Many employees have major medical coverage through Songer Benefits that protects against catastrophic medical expenses, with few exclusions. However, employees must often pay part of these medical expenses because of deductibles and coinsurance provisions. Comprehensive Major Medical Coverage With comprehensive major medical coverage, a single major medical contract covers practically all medical expenses. Once the insured satisfies the deductible, the contracts cover most medical expenses subject to a coinsurance provision. Most comprehensive medical expense contracts contain modifications of deductibles and coinsurance provisions for certain expenses, often resulting in 100 percent of reasonable and customary charges. Characteristics of Major Medical Coverage The distinguishing features of major medical expense plans include a broad range of covered expenses, exclusions, limitations, deductibles, coinsurance, and unlimited overall maximum benefits. Covered Expenses Major medical plans give broad coverage for necessary expenses incurred for medical services and supplies that a physician has ordered or prescribed. The services and supplies, which the contract specifies, generally include essential health benefits and other benefits such as
• hospital room and board. Some plans also provide benefits for room and board in alternative facilities, such as birthing centers.
• other hospital charges
• charges of outpatient surgical centers
• anesthetics and their administration
• services of doctors of medicine or osteopathy
• professional services of a registered nurse. The services of a nurse-midwife, nurse practitioner, and nurse anesthetist may also be covered.
Most states mandate that the insure- acne contract cover services of certain types of providers other than physicians and nurses as long as the service is a covered benefit and the provider operates within the scope of their license. • services of certain other types of providers. The list of providers varies from state to state. It may include one or more of the following: acupuncturists, audiologists, chiropractors, dentists, marriage and family therapists, dietitians, optometrists, physical therapists, physicians' assistants, podiatrists, psychologists, social workers, and speech pathologists.
• prescription drugs
• physical and speech therapy
• diagnostic X-ray and laboratory services
• radiation therapy
• blood and blood plasma
• artificial limbs and organs
• casts, splints, trusses, braces, and crutches
• rental of wheelchairs and hospital beds
• ambulance services Even though coverage is broad, major medical contracts contain specific exclusions and limitations.