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Plan Tiers

Plan tiers refer to the different levels of coverage available within a group or individual insurance plan. Each tier offers a varying combination of benefits, coverage limits, and premium costs, allowing members to choose the option that best fits their needs and budget. Tiers are commonly labeled as Basic, Enhanced, or Premium, though terminology can differ by insurer. Higher tiers typically provide more comprehensive coverage and higher annual or lifetime maximums, while lower tiers focus on essential protection at a lower cost.

Plan tiers are often used in extended health, dental, and vision insurance.

Example:

An insurance company might offer three plan tiers: Basic coverage with 70 percent reimbursement for prescription drugs, Enhanced coverage with 80 percent reimbursement, and Premium coverage with 90 percent reimbursement and higher dental maximums. Those applying for insruance can select the tier that matches their family’s healthcare needs.

What to Watch For:

Compare the coverage details, coinsurance percentages, and annual maximums for each tier before choosing. Some tiers may include additional benefits, such as vision care or paramedical services, that are not part of lower-level plans. Once enrolled, changes to plan tiers may be restricted - where upgrading to a higher plan tier may require medical underwriting.

Related Terms

Paramedical Disciplines

Paramedical disciplines refer to regulated health professionals who provide therapy or rehabilitation services outside of hospital settings. Common examples include physiotherapists, chiropractors, massage therapists, acupuncturists, naturopaths, osteopaths, psychologists, and speech-language pathologists.

Pay-Direct card / Drug card

A pay-direct card, also known as a drug card, is a plastic or digital card issued by your health insurance provider that allows pharmacies to bill your insurer directly for eligible prescription drugs. Instead of paying the full cost upfront and submitting a claim later, you pay only your portion - such as a deductible or coinsurance - at the point of sale.

Per Incident

Per incident refers to the way certain insurance benefits are calculated or limited based on each separate event, illness, or accident rather than by year or lifetime. When a benefit is paid “per incident,” it means you are eligible for reimbursement each time a new, distinct occurrence happens, up to the maximum amount specified for that type of claim.

Per Person / Per Family

Per person and per family describe how benefit limits, deductibles, or maximums are applied within a health or dental insurance plan. A per person limit means the specified amount applies individually to each insured member, while a per family limit represents the total combined coverage for all members under one policy.

Per-Practitioner Annual Maximum (Paramedical)

The per-practitioner annual maximum is the total amount your plan will reimburse for services from one specific type of provider in a single benefit year. For example, if your plan pays up to $500 for massage therapy annually, once that amount is reached, additional treatments from that provider type are no longer covered until the next year.

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