Miscellaneous Benefits--Mammography Screening
In previous articles we have discussed aspects of various kinds of coverage of provider and non-provider services subject to co-pay and deductibles. In this section of Benefits and Claim Procedures we will take a look at several Miscellaneous Benefits available under the model individual health insurance policy we have been reviewing.
(Typical wording*):
Miscellaneous Benefits
Miscellaneous Benefits are not subject to any Co-Pays, deductibles or the Insured Coinsurance Percentage, unless otherwise indicated below. Subject to all applicable definitions, exclusions, limitations, waiting periods and other provisions contained in this Policy, as well as any riders, endorsements or amendments attached hereto, We promise to pay to or on behalf of each Insured the applicable Company Insurance Percentage of the amount of professional fees and other applicable medical diagnostic or treatment expenses and charges that constitute Covered Expenses incurred by each applicable Insured for the following described Miscellaneous Benefits, which in each instance was Medically Necessary: |
"Miscellaneous Benefits" means only benefits for treatments, procedures, services and supplies that are specifically described in this "Miscellaneous Benefits" provision. If a treatment, procedure, service or supply is not specifically described in this provision, then fees charged and expenses associated with such items are not covered under this provision.
Here, again, it is worth noting all the different ways your expenses for medical treatment and services can be reduced or not covered – coinsurance, deductibles, co-pays, exclusion, limitations, waiting periods and definitions in the policy or by rider, endorsement or amendment to the policy. Through constant analysis the company is always on the watch to try to make sure that it is not offering more benefits than it can afford to pay out.
(Typical wording*):
Miscellaneous Benefits (cont.)
1. Mammography Screening – Routine Screening Exams: Services Provided by Participating Providers and Non-Participating Providers for screening by low dose Mammogram to detect the presence of occult breast cancer, as follows:
a. a single baseline Mammogram for female Insureds 35 to 39 years of age;
b. one Mammogram every two (2) years for female Insureds 40 to 49 years of age;
c. an annual Mammogram for each female Insured 50 years of age or older; or d. when deemed necessary by a Provider.
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A mammogram is the x-ray examination of the breast using equipment dedicated specifically for mammography. It includes, but is not limited to, the x-ray tube, filter, compression device, screens and films and cassettes, with an average radiation exposure delivery of less than one rad mid-breast, with two views of each breast.
*Wording may vary from contract to contract and from state to state.
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