How it works
The three gates every claim passes through
1. Deductible. The patient pays this amount first; it comes straight off the top of the bill. 2. Coinsurance percentage. The plan pays its percentage of what remains — 100%, 80%, or 50% are the common tiers. 3. Annual maximum. Whatever the percentage produces, the plan will not pay more than the benefit dollars the patient has left this year. This calculator runs those three steps in order and shows each one.
Estimates are for the conversation, not the claim
Use the result to help a patient understand roughly what treatment will cost them today, then file a pre-treatment estimate with the insurer for any major work so the real numbers are confirmed in writing before you start.
Worked example
A $1,000 crown procedure, $100 of deductible left, 80% coverage, $1,500 of annual max remaining: $1,000 − $100 = $900 goes through coverage; 80% of $900 = $720 from insurance; the maximum is not reached, so the patient pays $280 ($100 deductible + $180 coinsurance).
Same case, only $500 of annual max left: the 80% figure of $720 is capped at $500, so insurance pays $500 and the patient pays $500.
Frequently asked questions
What order are deductible, coverage, and maximum applied in?
Deductible first: it comes off the bill before any percentage is calculated. Then the plan's coverage percentage applies to the remainder. Finally, the annual maximum caps what the plan will pay out. The patient owes everything the plan does not pay.
What do 100/80/50 plans mean?
Many US dental plans follow a 100/80/50 pattern: preventive care (exams, cleanings) at 100%, basic restorative work (fillings, extractions) at 80%, and major work (crowns, implants, dentures) at 50% — all after the deductible and subject to the annual maximum.
Why might the real claim differ from this estimate?
Plans may pay on a 'usual and customary' fee schedule lower than your office fee, apply waiting periods or missing-tooth clauses, downgrade materials (for example paying for amalgam on a posterior composite), or coordinate benefits with a second plan. Always confirm with a pre-treatment estimate from the insurer.
Does the deductible count toward the annual maximum?
Generally no — the annual maximum limits what the plan pays out, while the deductible is money the patient pays before coverage starts. They are separate buckets, which is why this calculator applies them separately.
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