Explaining “Annual Maximum” and Other Dental Plan Terms

Year after year, dental insurance is listed as a highly valued benefit. However, research shows that many have trouble fully understanding dental insurance. Employees and individual consumers may not connect how their dental benefits help protect their overall health. One of their biggest concerns are costs, thinking they can’t afford dental care, even in an emergency.

Here’s a refresher on common terminology so you are prepared to answer their questions, and ultimately sign up for and use them. When educating employees and your clients about dental insurance terminology, remind them about the value of dental coverage in protecting their smile and overall health.

Understanding dental insurance terminology

Educating employees and your clients on dental insurance terms helps them better understand their coverage. Better understanding usually means they’ll value their benefits and use them throughout the year to help maintain good health.

Here’s an overview of some dental insurance terms you may come across:

Maximum benefit

These are limits on how much the plan will pay for dental services.

• Annual maximum – The total amount the plan will pay each year for each person covered. Once this limit is reached, additional costs are out-of-pocket until the next year.
• Lifetime maximum – A one-time spending limit, typically used for orthodontic treatments. Once the plan reaches this limit, it won’t cover more of these services for the member’s lifetime.

Plan benefit

This describes what services are included, when coverage starts, and what portion the plan covers.

• Covered services – Outlines the types of dental treatments included in the plan, divided by levels such as preventive care (like cleanings), basic care (like fillings), and major care (like crowns).
• Deductible – The amount a member pays upfront before the plan starts covering treatments. Only eligible costs go toward meeting this amount. Deductibles can be per year or per lifetime.
• Coinsurance – After the deductible is met, the plan usually covers a percentage of costs for each service. For example, the plan may cover 80%, and the member pays 20%.

Provider network

These terms explain how choosing certain providers can affect costs.

• In-network – In-network providers offer services at discounted rates, reducing out-of-pocket costs.
• Out-of-network – Out-of-network providers charge full price. Members pay more if they go out-of-network.

Timing of coverage

These clarify when benefits apply and when coverage starts.

• Calendar year vs. benefit year – Some plans operate on a standard calendar year, while others start and end at different times. Knowing this can help members plan how and when to use benefits.
• Waiting period – Some treatments may have a waiting period before coverage begins, often for costly services like crowns. Members may need to wait a specific time before these benefits kick in.

By understanding key dental insurance terms, members can make informed decisions about their care, avoid unexpected costs, and get the most out of their dental plans. Encourage employees and your clients to familiarize themselves with their plan’s benefits, provider networks, and coverage limits. This knowledge empowers them to prioritize their oral health, which in turn supports their overall well-being—all while making the most of their dental coverage.