1. Basic Medical Expense Policy
    • 3 Fundamental coverage 
    • Hospital Expense 
    • Surgical Expense 
    • Other Medical Expense
  2. Hospital Expense
    Covers daily hospital room & board expense (Semi Private room rate).

    The daily rate is doubled if the insured is in intensive care.

    Miscellaneous Hospital Expense: anesthetics, operating rooms, lab work, dressings, ect
  3. Surgical Expense
    For each type of surgery there is a specific maximum dollar amount that will be paid for the operation.
  4. Other Medical Expense
    Additional benefits beyond those provided by the Hospital Expense and Surgical Expense

    • In hospital physician visits
    • Emergency accident benefits and ambulance
    • Maternity 
    • Mental and Nervous disorders
    • Hospice
    • Home Health Care
    • Outpatient Care
  5. Comprehensive Major Medical Expense Policy
    Limits of Coverage: high limits, broad range of medical expenses; often referred to as catastrophic insurance
  6. Deductibles: NO DEDUCTIBLE
    NO Deductible (aka first dollar coverage): will apply to specific screening or tests.
  7. Deductibles: PER PERSON
    Applies to each person
  8. Deductibles: Per Calendar Year
    Applies to call injuries or sickness occurring within a calendar year.  

    *Carry-over Provision: deductible for a claim filed in the last three months of the year will "carry over" to fulfill the next calendar year deductible.
  9. Coinsurance (co-payments)
    Insured and the insurer share medical expenses and often referred to as percentage of participation.  

    Typical Co-Payments 

    • 80/20
    • 70/30
    • 50/50
  10. Stop Loss
    Where the insured no longer participates in the co-payments and therefore the losses "Stop" for the insured. (also referred to as out of pocket expense)
  11. Cost Containment Provisions
    Concurrent Review: review of ongoing medical expenses at the time of hospital admission and during course of treatment. 

    Retrospective Review: review of medical expenses after the medical treatment.
  12. Policy Provisions : COVERED
    • Hospital room and board 
    • Hospital surgery costs 
    • Physican Services
    • Nursing Services 
    • Outpatient Services 
    • X-rays and other diagnostic test 
    • Ambulance 
    • Prescription drugs 
    • Dental Services if result of accident
    • Prosthetic Limbs
  13. Policy Provisions : Limitations (Covered but Limited)
    • Mental or emotional disorders
    • Maternity
    • Substance abuse 
    • Chiropractic services 
    • Pre-existing conditions
  14. Policy Provisions: Exclusions
    • Experimental procedures
    • Workers compensation
    • Cosmetic surgery 
    • Military Services 
    • Dental care, except accident
    • Eyeglasses
    • Routine physicals and medical care
    • overseas residence
    • Non-Prescription drugs
  15. Reinstatement of Individual Health Policies:
    Reason for Reinstatement: Oklahoma Statutes mandate that Oklahoma residents (including spouses and dependents) that are activated for military service and become eligible for federal government sponsored health insurance as a result of such activation, will not be denied reinstatement into their previous individual health plan as follows: ON NEXT CARD
  16. Reason for Reinstatement Cont..
    1. Must apply for reinstatement within 30 day

    • Insurer cannot refuse to reinstate for any medical reason
    • This reinstatement is not related to COBRA

    2. Dishonorable discharge negates this regulation for veteran, spouse, and dependents
    Oklahoma State Statues mandate that Minimum Standards must be included in every Health Benefit Plan written on a individual or group basis.

    • Basic Medical Expense Policy
    • Comprehensive Major Medical Expense Policy 

    Health Benefit Plans do not include insurance policies covering only a specific disease, accident, or other limited benefit coverage.
  18. Newborns (36 O.S. Section 6058)
    Every health benefit plan (individual and group) must provide coverage for a newborn from the moment of birth.  Coverage shall be provided for injury and sickness, including congenital defects and abnormalities.  The insured must motify the Insurer within 31 days to continue the coverage beyond the 31-day period.

    Section 6058a: May not deny enrollment because 

    • child does not reside with parent
    • child was born out of wedlock
    • child is not claimed as a dependent on tax return
  19. Adopted Children (36 O.S. Section 6059)
    under the age of 18 months, the medical costs associated with birth must be included and can be paid retroactive
  20. Mammogram Screening (36 O.S. Section 6060)
    • For females age 35
    • The amount paid shall not exceed $115.00
    • The screening is NOT subject to the deductible, co-pay, or coinsurance

    Any female age 35-39, shall be entitled to a screening once every 5 years

    40+ shall be entitled to a screening ANNUALLY
  21. Bone Density Testing (36 O.S. Section 6060.1)
    • Females, age 40 or over, when requested by a primary care physician
    • Screening is subject to the deductible, co-pay, or coinsurance
  22. Diabetes (36 O.S. Section 6060.2)
    Must include coverage for the cost of diabetes care when prescribed by a physician

    • Blood glucose monitoring, including test strips
    • Insulin and insulin injection aids, syringes, and insulin pumps
    • Diabetes self-management training (aka nutritional training) 
    • **Not included WEIGHT LOSS**
  23. Maternity Coverage (36 O.S. Section 6060.3)
    • 48 hours for normal delivery
    • 96 hours for caesarian delivery
  24. OB/GYN (36 O.S Section 6060.3a)
    • Must provide coverage for a routine annual examination
    • Applies to groups of 50 or more employees
  25. Child Immunization (36 O.S. Section 6060.4)
    Coverage is provided from birth-18 years of age

    • Includes immunizations required by the Board of Health
    • No deductible and no co-pay shall apply
  26. Brest Cancer Patient (36 O.S. Section 6060.5)
    Must provide minimum inpatient care (hospital stay) for breast cancer surgery.

    • 48 hours for mastectomy
    • 24 lymph node dissection
    • cost for reconstructive surgery that occurs within 24 months must be included
  27. Mental Disorders (36 O.S. Section 6060.10)
    Must Provide coverage for severe mental illness


    • Bipolar
    • Schizophrenia
    • Depression
    • Panic disorder
  28. Coverage for Prostate Screening (6060.8)
    Must provide for an annual screening  not to exceed $65.00

    • Age 50 or older for all males
    • Age 40 or older for high risk
    • No deductible and no co-pay

    Screening must include both:

    • Prostate-specific blood test
    • digital(physical) rectal examination
    • Screening provides no coverage for the treatment of prostate cancer, i.e., rediation therapy
  29. Colorectal Cancer Screening (6060.8a)
    • Age 50 or older
    • Less than age 50 and at high risk
  30. Chemotherapy (6060.9)
    • Must provide for wigs and scalp prostheses necessary for comfort
    • Not to exceed $150.00
  31. Audiological Services (6060.7)
    Audiological services and hearing aids up to the age of 18
  32. Dental Procedures (6060.6)
    Must Provide coverage for anesthesia expenses for insured severely disabled or a minor eight(8) years old or less.
Card Set
Medical Expense Insurance