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MAXIMUM BENEFITS

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benefit
Benefits
covered percent
deduct
deductible
family
individual
maximum benefits
met
percentage
remaining term
rollover policy
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    Please read the resource and feel free to ask if you have any questions. Thanks!
   
 

Materials & Instructions Scoring Keys Expert Answers Peer Answers

   
C2s2
  • A – Maximum Benefits information
    • Maximum Benefits – this is the amount that can be spent in one calendar year or fiscal year plan when procedures are done
      • example: a plan may have $1500 per calendar year or fiscal year
      • this plan may be expended within one year plan
      • once all of the funds are used up because of dental treatment, then it will be maxed out
      • when the new year plan comes, the maximum benefits will be replenished back to $1500
    • Remaining – this is the amount left from the maximum benefits after some procedures are already performed
      • example: if the plan has a maximum benefit of $1,500, and the treatments have used up $500, then the remaining amount would be $1,000
      • when calling the CSR, most of them mention both the amount used and the remaining amount
    • Term – This could be the calendar year, fiscal year, or month to month
    • Start of the fiscal year – if the plan is on a fiscal year, when you should take note of the beginning of the plan
      • January is 1, February is 2, March is 3, May is 4, and so on
 
  • Deductible information – deductible is an amount that the patient has to pay within the whole year plan – this could be paid in portions
    • Individual – this is the individual deductible or the deductible for the patient’s individual account
    • Met $ - the amount already paid by the patient
    • Family – this is the deductible for the patient’s family account; each member of the family account shares this deductible  
    • Met – the amount already paid under the family account
 
  • Rollover on Policy:
    • Yes or No
 
  • Percentage covered for procedures – insurance plans usually do not pay 100% for the same procedures. Procedures are classified under preventive, basic, major, periodontics, endodontic and oral surgery (OS). Each of these procedures is paid differently.
      • For example, preventive procedures may be paid 100%, basic procedures may be paid by the insurance at 80%, the insurance may pay 50% for the major procedures, and so on