Group Health Insurance Coverages
MR. WATSON: Group Health Insurance Coverages (discussed as individual plans in a previous chapter. Same thing, but it is group now.
- Group basic "first dollar", no deductibles, no co-insurance, and
- Group major medical. Deductibles and co-insurance. Lower premiums than individual major medical and better benefits.
MR. WATSON: Which one would you rather have?
ALL: Major medical.
MR. WATSON: Which one has the best benefits?
ALL: Major medical.
Dental insurance****
Dental care is designed to cover the costs associated with
- normal dental maintenance,
- as well as oral surgery,
- a good root canal, and
- orthodontia (braces).
The coverage may be
- scheduled; a flat dollar amount (listing the dollar amount to be paid for each procedure).
- non-scheduled; they pay on a reasonable & customary method (the average in a given geographical area)
- Deductibles and coinsurance features are typical, though some policies will cover routine cleaning and oral exams at 100 percent. No deductibles for routine cleanings.
Vision care****
- Pays on a reasonable & customary method (the average in a given geographical area)
- Eye exams
- Eye-wear often excluded
MR. WATSON: Vision care. Take a stab at that one. Does it cover the eye wear? Usually no. It covers the exams.
MR. WATSON: Let me ask you this. Would glaucoma be covered under vision care?
ALL: NO. ?
ALL: Yes.?
MR. WATSON: No. It would cover the detection of it, but your major medical or other health plan (HMO,PPO, POS, etc.) would cover the fixing of it. Y’all understand?
ALL: Yes.
Coordination of benefits****
MR. WATSON: Coordination of benefits .
MR. WATSON: Coordination of benefits. Found only in group insurance.
MR. WATSON: The purpose of coordination of benefits, found only in group policies, is to prevent the insured from receiving the 80 percent with one company and another 80% with another company and make out like a bandito. Designed to prevent duplication of benefits and/or over-insurance when an insured is covered under more than one group plan.
MR. WATSON: Just a side note. Remember that if a person has Medicare and also has other insurance, Medicare pays last.
MR. WATSON: Jeanne and I are married. Follow this. I work for IBM. Jeanne works for Westinghouse. I am covered under IBM's major medical plan as a primary insured, but she is my dependent.
MR. WATSON: She's covered under Westinghouse, their major medical, as a primary insured, and through that Westinghouse coverage I'm covered as her dependent. IBM is my primary plan. IBM is her secondary plan. Westinghouse is her primary plan, Westinghouse is my secondary plan. If I get sick, I apply to my primary plan, which is IBM. They pay 80 percent after I paid the deductible. I apply to my secondary plan, which is Westinghouse; I pay the deductible, and they pick up the 20 percent. Does that make sense?
ALL: Yes.
Subrogation
MR. WATSON: The insured transfers the "right of recovery against others" to the insurance company. Subrogation is the right for an insurer to pursue a third party that caused an insurance loss to the insured. Let's say the insurance company pays the claim, the hospital bill. If the insurance company believes other insurance companies are liable for the claim, they can sue to make them pay. Called subrogation rights. Let's say another driver ran a red light and demolished your car. He was uninsured. Your company will pay to repair your car but will then go after the other driver to recoup their loss. Know this.
Maternity
MR. WATSON: Maternity - treated like any other claim. If it is an 80/20 plan, then the insurance company will pay 80%, it is treated like any other claim.
MR. WATSON: In other words, if they are going to pay 80 percent for the common hospital stay, they'll pay 80 percent for maternity.