Maximum Benefit Payments Sample Clauses

Maximum Benefit Payments. The maximum annual benefit payment is (b) (4) of paid allowable charges, per enrollee per contract year. The maximum lifetime benefit for orthodontic services is (b) (4) per enrollee. The allowable amount paid by the contractor for some diagnostic and preventive care services (except sealants), and emergency services shall not be included in the annual benefit maximum (See Attachment 2, Benefits, Exclusions and Limitations for a complete listing). In addition, the allowable amounts paid for all other covered services shall be included in the annual benefit maximum. Enrollee cost shares shall not count against benefit maximums. C.5.5.1. In OCONUS areas, the allowable charges used to reach the annual benefit maximum shall be calculated based on the contractor’s approved provider fee schedule. The contractor shall base its allowable charge schedule on the ninety-fifth (95th) percentile of undiscounted charge data obtained from the contractor's most current (2004 or later) District of Columbia region provider fee schedule. This fee schedule shall be updated by the contractor on an annual basis to coincide with the start date of the next contract option period. The contractor shall pay OCONUS claims for covered services at the lesser of: C.5.5.1.1. Billed charges, less applicable cost shares, or H94002-05-D-0001 C.5.5.1.2. The ninety-fifth (95th) percentile of the contractor's most current (2004 or later) provider fee schedule for the District of Columbia region, less applicable cost shares.