What Does a Lifetime Maximum Benefit Mean on Dental Insurance?
The Lifetime Maximum Benefit is the total amount an insurer will pay for a dental service, like modern orthodontics, for that insured person.
There are some essential things to understand about your dental insurance. One that you may or may not have noticed is a term called lifetime maximum benefits, which is what what usually applies to modern orthodontics. Knowing how this works can be helpful for planning your modern orthodontic treatment.
So, What is the Lifetime Maximum Benefit?
The Lifetime Maximum Benefit is as it sounds. It describes the maximum amount an insurer will pay for a dental service for that insured person. It should not be confused with your annual maximum, which is the maximum dollar amount an insurer will pay for the insureds’ dental care in a given period, usually a calendar year. It is common for insurers to have a Lifetime Maximum Benefit for orthodontic treatment and TMJ (Temporomandibular joint disorders). [i]
In other words, unlike your annual maximum, which renews every year, once you use your Lifetime Maximum Benefit that’s all there will be.
For many cases of orthodontics, this fact is not a problem. Most people only have their orthodontic treatment the one time.
However, for patients with multiple phases of orthodontics, any costs associated with the first phase will be applied against that maximum, reducing what will be available for the subsequent phases. That means that the insured may (and probably will) have higher out-of-pocket costs for the second phase than the first.
How Does it Work?
Once you claim that orthodontic benefit, they will apply the funds. How they use the funds depends on the policy and the insurer, so review this benefit if you or someone you love (and insure) is entering modern orthodontic treatment.
For example, some policies have a straight maximum. The number is the number, and once you claim it, they pay it in a lump sum.
However, other policies might do something different, covering only a fixed percentage in a plan year. That would mean your payment would be limited to XX% of the lifetime maximum per calendar year. Still, others might have a maximum per year for a set number of years (usually two).
Therefore, if your maximum lifetime benefit is $1,200 for orthodontic treatment, but you have a 50% maximum per year, your dental insurance would pay $600 for two years—unless your treatment was less than one calendar year. In that case, your remaining $600 lifetime benefit would wait if or when you need it again. [ii]
If I Change Policies, Will the Lifetime Maximum Reset?
Sometimes, the lifetime maximum is policy-specific, meaning it will not reset as long as the patient has that policy. However, it may reset if the company or the patient switches benefit plans. Then again, it may carry over. Be sure to ask your plan provider about your specific circumstances.
Another scenario that might result in a reset for the lifetime maximum would be if a child uses their orthodontic coverage on their parent’s policy but then gets a plan as an adult. In that case, the child/adult would get a new lifetime maximum benefit—which might come in handy if they don’t wear their retainer after childhood treatment.[iii]
(On a side note: Remember also that orthodontic benefits often have age specifications, too. For example, many policies limit orthodontic coverage to people under 18; others have no age limits or cover adult orthodontics, meaning over 18, too. So, be sure that you or the person you are insuring meets those age limits or parameters. In addition, there might be a waiting period to access the lifetime maximum, usually 12 months from the start of the insurance coverage.)
What Should I Ask about Lifetime Maximums for Orthodontic Treatment?
If you are in an open enrollment period and choosing a dental plan for yourself or your family, there are a few things to look for or ask the benefits administrator. These include:
Does this plan have benefits for someone my age? The age of my dependent?
How do in-network and out-of-network work with orthodontics?
Do I need a referral to go to the orthodontist?
Can you explain how the coverage limits work per year and what that means to me for the remainder?
What are the waiting periods and deductibles for orthodontic coverage?
Bloom Smile Studio accepts most major dental insurance plans. If you have orthodontic benefits and you meet the conditions of your policy, your lifetime annual maximum could cover a significant amount of your treatment.
For whatever falls outside the Lifetime Maximum Benefit, we can provide flexible payment plans for the balance. Moreover, if you pay all or part of your orthodontic expenses out of pocket, we can also arrange a flexible payment plan that fits your budget. Contact us with your policy information and our team can sort out the details.
To schedule your free consultation today, call Bloom SMILE STUDIO office in GARDEN GROVE at 714-430-8454.
Bloom SMILE STUDIO in GARDEN GROVE has a long history of improving our patient’s smiles. We provide modern orthodontic treatments delivered with old-fashioned excellence in patient experience. Follow us on Facebook and Instagram.
[i] How Does Dental Insurance Work? Understanding Dental Coverage | Delta Dental of New Jersey (2023). Available at: https://www.deltadentalnj.com/our-plans/dental-benefits-explained#:~:text=The%20lifetime%20maximum%20is%20the,are%20orthodontic%20treatment%20and%20TMJ. (Accessed: 14 April 2023).
[ii] Guide to Your Orthodontic Lifetime Maximum | Delta Dental of New Jersey (2023). Available at: https://www.deltadentalnj.com/blog/entry/2020/guide-to-your-orthodontic-lifetime-maximum (Accessed: 14 April 2023).
[iii] What Are Lifetime Maximums and How Do They Work? (2023) Deltadentaltn.com. Available at: https://www.deltadentaltn.com/content/dam/member-companies/tn/ddtn/resources/dental-benefits-102/9635%20DentalIns%20102-LifetimeMax-TN.pdf (Accessed: 14 April 2023).