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Major Medical Plans

Whether you are an employer looking for ways to provide cost-effective coverage for your workers or you're an individual trying to find the best plan for your needs, major medical plans should be an option worth considering.

Let's look at some of the basics you should know about this type of health insurance.

Major Medical Plans: Defined

Major Medical Plans can have two different definitions, the older version and the newer definition. It's important when speaking about this topic to clarify what the discussion is about. Most of the time it will be about the latest definition, we will first discuss pure Major Medical Plans in the market place because they have been around the longest.

Major medical plans are a type of indemnity or fee-for-service insurance. Basically that means users have complete freedom to choose any physician or medical facility they want and are not limited by a network of providers. As with many other types of health insurance, users must pay a deductible - generally around $500 (individual preference dictates the level) per year - before the insurance will cover any costs. After the deductible is met, the insurance provider will pay a percentage of the bills. That percentage runs between 70 and 80% depending on the plan. The member pays their percentage. The insurance carrier is responsible for paying the rest of the bill, limited to annual of life time maximums.

Major medical plans are a little different than other types of indemnity insurance because they are meant to protect people from the devastating financial costs associated with long-term or serious illness and injuries. For that reason, the plans cover many services not included in other types of indemnity insurance, including prescriptions, some diagnostic tests, and medical care at home or in the hospital, and private nurses.

Not all major medical plans are created equal. They actually come in two types: comprehensive and supplemental. Comprehensive plans are meant to be stand-alone medical insurance policies that cover all of the medical expenses after the deductible is met. In fact, some comprehensive policies will even provide full coverage for emergencies without requiring consumers to meet the deductible normally required.
Supplemental plans work in conjunction with additional insurance coverage. Their purpose is to help cover costs and services that may not be included in the primary insurance plan. For example, if your primary insurance does not pay for private nurses then the supplement insurance can kick in and cover those costs.
Both types of major medical plans usually set limits on how much they will pay in benefits for each person covered under the policy.

The most recent version of the term Major Medical Plans is describing different Preferred Provider Organization (PPO) plans. When speaking about Major Medical Plans now, this pertains to all expenses covered in the plan. Benefits from co-pays in the doctors office, prescriptions, preventative care, and inpatient and outpatient services at the hospital, are covered by PPO plans today. PPO plans include two sets of benefits in the policy, in network and out of network benefits, the out of network benefits are usually referred to as out of network benefits. Out of network meaning you can utilize any provider you choose. When using services inside of the network, you are seeing doctors in the PPO network and other providers contracted. When having a conversation with anyone always spend a few moments going over definitions. In the long run it will save both parties aggravation.

So there are no misunderstandings, with a PPO plan when referring to major medical benefits, if speaking about in network benefits the conversation is referring to claims inside the PPO network. If the conversation is about out of network benefits, all claims fall under this heading because everything is subject to a separate deductible and coinsurance and you can go to any provider.

Advantages of Major Medical PPO Plans

This type of delivery system is the best of both worlds. With a PPO plan you have two sets of benefits at all times. When using the in network benefits, you'll pay small co-pays and lower deductibles and coinsurance than going out of network. Here you have a separate higher deductible and more money out of pocket with the coinsurance. You get both sets of benefits. You decide what benefits you want to utilize, in network or out of network! Either way, you have complete freedom of choice.

First, in network users don't have to worry about being balanced billed for services in network. Providers agree contractually to accept your payment in full. Also networks are usually national networks now, it isn't likely to find a doctor you need out of network nowadays, however if it happens you have that choice. Upon selecting a doctor or hospital that isn't in network, if you will notify the PPO Company they will assist you in keeping the cost down for you.

Second, more services are typically covered under PPO plans. As stated earlier, prescriptions are covered with low co-pays, preventative care is limited to one check up a year (state mandated benefits are adhered too), and sometimes the emergency room benefits are covered by a small co-pay. Even out of network emergencies are treated as if they are in network benefits. A PPO comes in handy when you have selected going out of network for services, you have a built in guide to knowing what type of discounts a provider will consider instead of paying retail.

The Bottom Line

Some believe the old Major Medical plans are on a come back. Because of t he high cost of PPO plans and HMOs, Insurance carriers are looking for an alternative to lower cost products in the market place. The only way to do this is to shift costs back to the consumer. For people on limited budgets who are in good health. The monthly premiums are typically lower, and the plans provide coverage for the types of medical costs people are most afraid of: those associate with long-term illnesses or serious accidents.

To recap, PPO plans in the market place today pay for all categories of benefits; from low co-pays to doctors in the network for check-ups to out of network coverage to any hospital. Older Major Medical Plans covered the more expensive hospital claims. Supplement Plans as an option picked up additional benefits. You may see Major Medical Plans of old making a come back. With the high cost of health insurance today, the consumers will look for alternatives. Know what is being said in the conversation. It's too costly to pretend you know what is being said in the conversation. If you are not sure of definitions, ASK? It is too expensive to assume anything today.

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