What is fixed benefit health insurance?
Fixed benefit plans are also sometimes referred to as indemnity insurance or fee for service insurance. These plans are designed to give your traditional health insurance a boost by paying a preset — “fixed” — payment when you receive any of the qualified medical services specified in the plan. The benefit paid out stays the same no matter what the total bill for the qualified service was and no matter what other insurance pays.
What do fixed benefit health insurance plans cover?
Fixed benefit plans help cover some of the most common medical costs you and your loved ones might face. These plans offer a preset benefit amount. Some benefits increase the longer you have a plan.
See how fixed benefit insurance plans can help cover costs
With your fixed benefit plan, you may be able to:
Apply benefit payments toward your other health plan's deductible
Get cash to help cover prescription drug copays
Help pay your share of lab or diagnostic costs, like for blood tests or X-rays
Have money for unforeseen expenses from a planned or an unplanned surgery
How do fixed benefit plans work?
When you have a fixed benefit health plan, here are some things you’ll need to know to use your benefits:
-
You or your provider submit a covered expense. The fixed benefit for that covered service is then paid, no matter what other insurance coverage you may have.
-
You don't have to meet a deductible before you receive benefits.
-
You choose the doctor or health facility you need.2
-
You can go to any doctor or health care facility you want. However, you may save money with discounted rates for services if you use providers in your plan's network (varies by state).
-
You can apply year-round, not just during an enrollment period or because of special circumstances.
Frequently asked questions about fixed benefit health insurance
Explore FAQs about fixed benefit health insurance to learn how to choose a plan for you.
Fixed benefit insurance can help you manage potential out-of-pocket costs from your main health insurance plan. This includes expenses like deductibles, copays and coinsurance — things you pay before your insurance plan pays benefits
With traditional health insurance, your plan typically pays for all or a percentage of covered expenses after you meet a deductible, pay a copay or reach an out-of-pocket cost limit. You pay for qualified expenses first, then your insurance company usually covers their portion based on the terms of the policy.
Fixed benefit insurance flips how you’re paid. You or your provider are paid a predetermined, fixed amount of benefit for covered health care expenses. After that, you’re responsible for the rest.
Fixed benefit insurance is not major medical insurance. Fixed benefit insurance provides limited benefits, paying a set amount for covered services up to a maximum for the year. It doesn’t cover all the essential health benefits outlined by the ACA and doesn’t qualify as the minimum essential coverage. Also, it will not cover expenses related to preexisting conditions for the first 12 months of coverage. In fact, it’s designed more as a supplement to a major medical plan.
It’s important to understand these differences:
- Indemnity insurance does not provide the coverage required under the Affordable Care Act (ACA)
- It does not provide coverage for all the essential health benefits outlined in the ACA
- It will most likely not provide coverage for expenses from preexisting medical conditions for the first 12 months of coverage
Nothing beyond your monthly premium, which is what you pay to have the plan. You don’t have deductibles or copays with fixed benefit health insurance. If you have services provided for a covered expense, the benefit is paid after the claim is submitted.
Yes. The fixed benefit health plan pays you for the covered expense, even if your other health insurance plan also covers that service.
No, where you go for care is up to you. Since you are paid a fixed amount for covered services up to an annual maximum amount, the plan doesn’t restrict you to a specific network of doctors or providers.
Keep in mind that your main health insurance may require you to stay within a certain network of providers.
Yes, in some plans. Many fixed benefit plans come with benefits paid for a certain number of prescription fills per year. Plans in most states come with a prescription discount card to help with the ongoing costs of medicine.
Yes, many fixed benefit plans pay for specified preventive or wellness services.3
In some states, fixed benefit health plans come with an included telehealth membership so you can access a doctor by phone or app without leaving your home.
Why choose fixed benefit health insurance plans?
Learn more about fixed benefit health insurance
Explore more supplemental plans
View more plans, like dental, vision and other cash-benefit plans, that offer coverage for expenses not covered by a medical plan.
Need help finding a plan?
Answer a few questions to see which insurance options may be available for you.