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Basic Medical Expense policies
Provide coverage for Hospital, Surgical and Physicians Medical Expense.
-Purchased as a individual or group policy.
-provide first dollar coverage (no deductibles).
-limited benefit periods and low coverage limits.
Major Medical Expense Policy
-A supplement (in addition) to Basic Medical or as a stand-alone policy.
-individual or group policy.
-Take over when the Basic Policy runs out
Hospital Expenses
-Pay for covered expenses incurred during a hospital stay.
1. Daily hospital benefit - Room and Board
2. Miscellaneous expenses - Other Medical Expenses (X-Rays, MRI, Prescriptions, Doctor Visits)
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Daily Hospital Benefit
-Cost of a hospital room, up to a daily $ limit. The limit may be expressed either as a dollar amount, e.g. $500 per
day, or it may be expressed as the Usual, Customary and Reasonable (UCR) and Charge
Usual, Customary and Reasonable (UCR)
Insurance company will pay an amount for a given procedure based upon the average charge for that procedure
in that specific geographic area. The coverage is subject to a maximum amount or number of days.
Benefit Schedule
-Specifically states what is covered in the plan and for how much. The coverage is subject to a maximum amount
or number of days.
Indemnity
Insured pays the bill and is reimbursed by the insurance company up to a specified limit amount. Medical expense
policies that pay a fixed rate provide the insured with a stated benefit amount for each day of hospital
confinement.
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Reimbursement
Policyowners obtain medical treatment from whatever source they want and submit their charges to their insurer
for reimbursement (actual amount).
Service Based Contracts
-Pay doctors and hospitals directly according to the # of days of coverage that is provided in the contract for
each event and are prepayment plans. Once a claim is settled, the insured will receive an Explanation of Benefit
(EOB), which is a written confirmation that the claim was paid. Blue Cross and Blue Shield, Health Service
Corporations and Medicare coverage are all provided on a Service Basis.
Miscellaneous Expense Benefits
-Secondary benefits (inside benefits) because they occur inside the hospital for charges related to the stay. X-rays,
prescriptions, MRI's, anesthesia and lab fees are usually separate fees incurred during a stay. Miscellaneous
Expense Benefits have separate limits, referred to as Inside Limits. The are expressed usually as a multiple of the
daily amount (UCR)
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Surgical Expense
A schedule of procedures lists the amount allowable for each procedure. If a surgical procedure is not found in
the schedule, it will still be payable. The amount payable for a procedure not listed is based on its relative value to
a procedure of similar difficulty. There are usually no deductibles.
Surgical Schedule
Is simply a price list. Each procedure is listed and a dollar amount assigned and if a procedure is not listed in the
schedule it is still paid.
Relative Value
scientific method of paying different benefits based on the region of the country an insured lives. It is based on
assigning a value to each procedure and using a conversion factor. A schedule of assigned points for each
procedure must be included in the policy.
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Basic Medical Expense policies
Provide coverage for Hospital, Surgical and Physicians Medical Expense.
-Purchased as a individual or group policy.
-provide first dollar coverage (no deductibles).
-limited benefit periods and low coverage limits.
Major Medical Expense Policy
-A supplement (in addition) to Basic Medical or as a stand-alone policy.
-individual or group policy.
-Take over when the Basic Policy runs out
Hospital Expenses
-Pay for covered expenses incurred during a hospital stay.
1. Daily hospital benefit - Room and Board
2. Miscellaneous expenses - Other Medical Expenses (X-Rays, MRI, Prescriptions, Doctor Visits)
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Daily Hospital Benefit
-Cost of a hospital room, up to a daily $ limit. The limit may be expressed either as a dollar amount, e.g. $500 per
day, or it may be expressed as the Usual, Customary and Reasonable (UCR) and Charge
Usual, Customary and Reasonable (UCR)
Insurance company will pay an amount for a given procedure based upon the average charge for that procedure
in that specific geographic area. The coverage is subject to a maximum amount or number of days.
Benefit Schedule
-Specifically states what is covered in the plan and for how much. The coverage is subject to a maximum amount
or number of days.
Indemnity
Insured pays the bill and is reimbursed by the insurance company up to a specified limit amount. Medical expense
policies that pay a fixed rate provide the insured with a stated benefit amount for each day of hospital
confinement.
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Reimbursement
Policyowners obtain medical treatment from whatever source they want and submit their charges to their insurer
for reimbursement (actual amount).
Service Based Contracts
-Pay doctors and hospitals directly according to the # of days of coverage that is provided in the contract for
each event and are prepayment plans. Once a claim is settled, the insured will receive an Explanation of Benefit
(EOB), which is a written confirmation that the claim was paid. Blue Cross and Blue Shield, Health Service
Corporations and Medicare coverage are all provided on a Service Basis.
Miscellaneous Expense Benefits
-Secondary benefits (inside benefits) because they occur inside the hospital for charges related to the stay. X-rays,
prescriptions, MRI's, anesthesia and lab fees are usually separate fees incurred during a stay. Miscellaneous
Expense Benefits have separate limits, referred to as Inside Limits. The are expressed usually as a multiple of the
daily amount (UCR)
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Surgical Expense
A schedule of procedures lists the amount allowable for each procedure. If a surgical procedure is not found in
the schedule, it will still be payable. The amount payable for a procedure not listed is based on its relative value to
a procedure of similar difficulty. There are usually no deductibles.
Surgical Schedule
Is simply a price list. Each procedure is listed and a dollar amount assigned and if a procedure is not listed in the
schedule it is still paid.
Relative Value
scientific method of paying different benefits based on the region of the country an insured lives. It is based on
assigning a value to each procedure and using a conversion factor. A schedule of assigned points for each
procedure must be included in the policy.
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