Plan Benefits

The following is a description of each of the benefits available under the Markel Basic Health Insurance program. Be sure to review the Plans & Rates information for each of the specific benefit options offered.

When medical care is received, the insured employee pays the provider at the time of the visit (or, if agreed with the provider, upon receipt of a bill for services). Then the insured employee submits a claim under the Markel Basic Health Insurance plan and the plan reimburses the insured employee the stated benefit amount for covered services. Even if the bill is less than the stated benefit amount, Markel Basic Health Insurance pays the stated benefit amount.

Doctor’s Office Visits

Benefits are payable for as many as 5 visits per covered person per calendar year. One visit of the five may be used for an annual checkup.

Diagnostic Testing or X-ray

Benefits are payable for as many as 3 visits per covered person per calendar year when doctor-ordered diagnostic tests and x-rays are performed in the doctor’s office or in an outpatient facility. One visit of the three may be used for diagnostic testing or x-rays during an annual checkup.

Child Wellness Visits

Benefits are payable for children through age 5 for their “well child” visits at the following intervals:

• birth
• 2 months
• 4 months
• 6 months
• 9 months
• 12 months
• 18 months
• 2 years
• 3 years
• 4 years
• 5 years

"Well child” care is for the periodic review of a child’s physical and emotional status. Care received during the visit may include physical examination, developmental assessment, immunizations, lab tests and vision and hearing screenings. All services must be provided by, or under the supervision of, a doctor and must be provided in one visit. The Child Wellness Visits are in addition to the 5 Doctor’s Office Visits available when the child is sick or 1 visit may be used for an annual checkup.

Hospitalization

Benefits are payable for each day confined as an inpatient in a hospital up to 100 days per confinement.

When an inpatient in an Intensive Care Unit or Coronary Care Unit, daily benefits are doubled for up to 30 days. If still hospitalized after the 30 day maximum, benefits will return to the “regular” daily benefit amount for the balance of the 100 day maximum per confinement.

When an inpatient for a Mental & Nervous condition or for Alcohol or Drug Abuse, 50% of the daily benefit amount is available up to a maximum of 30 days per confinement.

When hospitalized as an inpatient for at least 3 days and then, within 3 days, transferred to a Convalescent Facility, 50% of the daily benefit amount is available up to a maximum of 60 days per confinement.

Emergency Room

Benefits are payable for visits to the emergency room when not admitted as an inpatient stay. 3 visits per covered person, per calendar year are available for injury and 1 visit per covered person, per calendar year is available for sickness.

Surgery

Benefits are payable for 1 inpatient surgery and 1 outpatient surgery per covered person per calendar year. Outpatient surgery must be performed in a hospital or outpatient facility; i.e. not in a doctor’s office.

Dental Care

Benefits are payable for various dental care services up to a $1,500 maximum per covered person per calendar year. Refer to the Dental Schedule for specific reimbursements for specific types of care.  Note that some benefits require a 12 month waiting period before benefits are available. In addition, periodontal care is limited to $500 and orthodontia treatment is limited to $750. Orthodontia treatment is available to children and adults.