What is MediHOP?
MediHOP is a “Secondary” supplemental health plan that integrates with a “Primary” major medical plan to provide benefits to cover out-of-pocket medical expenses due to hospital confinement and outpatient treatment. Covered expenses are the unpaid portions of charges applied to deductible, co-insurance & copays for medical care that is eligible for reimbursement under the deemed allowable by the primary major-medical plan and which are not excluded from coverage.
The healthcare industry and network providers commonly address this as “Primary” & “Secondary” insurance coverage. A couple of common examples most people are familiar with is when someone has Medicare “Primary” and a Medicare Supplement “Secondary” or when an insured is dual covered both under their employer plan “Primary” and their spouse’s employer plan “Secondary”.
How does MediHOP work?
Insureds will have a simple two card ID system Major Medical Plan “Primary” + MediHOP “Secondary”. MediHOP works with any Major-Medical carrier, both fully insured health plans and self-funded health plans.
- 1st Step: Providers electronically file claim to the network provider of the “Primary” major medical plan. Claim will be repriced and discounted per the PPO contracted rates of the network provider. Re-priced claim will then be adjudicated and paid accordingly by the Primary major medical carrier. Certain procedures will be applied to the deductible, co-insurance & copays. The Primary major-medical plan will send an EOB (Explanation of Benefits) to the provider and insured showing the amount that was applied to deductible & co-insurance.
- 2nd Step: Providers will electronically file the claim along with EOB to the “Secondary” MediHOP plan. MediHOP pays for covered benefits that have been applied to deductible & co-insurance up to the maximum calendar year benefit selected by the employer. MediHOP will send an EOB to the provider and insured showing the amount that was paid towards the out-of-pocket expenses.
What does the insured owe?
Once the MediHOP deductible has been met (if any) and the MediHOP benefit has been paid, the insured would be responsible for the balance owed (if any) up to the “Primary” major medical annual calendar year out-of-pocket maximum.
How will the MediHOP plan work with my primary major-medical plan?
The primary major medical plan will have a calendar year deductible and co-insurance limit which has an annual maximum limit on out-of-pocket expenses. Once the calendar year out-of-pocket maximum is reached the “Primary” major medical plan will cover 100% of remaining charges for the rest of the calendar year. The MediHOP plan may have a calendar year deductible with a certain benefit level chosen by your employer. For MediHOP to pay, a procedure must be covered by the Primary major medical carrier and applied to the deductible co-insurance or copays. If the procedure is not covered by the Primary major medical carrier (ex: cosmetic procedures) the major-medical carrier would simply deny the claim, therefore MediHOP would not have an EOB to pay from.
Do providers like MediHOP and will any provider accept MediHOP?
Most providers love to get paid and in a timely manner. Due to the Affordable Care Act the cost of healthcare has escalated considerably from just a few years ago. Employers have been forced to move to higher deductibles and out-of-pocket limits which has caused undue hardship on millions of hard working Americans. This has created a chain reaction and has resulted in providers being forced to send insureds to collections or write off unpaid debts from insureds owing thousands of dollars in deductibles and out-of-pocket expenses that they have been unable to pay. The national average of collected debt by providers is approximately (16%). This means MediHOP has been a life saver for thousands of insureds and providers by providing a benefit to help pay deductibles and out-of-pocket expenses that have been left behind. Providers quickly become accustomed to the simplicity of filing both plans and love the fact that they get paid instead of writing the debt off or dealing with collection companies. Very seldom do we see a provider that will not accept MediHOP.
My Primary major medical plan went to a high deductible and out-of-pocket limit. Will I be responsible for that?
Yes & No. You now have a two card ID system called “Primary” + “Secondary”. Let’s say that you have a “Primary” major medical plan with a $5000 deductible, 80% co-insurance limit to a total maximum out-of-pocket of $6000. Your employer has also selected a “Secondary” MediHOP plan that has a $500 deductible and has a $5500 benefit to pay towards procedures that are applied to the “Primary” major medical deductible, co-insurance & copays. Quick example: If you are hospitalized you would present both cards to the hospital. They would verify your benefits with the “Primary” major medical plan and they would say that you have a $5000 deductible and a total out-of-pocket of $6000 (at this point this becomes the insureds responsibility). But, it doesn’t stop there. They would then verify your benefits with the “Secondary” MediHOP plan which now changes your deductible from $5000 to $500 and then pays $5500 in benefits towards the out-of-pocket expenses. So, yes you become the responsible party first and then the MediHOP plan assumes the second part of that responsibility. There was a total of $6000 of debt you would have been responsible for, but because you have MediHOP you would be responsible for the $500 MediHOP deductible and MediHOP would be responsible for the balance of $5500. Once the $6000 is met for the calendar year the “Primary” major medical plan will pay 100% for the rest of the year. This scenario works the same way on outpatient procedures.
Claims Payment Example: $50,000 Hospital Bill
Major Medical: $5000 Deductible, 100% Co-Insurance, $5000 total out-of-pocket
MediHOP Benefit: $500 Deductible, $4500 Benefit
1st Step: (Provider files claim with primary major medical carrier. EOB is sent back to provider and insured showing what has been applied to deductible & coinsurance)
Primary: Major Medical
Billed Amount: $50,000
Network Discounted to: $25,000 (Actual claim payment due after PPO discount)
Medical Carrier Pays: $20,000 (Carrier pays 100% after insureds deductible)
Insureds Responsibility: $5,000 (Total out-of-pocket)
2nd Step: (Provider files claim with MediHOP. MediHOP pays allowable benefits. EOB is sent back to provider & insured showing how benefits have been applied.)
Insureds Responsibility: $5,000 (Total out-of-pocket)
MediHOP Deductible: $500 (Insureds Responsibility)
MediHOP Benefit: $4,500 (Paid to Provider by MediHOP)
Insureds Balance Owed: $0
As you can see, without MediHOP insured would have owed $5,000 for the hospital stay. Provider would have to collect from insured. With MediHOP, insured only owes the provider the $500 MediHOP deductible. MediHOP pays $4500 to provider directly.
MediHOP 2-Card Guide