Medical GAP Coverage

Oberlin Marketing
Fort Wayne, IN
(260) 486-9739
Medical GAP Coverage
A product
designed to help
bridge the “gaps”
in traditional
insurance. A
solution to rising
healthcare costs.
Helps employers save
premium dollars and
helps employees
protect themselves
against financial
strain created by
increased out of
pocket costs.
Healthcare Costs
are out of control.
Fifteen years ago,
GAP was not
needed. In today’s
market, agents
and their clients
are being forced
to find
The following slides give a great
visual effect of the direction our
group health market is headed. In
order continue positive growth,
agents and their clients must be
willing to adapt to the changes.
This slide shows how in just over 10 years, the cost of healthcare
has risen almost 175%, with a good portion of that increase
coming in the last 5 years.
Inpatient Hospital Benefit
- $500 - $10,000 annual maximum per insured person.
- The max for an insured’s family is 3x the above coverage.
* This coverage is for inpatient stays, inpatient surgery, inhospital physician charges, and emergency room treatment
if admitted to hospital.
Outpatient Hospital Benefit
- 40%-70% of the inpatient hospital benefit per insured.
- The family benefit is 3x this coverage as well.
* This coverage is for services rendered in hospital
emergency room, hospital outpatient facility, outpatient
surgical facility, or MRI facility.
Physician Office Visit
- $10-$50 per visit per insured person; 1-3 visits per year.
Ambulance Benefit (Accident Only)
- $50-$350 per person. 3x the benefit per family.
- Retention – When renewal cases have increases, GAP
gives the agent another option to help renew the case.
- New Business – When an agent can bring a fresh idea to
a prospect that they have never seen before, it
differentiates that agent from the competition. If the
agent can show the employer a savings and keep the
out of pocket expenses down, the odds of winning that
case are much higher.
- Commission – Agents and agencies will earn
commissions when a GAP is sold. This is a way to earn
additional money on top of the commission earned in
the sale of the group case itself.
Presentation of how gap fits with the proposed medical plan
(21 enrolled lives)
Renewal Medical Plan
Proposed Alternate Plan with Gap
Out-of-Pocket Max
Monthly Premium
(based on census)
Savings Created
Annual Commisions:
Inpatient Hospital Max
Outpatient Hospital Max
Gap Monthly Premium
Net Savings
$5,075.99 (29% savings)
Major Medical:
$7,560 (based on $30 per head)
CMB Gap:
$3,631 (48% extra commission)
- No deductible with our gap plan
- Outpatient benefit can go all the way up to $7,000
- Rates are extremely competitive.
- Will pay benefits for deductibles, coinsurance AND
copayments covered by the health benefit plan.
- Family limit is 3x the insured benefit. (Opposed to 2x)
- Guaranteed Issue with no pre-ex.
Current Plan (37 Employees)
Competitor Medical Bridge
Crescent Medical Bridge
$500 Deductible
$500 Deductible
Hospital Confinement = $1,000
Outpatient Surgery ONLY = $250 - $1,000
(This will pay out as low as $250 or as high as $1,000
depending on the type of surgery).
Coverage Amount
Emergency Room = $100
Ambulance = $100
Diagnostic Testing = can be added but significantly
increases the rate. The benefit pays only $100-$200
depending on the test).
Dr. Office Visit = $25 one time
Plan Type
_Birth in first nine months NOT covered.
_Pre-existing conditions period of 12 months
after the effective date of coverage.
_Coverage not provided for employees over
the age of 64.
Indemnity - Pays a lump sum benefit,
regardless of claim amount.
Inpatient Hospital Benefit = $1,000
Outpatient Benefit = $700
(covers surgery, emergency room visits, and
radiological diagnostic testing. Will pay up to benefit max
($700) towards any deductible, copayment, or coinsurance
amount covered by the Insured Person's Health Plan.)
Ambulance = $100
Diagnostic Testing = Covered under Outpatient Benefit.
This is very important as the average MRI costs over $1,000).
Dr. Office Visit = $25 twice a year
_No employee maternity exclusions
_No Pre-existing condition exclusions
_No age limit for employees
_Policy is Guaranteed Issue
Supplemental Medical Expense Plan
(Traditional Gap) - Follows the Insured's Health
Benefit Plan and only pays the applicable deductible,
coinsurance, or copayment charge up to the benefit
This group switched to a $10,000 deductible plan with copays and per occurrence deductibles . They implemented a
very common HRA plan that will pay a max of $8,500. The employees have to satisfy a $1,500 deductible before any
benefit is paid out. The below chart shows why switching to a Crescent Medical Bridge Gap Plan may be a better option.
Money Saver HRA
Crescent Medical Bridge Gap
First Dollar Coverage
Employees must satisfy a $1,500 deductible
before any money is paid out. Will not cover
the per occurrence copays associated with
hospital stays, outpatient surgeries, and
outpatient diagnostics.
No deductible. Gap will pay First Dollar
for eligible expenses. This includes
deductibles, copays, and coinsurance.
This will also cover the $500 per occurrence for
Hospital stays and the $250 per occurrence for
outpatient surgery, as well as the $300 copay for
outpatient major diagnostics.
Plan usually has coinsurance built in which
can increase the total out-of-pocket.
No coinsurance. Gap pays first dollar.
Aggregate Coverage Max
Plan has a max coverage of $8,500 for
Inpatient and Outpatient expenses
Inpatient = $10,000
Outpatient = $7,000
Monthly Rate based
on census
$1,401.15 savings
What makes them different?
Claim example using a
typical shoulder injury
followed by an MRI and
Money Saver HRA
Crescent Medical Bridge Gap
MRI = $1,400
Plan has $300 Copay
MRI = $1,400
Plan has $300 Copay
Employee pays $300
Gap pays $300 copay
Outpatient Surgery = $6,000
Plan has $250 per occurrence
deductible. Money
Saver has $1,500 deductible
Outpatient Surgery = $6,000
Plan has $250 per occurrence
Employee pays $250 per occurrence deductible
Gap pays $250 per occurrence deductible
Employee pays $1,500 Money Saver deductible
Gap pays $6,000 for cost of surgery
Total Cost for Employee = $2,050
Total Cost for Employee = $0
Gena Gilleo – (800) 486-9739
- Name and brief description of group.
- Census with name, birthdate, and coverage level.
- Copy of current and renewal plan including rates.
- List of several alternate plans with higher deductibles
and lower premiums.
- We also need to know what state the business is
headquartered in.
- Kaiser/HRET Survey of Employer-Sponsored
Health Benefits, 2005-2001
- Sally Pipes, President of the Pacific Research
Institute. “Forbes Magazine” 10-10-2011

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