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

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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.

Affordable Care Act FAQs

Major medical insurance rates for 2019 will be finalized when 2019 open enrollment begins on Nov. 1, 2018. You may be able to find preliminary premiums for certain areas beforehand. Organizations such as the Henry J. Kaiser Family Foundation track insurer filings ahead of open enrollment; you can view the Kaiser Family Foundation’s “Tracking 2019 Premium Changes on ACA Exchanges” analysis here. Only you can determine whether or not health insurance plans in your area are what you consider to be affordable. You may want to shop around and compare ACA-compliant major medical insurance as well as non-ACA-compliant coverage options. You may qualify for a premium tax credit to help lower your monthly premium when you purchase major medical insurance from or a state-based health insurance exchange. Use our calculator to estimate your tax credit for 2019. Learn about some coverage options when you don’t qualify for a subsidy. Use Agent Finder to search for a local agent who can help you explore your options.
The Affordable Care Act makes subsidies available to qualified individuals who purchase health insurance from or a state-based exchange.   You can also obtain estimates while you are shopping by using an online calculator tool. Such estimates may help you decide which major medical plan to select and help you decide whether or not to enroll in additional coverage such as medical gap insurance or hospital indemnity insurance, which can help with out-of-pocket medical expenses. Estimate your subsidy now.
You may want to consider alternative coverage that isn’t major medical insurance but that can help you pay for unexpected medical expenses. Such coverage may include short term medical insurance and hospital indemnity insurance. If you are concerned about your major medical insurance policy’s high deductible, you may want to consider supplemental insurance to help with out-of-pocket expenses not covered by your major medical policy. Learn more about supplemental insurance. Find out what you can do if you think you can’t afford coverage.

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

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[1] ObamaCare Guaranteed Issue. (2018). Obamacare Facts. Retrieved 18 April 2018, from