Covered Health Services
You have a lot of choice in deciding which services you want to cover. You will find, however, that the differences between the health plan one employer offers and the health plan another employer offers are more likely to be in the levels of reimbursement they offer than in the types of care that they cover. For example, if you look at 10 different employer plans from different parts of the country, they'll all cover surgery on an inpatient basis, but some may have 80 percent reimbursement above a $100 deductible, others may reimburse at 90 percent if a network provider is used and 70 percent if not, and still others may reimburse at 100 percent if the surgery is performed on an outpatient basis.
The big twelve. The expenses that you will find covered by almost every health care plan are:
- treatment of illness, disease, or accidents
- medical, surgical, exploratory, therapeutic, or emergency care
- inpatient hospital room, incidentals, and treatment
- outpatient surgery and treatment
- doctor's office visits and treatment
- nursing services
- diagnostic care, such as x-rays, MRIs, or blood tests
- prescription drugs
- dental, vision, or hearing care, if required due to an accident or injury
- pregnancy and childbirth costs
- durable medical equipment purchase or rental
- specialty care, such as that provided in the Intensive Care Unit or Cardiac Care Unit
Common exclusions. The exclusions that you'll find in almost every policy are:
- work-related injuries covered by workers' compensation
- services not recommended by a physician
- charges above those defined by the plan as reasonable and customary
- cosmetic surgery
- experimental procedures, drugs, or surgery
Mental health and substance abuse. Most states have laws that require insurance companies to include coverage for mental health and substance abuse. Generally, if those coverages are required in your state, they will be included as part of the standard policy and their cost will be reflected in the premium. Therefore, you do not have to purchase additional coverage or buy an extra policy.
Dental, vision, and hearing benefits. The standard policy usually covers dental, vision, and hearing benefits only if the expenses are related to an accident or injury. If you want to purchase additional coverage for your employees, you should shop around for the best rates. Although many large employers offer dental, vision, and hearing benefits, few small employers do.
Some states have specific rules about what coverages must be provided to employees:
|
