Navigating the health insurance landscape can be overwhelming, especially when understanding the various insurance options available and their specific coverage areas.
This article explores the ins and outs of major medical insurance plans and the types of plans available within this category. We’ll walk you through the insurance types, eligibility requirements, enrollment procedures, and how to use, renew, and change your coverage.
What Is Major Medical Insurance?
Major medical insurance, or comprehensive health insurance, is a type of health insurance plan that offers extensive coverage for a wide range of medical services and treatments.
It is designed to protect individuals and families from high medical expenses resulting from unexpected illnesses, injuries, or chronic conditions. Major medical insurance meets all the minimum essential benefit standards of the Affordable Care Act.
Plans may vary in coverage levels, deductibles, copayments, and network restrictions. Some plans may also offer additional benefits, such as dental and vision coverage or coverage for alternative therapies.
What Does Major Medical Insurance Cover?
Major medical insurance typically covers the following healthcare services:
- Emergency Care
- Hospitalization
- Doctor Visit
- Diagnostic Tests
- Preventive Care
- Rehabilitation Services
- Home Health Care
- Hospice Care
- Prescription Medications
- Chronic Condition Management
- Maternity And Newborn Care
- Mental Health Services
Types Of Major Medical Plans
Major medical plans are categorized into different types. These plans are designed to offer comprehensive coverage for various medical services.
Health Maintenance Organizations (HMOs)
HMO plans require members to choose a primary care physician (PCP) and get referrals from the PCP to see specialists. These plans often have lower out-of-pocket costs and premiums but require members to receive care within a specified network of doctors and hospitals. Out-of-network care is usually not covered except in emergencies.
Preferred Provider Organization (PPO)
PPO plans offer more flexibility in choosing healthcare providers. Members can see any doctor or specialist without needing a referral, both within and outside the plan’s network. They offer some coverage for out-of-network care but are more expensive than staying within the network.
Exclusive Provider Organization (EPO)
EPO plans combine elements of HMO and PPO plans. Members must choose a primary care physician and receive specialist referrals. However, some EPO plans may offer limited coverage for out-of-network emergency care.
Point Of Service (POS)
POS plans are a hybrid of HMO and PPO plans. Members choose a primary care physician and need specialist referrals. POS plans offer some coverage for out-of-network care, but the coverage levels are often lower than in-network care.
High Deductible Health Plan (HDHP)
HDHPs have higher deductibles and typically lower premiums. These plans are often used with Health Savings Accounts (HSAs), allowing individuals to set aside pre-tax money to cover qualified medical expenses.
Catastrophic Health Insurance
Catastrophic health insurance protects you from extremely high medical costs in major emergencies like serious accidents, unexpected surgeries, or severe illnesses requiring extensive medical treatments.
Catastrophic insurance premiums are typically low, but the plans have high deductibles. This means you must cover your medical expenses out of pocket before the insurance coverage kicks in.
These plans typically have very little day-to-day health coverage. However, The Affordable Care Act (ACA) requires that all health insurance plans, including catastrophic plans, cover certain preventive services without requiring you to pay a copayment or coinsurance, even before you meet your deductible. These services include vaccinations, some screenings, and preventive services for women.
Benefits Of Major Medical Plans
Major medical plans, or comprehensive health insurance plans, offer various benefits that can provide financial protection and access to necessary medical care. Here are some key benefits of major medical plans:
- Broad Coverage: Major medical plans typically offer comprehensive coverage for various medical services, including hospital stays, surgeries, doctor visits, and more. This broad coverage helps ensure that individuals can access the necessary medical care.
- Financial Protection: Major medical plans often have high coverage limits and low out-of-pocket maximums, which can help individuals avoid large, unmanageable medical bills in case of serious illnesses or injuries.
- Preventive Care: Many major medical plans cover preventive care services at little to no cost to the insured individual. This includes vaccinations, screenings, and other services to help catch potential health issues early.
- Network of Providers: Major medical plans usually have a network of doctors, hospitals, and healthcare providers that they work with. When individuals use providers within the network, they can often benefit from negotiated rates and reduced out-of-pocket costs.
- Flexibility and customization: Major medical plans come in various options and can be tailored to suit different needs and budgets.
Cost Of Major Medical Plans
What you pay for major medical insurance plans can vary widely based on several factors, such as the type of plan you choose, the coverage, your location, age, medical history, and the number of people on the plan.
When figuring out the cost of important medical insurance, remember to think beyond just the monthly payment. Sometimes, plans with lower monthly payments could cost more due to higher deductibles or out-of-pocket limits.
The average monthly health insurance cost in 2023 is:
- Health Maintenance Organization (HMO): $390 – $930
- Preferred Provider Organization (PPO): $458 – $1,095
- Exclusive Provider Organization (EPO): $436 – $1,037
The price of these plans varies based on your age, family size, and income level. Some federal subsidies may be available in different income brackets that change the insurance price.
How Is Major Medical Insurance Different From Other Forms of Insurance?
Major medical insurance differs from other forms of insurance because it covers the necessary care associated with major medical issues and additional benefits, like preventative care and prescriptions.
| Types of Insurance | Major Medical Insurance | Short-term Health Insurance | Supplemental Insurance | Catastrophic Insurance |
| Coverage | Provides comprehensive coverage. Includes preventative care, hospital stays, prescriptions, and more. | Offers limited coverage for between 3-12 months. Covers unexpected illnesses and emergencies. | They are designed to cover additional costs your primary health insurance doesn’t cover. | It only covers worst-case scenarios, such as serious accidents. |
| Duration | Long-term. Typically renewable each year. | Short-term coverage that generally can’t exceed 12 months. | Depends on the policy—some last for weeks, months, or a year. | It lasts for at least a year but is renewable. |
| Costs | It can be more expensive due to comprehensive coverage. | Typically less expensive than major medical insurance but can still be pricey. | Cost can vary widely depending on the type of insurance chosen. | Premiums are low, but out-of-pocket costs are much higher. |
Eligibility Requirements For Major Medical Plans
Eligibility requirements for major medical plans can vary depending on the specific insurance provider, state regulations, and the type of plan you’re considering.
- Residency: You usually must be a legal resident of the state where you apply for insurance coverage. Some plans have restrictions on out-of-state coverage.
- Age: Most major medical plans cover individuals within a specific age range, from newborns to seniors. Some plans are tailored to different age groups. Medicare, for example, is only available for those 65 years and older or with a severe disability.
- Employment Status: Some major medical plans are offered through employers, and eligibility might be tied to your employment status (full-time, part-time, etc.) More often than not, only full-time employers can get employer-sponsored plans; even then, not all employers offer this kind of insurance.
- Citizenship: Major medical plans are available only to U.S. citizens, U.S. nationals, or lawfully present immigrants. Undocumented immigrants might have limited access to certain types of coverage.
- Income: Some plans, especially those offered through government programs like Medicaid or the Children’s Health Insurance Program (CHIP), have income-based eligibility requirements.
- Enrollment period: Many insurance plans have designated open enrollment periods during which you can enroll or change your coverage. Outside of this period, you may need to qualify for a Special Enrollment Period (SEP) due to certain life events, such as marriage, the birth of a child, or loss of other coverage.
How To Enroll In A Major Medical Plan
Enrolling in a major medical plan can vary based on different circumstances, such as enrolling through an employer, the Health Insurance Marketplace, or a government program like Medicaid or Medicare. Here’s a general overview of how someone can enroll in a major medical plan:
Health Insurance Marketplace
Visit the Healthcare.gov website during the Open Enrollment period. You can enroll during that time if you qualify for a Special Enrollment Period (SEP) due to a life event.
- Create an account on the marketplace if you don’t already have one.
- Provide personal and financial information to determine eligibility for premium tax credits or other subsidies.
- Browse and compare available health insurance plans based on coverage, costs, and networks.
- Select a plan that meets your needs and budget, and complete the enrollment process online.
Employer-Sponsored Health Insurance
The enrollment process usually occurs during an open enrollment period. You’ll receive information about the available plans, coverage options, and costs from your employer’s HR department. You can choose a plan that suits your needs and enroll during the designated enrollment period.
Medicare
Eligibility for Medicare is automatic at age 65 for those receiving Social Security benefits. But you can also enroll during the Initial Enrollment Period (IEP) around your 65th birthday. You can apply for Medicare online through the Social Security Administration’s website, call their toll-free number, or visit your local office in person.
Our experts at Enhance Health can help you compare various Medicare plans available. We can guide you through enrollment, help you complete the necessary paperwork, and meet enrollment deadlines.
Medicaid
This state and federally-funded program provides health coverage to eligible low-income individuals and families. Eligibility requirements vary by state, and you can apply for Medicaid coverage directly through your state’s Medicaid agency.
Get In Touch With An Insurance Broker
When enrolling in any health insurance plan, it’s vital to carefully review the plan details, coverage options, premiums, deductibles, copayments, and any other relevant information. You must also consider your healthcare needs and budget. Consult an insurance representative for guidance to determine the best option.
How To Change A Major Medical Plan
Depending on the health insurance you want and need, there are different rules regarding when you can change your major medical plan.
- The easiest time to change your health insurance plan is during the Open Enrollment Period. Every fall, both the ACA Health Insurance Marketplace and most employers have an Open Enrollment period.
- If you experience a qualifying life event like moving to a new state, changes in your income, or changes in your family size (for example, if you marry, divorce, or have a baby), you can make changes to your coverage outside of the Open Enrollment period. If enrolled, you can apply to Medicaid or Chip programs anytime or change your coverage.
- If enrolled in Medicare, you can change your coverage during the Annual Enrollment Period (October 15 to December 7 every year).
Conclusion
Major medical insurance is a comprehensive form of insurance covering various healthcare needs. This includes hospitalization, doctor’s visits, medications, and preventative care.
There are a few different types of major medical insurance that require different eligibility criteria. When deciding which plan to use, ensure you understand the plan type, eligibility criteria, coverage offerings, location restrictions, and personal characteristics.
One of the easiest ways to ensure you have all your bases covered is to consult with Enhance Health. We provide the tools, expertise, and support to make the insurance process easier.
Contact us today to help you find your perfect health insurance plan.
