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

You may want to consider alternative coverage that isn’t major medical insurance, but that can help you pay for unexpected medical expenses. Short term medical insurance is one such option. 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. Hospital indemnity insurance policies and medical gap are two types of supplemental insurance that can help. In some states, you must already have a major medical policy in order to obtain hospital indemnity insurance. Learn more about supplemental insurance. Find out what you can do if you think you can’t afford coverage.
There are many places to buy major medical insurance as well as alternative coverage, including, state-based health insurance exchanges, websites such as, and through health insurance agents. The best coverage and the right place to buy it largely depends on your personal situation. Should you shop around or renew your current plan? Not subsidy-eligible? Read about your coverage options. Learn where to shop by state.
Choosing health insurance coverage can definitely feel overwhelming, and the temptation can be to focus on monthly premium rather than the big picture. To find the best health insurance plan for you, start by considering your healthcare needs and budget for the year to come. Also, be sure to consider what your healthcare expenses were in the past year and if your current coverage was adequate. Did anything change, or do you expect it to change in the year to come? Learn how to choose the best health insurance option for you.

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.

Get Started with a Major Medical Insurance Plan

Save on Healthcare Costs – Learn More at Our Blog

by Sarah Sullivan June 2nd, 2020
by Cathy Jakicic April 1st, 2020