plan.
Questions to ask
- How much of my annual maximum is left?
- Can any of this treatment safely wait until my plan year resets?
- What's my cost after insurance, both now and if we wait?