An annual maximum is the most a dental plan will pay in a plan year. Once the plan has paid that much, everything after it is yours.

The reason this term needs its own entry is that it is the mirror image of a mechanism with an almost identical name. A medical plan’s out-of-pocket maximum is a ceiling on what you pay, after which the plan covers everything. A dental plan’s annual maximum is a ceiling on what the plan pays, after which you cover everything.

Opposite protections, similar words. Confusing them is how somebody starts a course of dental work in the summer believing they are protected and discovers in October that the benefit is exhausted with two crowns still to go.

In New York: three things follow.

Ask for the number and your usage before any large work. “What is my annual maximum, and how much of it have I used this year?” Then: “Does the plan have a waiting period for this type of work?”

Ask whether the treatment plan can be split across two calendar years. For work that is not urgent, sequencing across a January boundary uses two years of annual maximum instead of one. Practices do this routinely when asked, and rarely propose it. It is the single most valuable question on this page.

On Medicaid, this mechanism does not apply, and New York’s dental coverage changed substantially on January 31, 2024 under the Ciaramella v. McDonald settlement: root canals covered when medically necessary, crowns no longer blocked by the old four-pairs-of-teeth rule, implants covered in many cases, and replacement dentures no longer requiring a physician letter. A denial issued before that date was decided under criteria that no longer exist. The full picture.

One more boundary worth knowing: annual maximums are a dental convention. Medical plans regulated by New York do not impose lifetime or annual dollar limits on essential health benefits. If a medical plan appears to be capping what it will pay for a covered category, that is worth asking about in writing.

Also called: annual benefit maximum, yearly cap, plan maximum. Full guide: What a dental visit costs in New York.

More in Glossary of health coverage and billing terms

  • Formulary — A formulary is a plan's list of covered drugs, sorted into tiers that set your cost. What on-formulary means, how exceptions work, and New York's NYRx list.
  • Prior authorization — Prior authorization is a plan's approval before it pays for care. Who asks for it, what a denial says, where the deadlines are, and New York's appeal route.
  • Explanation of benefits (EOB) — An explanation of benefits (EOB) is your plan's record of a claim, not a bill. How to read each line, which one a bill must match, and what a denial means.
  • Out-of-pocket maximum — The out-of-pocket maximum caps your cost sharing for covered in-network care each plan year. What counts toward it, what never does, and the New York rules.
  • Deductible — A deductible is what you pay for covered care each plan year before your plan pays its share. How it works, what skips it, and which New York plans have none.

This page explains how the system works. It is not medical advice. More.