Carve-Out
A carve-out is a health plan design in which a specific benefit, such as prescription drugs or mental health services, is managed separately from the main health insurance policy.
What is a Carve-Out?
A carve-out is an agreement for specialized services outside standard coverage. These medical services are separated from a contract and paid under a different arrangement. These services often include critical areas such as prescription medications or specialized treatments like cancer care.
A carve-out policy is a specific agreement for specialized health services. This arrangement ensures that members receive focused and tailored care that may not be fully covered under standard insurance plans. These policies can help members access critical treatments efficiently.
What is the difference between a Carve-Out and Carve-in?
A carve-out refers to specialized services separated from standard coverage and paid under a different arrangement to ensure tailored care, often for critical treatments like prescription medications or cancer care. A carve-in, conversely, would refer to specialized services that are included within the standard coverage or contract.
Carve-out: Specialized services are excluded from the main contract and paid separately.
Carve-in: Specialized services are included within the main contract and covered under standard arrangements.
What are examples of a Carve-Out?
A health insurance plan might carve out prescription medications, meaning a separate company manages and pays for your prescriptions, even though your main medical care is covered by a different insurer.
If a child has ADHD, their pediatrician might bill the regular health insurance plan for a flu vaccine, but send a separate bill to a mental health benefits plan for the ADHD treatment because behavioral health services are carved out.
An HMO (Health Maintenance Organization) might carve out vision care benefits, selecting a specialized vendor to provide these services on a standalone basis rather than including them directly in the HMO's standard package.
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