It says that the (annual maximum payment plan) is $2000. Does this mean that my insurance will pay up to $2000, or does it mean that $2000 is the maximum I will have to pay a year for services? The dental insurance is called "SelectHealth Dental" I live in Utah.
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Hi, I'm a Claims Analyst at a dental office in the Bay Area of California, and I'd be more than happy to help you understand your dental insurance. Annual Maximum is the amount of money your insurance will pay AT MOST for procedures in that year. That means let's say you did a cleaning for $300, 2 fillings for $500, and a root canal for $1,100, they will pay all of this work just as long as it doesn't go over $2,000. Since this totals up to be $1,900, more than likely they will pay for it They don't, HOWEVER, pay for procedures in full. Each treatment is categorized in 3 different "tiers": 1) Diagnostic/Preventative (Which are Cleanings, Emergency treatments, fluoride, consultations, office observation, etc) 2) Basic (Fillings, Deep Cleanings, Root Canals, etc) 3) Major (Crowns, Bridges, Restorative work, etc) Many insurance policies vary in the amount thats covered, but typically general dental insurances cover 100% for Preventative, 80% for Basic, and 50% for Major. Since the cleaning is $300, we'll assume your insurance paid 100%. ($300) Since the fillings were $500, we'll assume your insurance paid 80%. ($400) Since the root canal was $1,100, we'll assume your insurance paid 80% ($880) Add the total and it's $1,580.00. That means your $2,000 maximum after all this dental work is done will only be $420.00 remaining on your plan. Anything not paid by the insurance is patient responsibility. This is considered a "Co pay." It is up to the dental office to uphold your co-pay and up to the patient to pay it. If you do not pay your co pay the dental office can file several referrals to various collection agencies and perhaps take legal action to the highest extent under jurisdiction. Typically, annual maximums do not roll over for years. It's basically a "use it or lose it" policy. Once the renewal date comes up, your insurance policy will reset to $2,000 (if not altered to higher or lower maximums). If you do anything over $2,000 for that same year you will have reached your maximum, therefore any additional work after the $2,000 cap you will assume all fiscal responsibility for the dental work. In essence you will not be covered for additional work after you have maxed out. Speak to your employer about getting in contract insurance policies and find dental offices that are in contract with your insurance. In-contract is beneficial for patients who wish to see lower "out of pocket" co pays. Though you may pay less for co pays and procedure, this comes at the expense of your paycheck as you will have to pay higher premiums for it. Be careful of what your plan DOES and DOES NOT cover. Some insurance plans do not cover Posterior (back teeth, aka molars) composite (commonly known as white or teeth colored fillings) fillings. Call your insurance company and request a breakdown of benefits so you know how much is remaining in your annual maximum and what kinds of procedures are you eligible for. Sometimes insurance plans also have Ortho coverage, ortho coverage maximum is SEPARATE from DENTAL maximum. However most ortho coverage is for dependents or spouses on the plan, many times not for the subscriber itself. Definitely call and get a breakdown of that Other than that I really do hope this helped you and educated you a little bit more about the world of insurance :) send me an email anytime if you have any questions regarding dental health or insurance policies as it is my job to help our patients at our office and also patients of anywhere else! Take care
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