Enhance Health

What Is Major Medical Insurance?

Securing comprehensive financial protection against soaring healthcare costs is vital. This is where Major Medical Insurance plays a role. 

Major medical insurance, also known as comprehensive health insurance or major medical coverage, is the most popular type.

It covers various medical expenses, including routine and unexpected medical needs, and offers comprehensive health protection. Major medical insurance offers individuals and families medical care without significant financial burdens.

This article explores the types of comprehensive health insurance, its cost structure, and its benefits. 

Overview Of Major Medical Insurance

Major medical insurance offers various healthcare services, including preventive care, routine doctor visits, emergency services, surgeries, and hospitalizations. 

The extent of the coverage is determined by the policy’s terms and the selected plan. Major medical insurance aims to cover significant and unforeseen medical events and may involve cost-sharing like deductibles, copayments, and coinsurance. 

Once the deductible is met, the insurance policy usually covers a significant portion of the remaining costs. Some major medical plans have a maximum out-of-pocket limit Once this limit is reached, the insurance company covers all eligible expenses for the rest of the policy year. 

Major medical insurance is essential for individuals and families who want comprehensive coverage and financial protection against the potentially unaffordable costs of extensive medical treatments and hospitalizations.

Types Of Major Medical Insurance

There are several major medical health insurance plans that offer varying coverage levels and cost structures. These include plans under the following types of insurance:

ACA Marketplace Health Insurance 

The ACA, also known as Obamacare, allows individuals to shop for healthcare plans within their budget that align with their needs while ensuring that all ten essential benefits are covered. 

These healthcare plans range in cost and type (Bronze, Silver, Gold, and Platinum), each covering a higher or lower percentage of costs. Those who apply for these plans may also qualify for cost assistance, like cost-sharing reductions (CSRs) and premium tax credits. 

Employer-Sponsored Health Insurance 

This is health insurance that employees are offered by their employer. Your job and location determine the type of health insurance, and it is usually only available to full-time employees. You’ll need to speak to your employer directly to learn more about this type of health insurance. 


COBRA, or Consolidated Omnibus Budget Reconciliation Act, is a type of health insurance that can kick in after job loss. It extends the same healthcare plan that was available to you as an employee for a period between 18 and 36 months. 

However, it does not apply if you have been fired for gross misconduct. In addition, the healthcare plan you were on must still be active for current employees in order for you to receive COBRA coverage.

Medicaid And Medicare 

  • Medicaid is a state and federally-funded program that provides health coverage to people with low income and people with disabilities. Eligibility and benefits, like with other plans, can vary by state.
  • Medicare is a federal program that provides health coverage for individuals 65 and older or under 65 with certain disabilities. It has different parts that cover hospital stays, medical services, and prescription drugs.

Student Health Plans

For some students, choosing a student health plan provided by a college or university may be their best option. These are usually best for students who have aged out of their parents’ plans or are living in an area where the plan does not cover them. 

These plans typically last for the academic year, but some universities offer extended plans that cover students during breaks. 

Benefits Of Major Medical Insurance

Major medical health insurance offers various benefits, making it a valuable option for individuals and families seeking comprehensive healthcare coverage. 

  • Comprehensive Coverage: Major medical insurance offers broad coverage for various medical services, including hospital stays, surgeries, doctor visits, prescription medications, preventive care, and more.
  • Emergency Care: Major medical insurance covers emergency medical services regardless of whether they are received within the insurance network.
  • Preventive Services: Many major medical insurance plans include coverage for preventive services at no additional cost to the policyholder. 
  • Prescription Drug Coverage: Major medical insurance plans often provide coverage for prescription drugs as part of the core coverage or as an optional add-on.
  • Network Discounts: Insurance companies typically have networks of healthcare providers with whom they have negotiated lower rates.
  • Out-of-Pocket Limits: Once a policyholder reaches this limit within a policy year, the insurance company covers 100% of eligible medical expenses. 
  • Flexibility: Major medical insurance offers different plans to cater to various needs.
  • Routine Healthcare: Beyond emergencies, major medical insurance covers routine healthcare services like doctor visits, lab tests, and screenings. 
  • Coverage for Chronic Conditions: People with chronic health conditions benefit from continuous coverage and access to necessary treatments and medications.

Cost Structure Of Major Medical Insurance

Major medical insurance costs vary depending on where you live, your age, individual vs. family coverage, and your chosen plan category. However, some of the costs associated with these plans include: 

  • Premium: The premium is the regular payment policyholders make to the insurance company in exchange for coverage. It’s typically paid monthly. Premiums can vary widely based on factors such as the level of coverage, the policyholder’s age, location, family size, and the insurance company’s pricing.
  • Deductibles: The initial amount a person must pay out of their pocket for covered medical expenses before insurance coverage kicks in.
  • Coinsurance: The percentage of medical costs a person shares with their insurance company after meeting the deductible.
  • Copayments: Fixed, predetermined fees individuals pay for specific medical services or prescriptions, usually at the time of service.
  • Out-of-pocket maximums: The highest amount an individual must pay for covered medical expenses during a policy period, after which the insurance company covers all costs.
  • Network Restrictions: Some major medical insurance plans have preferred networks of healthcare providers. If policyholders use in-network providers, their out-of-pocket costs are generally lower than if they go out of network. 

Eligibility Requirements For Major Medical Insurance

Eligibility requirements for major medical insurance can vary depending on the insurance provider, the specific policy, and the country or region’s regulations. 

  • You must be a U.S. citizen or legal resident.
  • People currently incarcerated are not eligible to enroll in a major medical insurance plan (through the ACA). 
  • You can’t purchase a plan through the ACA Marketplace if enrolled in Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), or have employer-sponsored health insurance.
  • You must enroll during the open enrollment period unless you have a qualifying life event. 
  • Geographic location will impact which plans you can apply for.

Choose The Right Major Medical Insurance Plan for You

You must consider several factors when choosing the right major medical insurance plan. This includes your needs and your family’s needs. If you know that you’ll need to frequently visit the doctor’s office and have any planned surgeries or procedures, you will need a higher degree of coverage. 

You’ll also want to consider premium costs. This is the monthly cost you pay for having the plan. 

Equally important is the network you have access to. Ensure your preferred doctors, specialists, and hospitals are in the plan’s network. Going out of network can be very expensive. 

Other aspects you may want to consider are: 

If you’re still unsure which plan to choose, consult with the experts at Enhance Health. We’re here to walk you through your options, answer any questions you have, and help you choose the right major medical insurance plan for your needs. 

How To File A Claim For Major Medical Insurance

Filing a claim for major medical insurance involves several steps to ensure you receive reimbursement for eligible medical expenses. You can contact your insurance company or a knowledgeable insurance representative to guide you. 

  1. Collect documentation: Obtain an itemized bill from the healthcare provider that includes details of the services provided, dates of service, and costs. 
  2. Complete claim forms: If your insurance provider requires specific claim forms, obtain them from the insurance company’s website or contact their customer service. 
  3. Submit claims: Submit your claim forms and supporting documents to your insurance provider. This can often be done electronically through their online portal, email, or regular mail. Keep copies of all submitted documents for your records.
  4. Wait for processing: The insurance company will review your claim and the supporting documents. This may take some time, so be patient.
  1. Follow-up:  If you don’t receive confirmation of your claim within a reasonable time or have questions about the process, contact the insurance company’s customer service for updates.
  1. Claim adjudication: The insurance company will evaluate your claim based on your policy’s terms and the provided documentation. They may approve the claim in full or partially or deny it based on their assessment.
  1. Reimbursement or Explanation of Benefits (EOB): If your claim is approved, you’ll receive reimbursement for the eligible expenses. If the claim is partially approved or denied, you’ll receive an Explanation of Benefits (EOB) that outlines how the claim was processed and any amounts not covered.


Major medical insurance is crucial for individuals and families to manage healthcare expenses and ensure access to essential medical services. It provides a safety net that helps ease the financial burdens associated with medical care.

There are many factors to consider when choosing a major medical cover, and the process can feel overwhelming.

If you still need to decide which major health plan to choose, get in touch with the experts at Enhance Health. We’re here to walk you through the process and answer any questions regarding the benefits you qualify for. Our professional insurance representatives are here to help you pick a health insurance plan that meets your needs. 

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