A Member is an employee or a dependent who is enrolled in a health insurance scheme.
Dependents are family members of employees enrolled in a health insurance scheme. They include the legally married spouse or common-law partner, and children of the employee or the covered spouse. Legally adopted children and foster children may also be dependents.
A newborn becomes eligible for coverage 15 days after birth. If the newborn is hospitalized on this date, the eligibility date becomes the day following the date of discharge from the hospital. Coverage will be effective on the first day of the month following the eligibility date.
Your Basic benefit may pay a limited amount for surgery and other medical benefits in one year. The Major Medical benefit is a supplemental benefit that may be used to pay for benefits after the basic amount has been exhausted and the deductible satisfied.
A Deductible refers to the amount of covered expenses that must be paid by the insured before benefits become payable by the insurer.
Yes. The lifetime maximum amount is the total benefit payable for each insured for all medical services covered under the plan of insurance.
The period for which coverage applies, usually one year.
Co-insurance is the percentage sharing of a charge between that borne by the policy and that borne by the insured person (e.g. 20% of the cost of prescription drugs is borne by the member and the rest by the insurance company).
For existing employees Coverage begins on the effective date of the policy or on the 1st day of the month following when a new employee becomes eligible.
Coordination of benefits is an approach to paying benefits when a member is covered by more than one plan of insurance. The insurance plan on which the member is the employee, pays 1st and the plan on which the employee is the dependent, pays 2nd, providing the total payment does not exceed 100% of the charge for the service.
Exclusions are specific services for which coverage is not provided.
Yes. Up to age 23, if the child is a full time student in a recognized educational or vocational institution.
Changes in your family, marriage or eligibility status may affect your health insurance coverage. You can make these changes through your Human Resource Department (HRD).
Health insurance premiums are usually payable monthly, in advance, by the employer on behalf of the employees.
No. The benefit is applicable only to female insured employees, and/or female insured spouses of male employees, for whom pregnancy is a covered benefit.
Providers are a wide group of duly licensed professionals and institutions engaged in providing healthcare services. Provider types include Medical, Dental, Optical, Pharmacies, Medical Laboratories, Hospitals and other registered facilities that provide healthcare services. Participating Providers are those that have been approved and accepted by MedeCus to provide services to its members on credit.
A UCR charge refers to a charge for healthcare that is consistent with the average rate or charge for identical or similar services in a certain geographic area.
Please use the following forms thusly: a. Individual Claim Form: To be completed when a Member visits a non-MedeCus Provider, pays upfront and needs to claim back to MedeCus for reimbursement. Forms must be submitted to MedeCus within 30 days from the date of service. b. Dental Claim Form: To be completed by MedeCus’ Dental Providers when online claim submission is not possible. Forms must be submitted to MedeCus within 30 days from the date of service. c. Optical Claim Form: To be completed by MedeCus’ Members or Optical Providers when online claim submission is not possible. Providers must submit this form to MedeCus within 30 days from the date of service, while Members have 90 days to do so. d. Claim Form for Participating Doctors and Diagnostics: To be completed by non-Dental and/or non-Pharmacy Providers when online claim submission is not possible. Forms must be submitted to MedeCus within 30 days from the date of service. e. Pharmacy Prescription Drug Claim Form: To be completed by Pharmacy Providers when online claim submission is not possible. Forms must be submitted to MedeCus within 30 days from the date of service.
