If you are looking for health insurance, you must make sure your insurance provides comprehensive coverage. This includes preventive care, emergency room visits, urgent care visits, surgical procedures, and inpatient hospital stays.

Fortunately, that is precisely what major medical insurance delivers. When someone is discussing typical health insurance coverage, they are usually referring to major medical insurance. But what is major medical insurance, and what does it cover?

Keep reading to learn more about major medical insurance, including what this health insurance covers, benefits, drawbacks, and more, to ensure you select the right policy for your needs.

Major medical health insurance covers all the minimum essential benefits and meets the standards of the Affordable Care Act (ACA) for individual and family coverage. Many individuals and families select major medical coverage to ensure all their medical expenses are covered no matter what health concerns might occur throughout the year.

What is Major Medical Insurance?

Major medical insurance is a specific type of health insurance plan that will help cover your medical expenses. It often covers preventive care services, urgent care visits, emergency room visits, prescription medications, and other routine medical expenses. However, this type of plan will not cover cosmetic procedures. It also has a longer duration than a short-term insurance plan. The goal of this plan is to minimize out-of-pocket costs for the policyholder.

When people talk about typical health insurance coverage, major medical plans are the type of insurance they’re thinking of. Major medical insurance plans are comprehensive, comply with the Affordable Care Act’s (ACA) regulations for qualifying health plans, and are designed to minimize out-of-pocket expenses for individuals and families.

For example, your major medical insurance plan should cover your annual wellness exam. If you catch a cold and have to go to the emergency room due to complications, the plan will also often cover that expense.

What do Major Medical Insurance plans cover?

Major medical insurance plans offer the ten essential benefits:

1. hospitalization
2. outpatient procedures (also called ambulatory care)
3. preventive care like check ups and immunizations
4. prescription medication
5. mental health and addiction counseling
6. laboratory services
7. emergency services
8. pediatric care
9. maternity and newborn care

These plans aren’t only sold through the official state and federal marketplaces. They can be sold off the exchange through licensed private brokers. For example, eHealth is a private marketplace that sells  alongside other insurance options like small business health insurance.

Key features and benefits of Major Medical Insurance plans

Major medical health insurance is designed to provide extensive coverage for significant healthcare needs, particularly in cases of serious illness and hospitalization. This type of insurance offers several key benefits:

• Coverage for preventative care: These plans typically cover essential preventive services, such as vaccinations, screenings, and annual check-ups, often at no additional cost to the policyholder. This can encourage early detection and prevention of serious health issues.
• Easier to obtain than other health insurance policies, specifically for those with pre-existing medical conditions
• Qualifies for the ACA, so fines can be avoided in states with tax penalties
• Accessibility: Major medical plans are generally more accessible, even for individuals with pre-existing medical conditions. This inclusivity is especially important under the Affordable Care Act (ACA), which prohibits denial of coverage based on pre-existing conditions.
• ACA Compliance: By qualifying for the ACA, these plans enable policyholders to avoid tax penalties in states that enforce them for not having health insurance.
• Potential for Subsidies: During Open Enrollment or a Special Enrollment period, these plans may qualify for subsidies, making them more affordable by significantly reducing the cost of premiums.
• Comprehensive Coverage: These plans often include a broad range of medical services and treatments, from routine care to specialized procedures, providing a safety net for various health care needs.

A major medical health insurance plan sold during Open Enrollment or a Special Enrollment period can also qualify for subsidies that significantly reduce the cost of premiums.

Potential drawbacks of Major Medical Insurance plans

Despite these advantages, there are drawbacks of major medical insurance plans to consider:

• Complexity: The extensive coverage and legal terms used in these plans can make them difficult to understand, requiring careful review and possibly professional advice to fully grasp the benefits and limitations.
• Longer Terms: Major medical plans often have set enrollment periods and terms, limiting the flexibility to change plans except during specific times like Open Enrollment or qualifying life events.
• Higher Premium Costs: The comprehensive nature of these plans typically results in higher monthly premiums compared to more basic insurance options. This cost factor is a significant consideration for those balancing healthcare needs with budget constraints.
• Can be difficult to understand due to legal jargon
• Terms are often longer, so you’ll have to wait to change plans
• More costly than other options in terms of monthly premiums since they offer many additional benefits.

Understanding these features, benefits, and drawbacks is crucial in deciding whether a major medical insurance plan aligns with your healthcare needs and financial capabilities.

How to choose the right insurance policy

Major medical insurance can help you afford a wide range of healthcare expenses, including emergency room visits, preventive health services, and surgical procedures. However, there are many plans to choose from, so finding the best policy for your specific needs can be challenging. Fortunately, our team is available to assist you.

Whether you purchase major medical coverage on or off the exchange, the choices can seem overwhelming. That’s why working with a licensed broker like eHealth is helpful. Our experienced agents can help you select the best plan for your needs and budget. Our services are free of charge and we offer 24/7 support after you enroll to help you manage your plan. With licensed agents in every state, you can shop for the best plans no matter where you live – all from the comfort of your own home. See all of the individual and family health insurance plans in your state to learn more about your options in major medical coverage and find the right plan.

Ways to enroll in Major Medical Insurance

Major medical health insurance can be purchased through official health insurance exchanges and through licensed brokers like eHealth who can also sell qualifying health plans. You are limited to buying on an exchange during certain times of year. The most common time to buy a plan is during the open enrollment period. You can also qualify for what is known as a special enrollment period if you have a qualifying event. These include:

• changing jobs
• getting married or divorced
• having a child
• Income change

If you wish to buy major medical health insurance at other times of year, or if you wish to purchase a plan that is not offered on the exchange, you also have the option of buying a policy off the exchange. Buying a policy off the exchange may have certain drawbacks. For example, plans purchased off the exchange are not likely to qualify for subsidies. Since these subsidies can have a major impact on the monthly premium cost, the monetary difference between on and off-exchange plans can be significant, even if the coverage is similar.

FAQs: What is Major Medical Insurance?

How do Major Medical Insurance plans differ from other healthcare plans?

Major medical insurance is different from other healthcare plans because it is more comprehensive. The terms for this type of health insurance plan are typically longer than a short-term one and provide more extensive coverage than a catastrophic one. For example, a major medical insurance plan will cover preventive care visits, but catastrophic health insurance will not. Additionally, major medical health insurance plans provide better coverage for chronic health conditions like diabetes and heart disease.

Is Major Medical Insurance required by law?

No, Major Medical Insurance is not required by law at the federal level. While the individual mandate under the Affordable Care Act (ACA) initially required most Americans to have health insurance or face a penalty, this federal penalty was eliminated in 2019. However, it’s important to note that some states have implemented their own health insurance mandates. Residents in these states may still be required to have health insurance or face a state-level penalty. If you are unsure about the requirements in your state, it is advisable to check local regulations to ensure compliance.

What happens if I need treatment that isn’t covered by Major Medical Insurance?

If you require a treatment that isn’t covered by your Major Medical Insurance, you will likely have to pay for it out-of-pocket. It’s crucial to thoroughly review your health insurance plan’s list of covered benefits to understand what is and isn’t included. Additionally, discussing alternative treatment options with your healthcare provider can be beneficial. They may be able to suggest different treatments that are covered under your plan or help you find cost-effective solutions for necessary treatments that are not covered.

How does Major Medical Insurance work with Medicare?

If you are eligible for Medicare, Major Medical Insurance can complement your coverage. This is often done through what is known as a Medicare Supplement Insurance Plan (Medigap). A Medigap policy helps cover additional costs that Medicare Part A and Part B might not fully pay, such as copayments, coinsurance, and deductibles. Essentially, Medigap fills the “gaps” in Medicare coverage, ensuring that out-of-pocket expenses are minimized. This setup allows you to have more comprehensive health coverage by combining the benefits of both Medicare and additional insurance through a Medigap policy.

What are some alternatives to Major Medical Insurance?

When the ACA was first signed into law, it included a requirement that all Americans have a health insurance plan or pay a penalty. In April 2020, the penalty no longer applied, allowing people to explore alternatives to major medical coverage.

One alternative that some people choose is catastrophic health insurance. Catastrophic plans differ from major medical health insurance in that they offer a very limited range of benefits. These plans will typically cover expenses associated with a hospitalization, surgery, major illness, or injury. However, they will not cover preventive care or minor health issues. The premiums for these plans are far lower than the premiums for major medical health insurance since they offer less coverage.

Short-term health insurance is another option that allows people to buy coverage that lasts up to 12 months or less. Short-term health insurance can be a good option if you find yourself in a transition such as moving or a job change.

Is Major Medical Insurance right for me?

Major medical coverage is a good choice for nearly anyone who wants to minimize expenses for preventative care, emergency services, and management of chronic conditions. These comprehensive plans are the best way to cover a full range of your daily medical care, while ensuring any unexpected medical needs do not create a significant financial concern. Although these plans will not cover every medical service, they will provide coverage for the widest range of services and care.