Major Medical Insurance

Comprehensive, ACA-qualifying healthcare coverage

Major medical insurance is comprehensive, long-term healthcare coverage. You may know it by a different name: “Obamacare 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 (see the next section).

Any health insurance plan that does not meet that minimum requirement is not considered a major medical plan.

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

Have a coverage question?

Contact us to speak with an agent now.

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 Insurance?

Beginning in 2019, the ACA individual mandate will no longer be enforced with a tax penalty for adults 26 and older that opt out of coverage without qualifying for an exemption.

Even though you won’t be required to carry a major medical policy under the law, you should still consider these more comprehensive plans if you:

  • Aren’t already covered on a parents’ or employer’s major medical plan
  • Have a pre-existing condition – major medical plans are guaranteed issue so you can’t be turned away because of past health conditions
  • Qualify for a subsidy – you may be able to get a better ACA plan at a more affordable rate than you think
  • Rely on prescription drugs – major medical plans are the only plans that require drug coverage

On the other hand, if you are younger, don’t rely on prescription medications and don’t have any pre-existing conditions, you may be able to get a lower cost (and less comprehensive) alternative health plan that primarily covers catastrophic injuries, and hospitalization due to an accident or critical illness.

When Can You Get Major Medical Insurance?

Non-employer based major medical coverage can only be obtained during the annual open enrollment period (typically Nov - Dec) unless you qualify for a special enrollment period due to getting married or divorced, moving to a new state or area where your plan isn’t available, having a child or losing your job.

Don’t Qualify For Special Enrollment + Still Need Health Coverage?

If you missed open enrollment, don’t qualify for or missed your special enrollment period, and don’t qualify for Medicaid or Children’s Health Insurance Program (CHIP), an option available to you is to protect your health and finances with alternative health insurance coverage. 

These types of plans are not ACA-qualifying major medical coverage and generally provide less coverage and fewer patient protections than major medical plans.

Regardless, they can help fill a health insurance coverage gap so that you don’t pay for unplanned medical expenses 100% out of pocket.

Consider a fixed indemnity hospital plan, short-term health insurance, or a combination of the two packaged together.

2 Ways to Get Started with a Major Medical Insurance Plan

Call to Speak to an Agent

Work with a Local Agent

by Jenifer Dorsey October 17th, 2018
man looking scared, surprised
by Jenifer Dorsey September 25th, 2018
by Jenifer Dorsey September 7th, 2018

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