Benefit Package

A benefit package is the array of benefits and covered services available in a particular health care insurance plan. This array differs in scope according to the negotiated[Page 43] contracts with the company benefit contractor. The costs of services often dictate what is included and what is not.

The package iterates the covered and noncovered services as well as details and defines the rights for expedited review and other covered challenges. It has become increasingly important to the insured to know and exercise their appeal rights. With rapid advances in treating disease and life-saving therapies, treatments are often not “covered” under the benefit package and require vigorous challenge to provide payment. These “experimental” clauses often deny life-saving care. The expedited appeal process is the avenue for the patient and family to pursue.

Medicare and Medicaid services require a basic minimum of service that a managed care company must provide to receive federal funds for these populations. For example, acute and subacute rehabilitation services for posthospital care must be included in the package. Dental coverage need not be included. Dental services are not included for the Medicare beneficiary and therefore need not be included in the benefit package offered to its clients by a managed care company. Acute and subacute rehabilitation services are included under Medicare and thus must be included. These “risks” are included in the total cost the insurance companies will charge for the Medicare and Medicaid contracts.