I need to figure out how to calculate dental insurance. For example, what the insurance will pay out and what the Pt's responsibility is. Lets say a Pt has a $2,500 treatment plan his/her yearly max is $1,000 and has not met his/her $50.00 deductible. Their coverage is preventative at 100 percent basic at 80 percent and major is covered at 50 percent. Can anyone give me several different examples of how I can figure out the Pt's portion. Now if the patient has used part of their yearly max again, how will I calculate this? Any help would be great.
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1. No benefit will kick in until the $50 deductible is paid. 2. Suppose the pt. gets x-rays ($85), exam ($60) and cleaning ($75)...which are all preventive care....then the total coverage received would be $220. 3. So now, the pt. will be eligible to receive additional benefit of $1000- $220 = $780 for the rest of that year. 4. Suppose it was determined that the pt. would need 5 fillings (basic care) at $100 each covered at 80%. So, for each filling the pt. will receive a benefit of $80 and the copay will be $20. So, in other words, for these 5 fillings pt. will end up receiving a total benefit of $400 5. At this point the pt will have a total benefit of only ($780 - $400) = $380 remaining for that year. 6. If at this point the pt. needs 1 root canal treatments at $900, 1 build up at $300 and 1 crown at $1200.....all of these will be covered by 50%. So, the pt's coverage should be respectively $450/-, $150 and $600. In other words, a total of $1200. But he / she has only $380 benefit remaining. Therefore, even if his / her plan says that for major dental work 50% is covered, the pt. will not receive that coverage because of the annual maximum benefit allowed under the plan. Hope this helped.
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