We’ve Got
You Covered.


Underwriting, Eligibility, & Rates

ELIGIBILITY :

  • ‐ Employee must be covered by a Health Benefit Plan*
  • ‐ Minimum size requirement for eligible groups is 10 eligible employees
  • ‐ Eligibility is restricted to W-2 employees and their dependents participating in the Health Benefit Plan. (1099 contract persons are not eligible, unless the "employer" is sponsoring the medical plan);
  • ‐ The Health Benefit Plan must have a common deductible for all conditions.
  • *A Health Benefit Plan is any self-funded or fully insured major medical or comprehensive medical plan. Health Benefit Plan does not include any limited medical program, Medicare or Medicaid. Plan limits will apply according to policy;

EMPLOYER CONTRIBUTION :

  • ‐ When employer contributes 100% of the employee premium, 100% participation will be required
  • ‐ Minimum employer contribution is 50% of the employee premium. When employer contribution is less than 100%, there is a 75% participation requirement of those employees taking part in their current health plan.
 

RATES :

  • ‐ Coverage is Guaranteed Issue
  • ‐ Initial Rates Guaranteed for 12 months;
  • ‐ Age based rates in following bands: Under Age-40, Ages 40 - 49 and age 50+.
  • ‐ A composite rate is available upon receipt of a census. Composite rates are subject to revision upon review of the final enrollment census.

Frequently Asked Questions

What does the MediHOP™ plan pay?

MediHOP™ will pay the applicable benefit percentage for the Covered Expenses up to the Coverage Year maximum. The Covered Person must be under a Doctor’s care, and the treatment must be for covered Injury or Sickness.

Covered Expenses are the unpaid portion of charges for medical care, treatment and services that are eligible for reimbursement under and deemed allowable by the Policyholder’s other Health Benefit Plan, which are not excluded from coverage under the policy.

What is Secondary Coverage?

Secondary coverage is supplemental medical coverage that is purchased by an employer group in conjunction with a Primary Medical plan to offset high out of pocket expenses for individuals and families.

Why do I need Secondary Coverage?

Unpaid medical bills can create financial hardship for almost every family. Bankruptcy, depleted savings and loss of real estate are a few risks directly associated with medical plans that have high out of pocket exposure. Secondary coverage can eliminate or reduce that risk significantly.

Are there any waiting periods or benefits not covered by the MediHOP™ plan?

Since the MediHOP™ coverage is a “true Supplemental plan” to an existing Major Medical plan; we follow the same guidelines as your Primary Medical plan. So, if something is not covered or allowed by your Primary plan; then the MediHOP™ will not cover it as well. We also follow the waiting period and eligibility requirements of the inforce medical plan.

How does having two medical cards work?

With our MediHOP™ plan; participants and providers will understand that there are two forms of coverage and there are two different payer ID’s.

1. Primary care or major medical plan (Card One) and
2. MediHOP™ Supplemental Plan (Card Two – “Secondary Coverage”).

Therefore, healthcare providers and or facilities should automatically send Primary Coverage claims information electronically for processing. Once that process has taken place and your initial claim is accepted and processed; our job is to make sure your provider has the information they need to make sure your “secondary benefits”; or MediHOP™ benefits are paid as well.

Who do I call with questions regarding my coverage?

You can call customer service at 1-866-950-2368.

How do I submit my medical claims?

We have set up an electronic payer ID for your provider to file the claim electronically; let your Provider file the claim for the Major Medical plan (Primary) and your MediHOP™ plan (Secondary).

The insured will need to provide his/her primary medical card as well as the MediHOP™ card to the provider. Most providers will file the claim electronically because it is easy and they get paid faster. A claims contact phone number is printed on the ID card along with the claims payer information for the provider. If needed, our customer service staff can and will send a letter to each provider explaining how to file claims.

MediHOP™ claims should flow as follows:

  1. The insured’s claim is filed with their major medical carrier and with MediHOP™ electronically.
  2. The insured’s major medical carrier will process the claim and the insured and provider will receive an EOB (Explanation of Benefits). This form describes the procedures covered, facility used, benefit paid and the amount applied to the insured's deductible or co-insurance.
  3. The provider will/should send and include an electronic copy of EOB as well as the standard CMS 1500 or a Hospital Claim Form (UB04). These forms describe the medical procedure codes and provide all the information needed to pay the secondary coverage claim.

Limitations & Exclusions

No benefits will be paid for loss caused by or resulting from:

  1. Intentionally self-inflicted injuries, suicide or any attempt thereat while sane.
  2. Declared or undeclared war or any act thereof.
  3. The Covered Person’s commission of a felony.
  4. Work-related Injury or Sickness.
  5. The Covered Person’s voluntary participation in a riot, civil commotion or disobedience, or unlawful assembly.

In addition, no benefits will be paid for:

  1. Co-payment amounts charged under a Health Benefit Plan.
  2. Non-Prescription Drug charges.
  3. Charges that are not eligible for reimbursement under a Health Benefit Plan.
  4. Charges for medical care, treatment and services, or portions thereof, that are in excess of what is deemed allowable by a Health Benefit Plan.
  5. Charges for care, treatment or services that are incurred at a provider that is not included in the provider network of a Health Benefit Plan (unless otherwise covered).
  6. Charges for which a Covered Person is not required to pay Cost Sharing under a Health Benefit Plan.

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