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Major Medical Insurance

Major medical insurance is comprehensive, ACA-qualifying health insurance coverage, also known as “Obamacare insurance.”

What Is Major Medical Insurance?

Since the Affordable Care Act (ACA) went into effect in 2014, all medical insurance plans being sold as major medical coverage are required to meet a set of minimum coverage standards as mandated by Obamacare (see the next section).

Any health insurance plan that does not meet that minimum requirement is not considered a major medical plan and does not fulfill the ACA’s individual mandate requiring anyone that does not qualify for an exemption to carry comprehensive major medical insurance.

What Does Major Medical Insurance Cover?

Long-term health insurance plans are required to cover the following healthcare services, often referred to as the 10 essential health benefits:

  • Ambulatory patient services
  • Emergency services
  • Hospitalization
  • Maternity and newborn care
  • Mental health and substance use disorder services, including behavioral health treatment
  • Prescription drugs
  • Rehabilitative and habilitative services and devices
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services, including oral and vision care

Major Medical Insurance Is “Guaranteed Issue”

Major medical insurance that qualifies as Obamacare is required under law to be “guaranteed issue.” That means you cannot be denied coverage based on health status (including pre-existing conditions), age, gender, or other factors.

However, you can be charged more for some things such as age, tobacco use, family size and geographic location.1

Do You Need Major Medical Health Insurance?

Most Americans need a primary health insurance plan in the form of major medical both to help protect their health and finances but also because, at present, it is required by law under Obamacare. However, some people are exempted from the ACA’s individual mandate.

Here’s how to determine if you need to purchase major medical insurance:

Do you already have coverage on a parent’s or an employer’s plan?

Under Obamacare, young adults can remain on their parents’ health plan until the age of 26.

And if you receive major medical health coverage as part of an employee compensation package, then you’re already covered and don’t have to obtain an individual major medical policy.

Do you already have coverage image

Already covered? Great! Supplemental coverage can help make your high-deductible primary health plan more affordable.

Find out if you're exempt from the ACA mandate image

Find out if you’re exempt from the ACA’s individual mandate

If you’re exempt, then according to law, you aren’t required to carry major medical insurance and will not be penalized with a tax if you choose not to carry it.

Is it a good idea to go without any health coverage? No. With the high costs of emergency care, surgery and hospitalization, an unexpected injury or illness could drain your savings account.

If a major medical plan is out of reach due to the high monthly premium, then an alternative option like a hospital indemnity plan can help protect your health and finances.

Consider your life stage, health, and financial circumstances

Most people at any stage of life would benefit from comprehensive major medical coverage because it unlocks access to preventive care and many other healthcare services that are not only critical when you’re sick or injured, but can help you maintain good health.

However, there may be temporary periods, especially during a life transition, when it may not make sense to carry a major medical policy. 

Consider your life stage, health, and financial circumstances image

Divorce, unemployment? An alternative insurance option with a lower-cost premium like short-term medical may make sense during temporary periods of uncertainty until you’re back on your feet.

Find out if you can obtain major medical now image

Find out if you can obtain major medical right now

Major medical insurance is only available during the annual open enrollment period unless you qualify for a special enrollment period.

Open enrollment typically runs from November to December each year. In previous years this window has been extended to increase access and encourage participation; however, the 2017-18 open enrollment period was only 4 weeks long.

If you aren’t able to enroll in a major medical policy now, an alternative insurance plan, like a hospital fixed indemnity plan, could help fill the gap until open enrollment.

Special Enrollment For Major Medical Insurance Plans

Some circumstances make you eligible for a special enrollment period, a timeframe outside of open enrollment during which you may enroll in a major medical plan either on the public marketplace or from a private provider.

Qualifying events include:

  • Getting married or divorced
  • Moving to a new state or area where your current health plan isn’t available
  • Having a child (including giving birth and adopting)
  • Losing your job

You only have 60 days from the time the event took place to participate in the special enrollment period.

Find out if you qualify for a special enrollment period by using a tool available on the healthcare.gov website and get more details about special enrollment periods.

Do you qualify for a special enrollment period and wish to obtain major medical plan options and costs? 

What If You Don’t Qualify For Special Enrollment + Still Need Coverage?

If you are not exempt, missed open enrollment, don’t qualify for or missed your special enrollment period, and don’t qualify for Medicaid or CHIP, the last option available to you is to protect your health and finances with alternative health insurance coverage.

These types of plans do not fulfill the individual mandate so you may still be subject to a tax penalty if you go longer than three months without an ACA-qualifying major medical plan.

However, they can help fill a gap in your major medical coverage so that you don’t face paying for unplanned medical expenses 100% out of pocket.

Take a look at the fixed indemnity hospital plan, short-term health insurance, or a combination of the two packaged together in a plan called Fusion.

Where To Get A Major Medical Health Plan

1

First, if you are able to enroll in a major medical plan now, see if you qualify for a subsidy. (Our health insurance calculator can help!)

2

Then, if you qualify, you will likely want to begin by shopping the public health insurance marketplace because the plans offered there allow you to use your subsidy.

3

If you don’t qualify for a subsidy or don’t like the options available on the state and federal exchanges, you can obtain a major medical policy from private insurance sellers such as Health eDeals (in conjunction with IHC).

It just takes 2 minutes to complete a short form and get advice from an insurance professional (or call the number on your screen).


1 ObamaCare Guaranteed Issue. (2018). Obamacare Facts. Retrieved 18 April 2018, from https://obamacarefacts.com/guaranteed-issue/