Gap Plans

With the slowing economy and employers finding it increasingly difficult to afford traditional health insurance premiums, A Gap plan fills a rapidly growing niche in the group health insurance marketplace by assisting employers to provide affordable health coverage to their employees.

A Gap plan is specifically designed to help save direct health insurance premium costs by allowing employers and employee’s greater freedom in selecting lower cost high deductible health plans. Simply put, by plugging in A Gap plan, employers may be able to raise deductibles and coinsurance to obtain lower cost coverage. A Gap plan helps to fill the gap in coverage for higher deductible health plans in relation to eligible expenses for deductibles, coinsurance and copays if hospital confined.

A Gap plan is a guaranteed issue insurance product with multiple plan options available, allowing employers to pick and choose the best fit.

A Gap plan is only available on an employer group basis to employees who have an underlying employer sponsored comprehensive major medical plan. Employees who are not covered under the employer’s major medical plan may not enroll in A Gap plan.

GAP PLAN FEATURES

Expenses must be covered by the insured person’s major medical or comprehensive medical plan to be covered under the gap policy.

Covers certain portions of the insured person’s cost sharing under their major medical or comprehensive medical plan (co-insurance, co- pays and deductibles) up to the maximum benefit selected if hospital confined.

HOW DOES IT WORK?

The insured submits a claim form with an EOB. As long as the claim is an eligible expense under the underlying major medical plan the vendor pays the insured the appropriate amount, subject to the exclusions, limitations and other provisions of the policy.

INPATIENT BENEFIT

If, as a result of a covered injury or sickness an insured person is hospital confined, under the regular care and attendance of a physician and the expenses are covered by the insured person's major medical/comprehensive policy, The vendor will pay up to the maximum indemnity benefit per calendar year. Hospital confinement must begin after the effective date of coverage.

Benefits are limited to:

The deductible the insured person is required to pay under the major medical/ comprehensive Policy.

Copays and the coinsurance amount the insured person is required to pay under the major medical/comprehensive Policy.

Benefits also will be payable for a covered Hospital emergency room treatment as follows:

Injury – up to the Maximum Benefit, subject to Exclusions & Limitations.

Sickness – up to the Maximum Benefit subject to Exclusions and Limitations, if the sickness results in Hospital Confinement within 24 hours of the Hospital emergency room treatment.

 

OPTIONAL OUTPATIENT BENEFIT

Outpatient benefits include treatment under the regular care and attendance of a physician at a hospital, physician’s office, outpatient surgical or emergency facility or a diagnostic testing facility or similar facility that is licensed to provide outpatient treatment.

The benefits are limited to the difference between the benefit paid by the underlying major medical/ comprehensive policy and the actual outpatient expenses incurred, which includes any out-of- pocket expenses such as deductible, co-pays and coinsurance.

Benefits are payable per person for outpatient treatment for a covered Injury or Sickness up to the maximum Outpatient benefit with a family maximum of 2 times the per person Outpatient benefit.

Expenses incurred means the charges for a service or supply that is covered by this Rider and given to an insured person due to an injury or sickness. The expense incurred must be medically necessary for the condition being treated. An expense or charge is deemed to be incurred on the date the service or supply that causes the expense or charge is given or obtained. 

Steps to building a Medical Gap Plan in Gulfport, Biloxi, Long Beach, Ocean Springs, Hattiesburg, Jackson & Pascagoula, Mississippi as well as Texas, Louisiana, Alabama, Tennessee & Florida.