Lecture 11 Medical Benefits: Traditional Plans (Indemnity Plans)Providers of Traditional CoverageBasic Medical Expense CoverageBasic Medical Expense Coverage - (cont.)Major Medical CoverageMajor Medical Coverage Characteristics - (cont.)Managed Care Provisions in Traditional PlansMedical Savings AccountsLecture 11Medical Benefits:Traditional Plans(Indemnity Plans)•Providers of Traditional Coverage–Blue Cross-Blue Shield–Insurance Companies•Basic Medical Expense Coverage•Major Medical Coverage•Managed Care Provisions in Traditional Plans•Medical Savings AccountsProviders of Traditional CoverageBlue Cross-Blue Shield vs. Insurance Companies–Regulation –Taxation–Form of benefits–Types of benefits–Reimbursement of providers–National coverage–Flexibility–Rating–MarketingBasic Medical Expense Coverage•Traditional–Hospital expense benefits•In-patient–Room and board–Other charges•Outpatient–Surgery–Preadmission testing–Emergency room treatment•Exclusions–Surgical expense benefits•Fee schedule•Relative value schedule•Reasonable and customary charges–Physicians’ visits expense benefits•In-hospital coverage•Out-of-hospital coverageBasic Medical Expense Coverage - (cont.)•Newer–Extended care facilities–Home health care–Hospice care–Ambulatory care–Birthing centers–Diagnostic x-ray and laboratory services–Radiation therapy–Prescription drug expense benefits–Vision care –Supplemental accident benefitsMajor Medical Coverage•Types–Supplemental–Comprehensive•Characteristics–Covered expenses–Exclusions•Occupational injuries or diseases•Cosmetic surgery•Convalescent, custodial or rest care–LimitationsMajor Medical CoverageCharacteristics - (cont.)–Treatment of Mental Illness, Alcoholism and Drug Addiction–Deductibles–Coinsurance–Maximum Benefits•Annual•Lifetime•Per causeManaged Care Provisions in Traditional Plans•Hospital certification•Second surgical opinions•Carve-outs for mental illness and substance abuse treatment•Maternity management•Pre-approval of visits to specialistsMedical Savings Accounts•Pilot program under Health Insurance Portability and Accountability Act•Personal savings account for unreimbursed medical expenses•Tax-exempt trust or custodial account•Contributions are tax deductible•Distributions for eligible expenses not taxable•Other distributions taxed and penalized (15%) if account holder is not 65, dead or disabled•Strict regulations on contributions and eligible