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.
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
Maternity and newborn care
Mental health and substance use disorder services, including behavioral health treatment
Rehabilitative and habilitative services and devices
Preventive and wellness services and chronic disease management
Pediatric services, including oral and vision care
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.
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:
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.
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.
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.