Major medical plans typically cover a comprehensive array of healthcare needs, including doctors’ visits, drugs and hospital care. These benefits can be delivered in several different ways:
These major medical plans typically have a deductible – the amount you pay before the insurance company begins paying benefits. After your covered expenses exceed the deductible amount, benefits usually are paid as a percentage of actual expenses, often 80 percent. These plans usually provide the most flexibility in choosing where to receive care.
PPO: Preferred Provider Organization
In these major medical plans, the insurance company enters into contracts with selected hospitals and doctors to furnish services at a discounted rate. As a member of a PPO, you may be able to seek care from a doctor or hospital that is not a preferred provider, but you will probably have to pay a higher deductible or co-payment.
HMO: Health Maintenance Organization
These major medical plans usually make you choose a primary care physician (PCP) from a list of network providers. Your PCP is responsible for managing all of your healthcare. If you need care from any network provider other than your PCP, you may have to get a referral from your PCP to see that provider. You must receive care from a network provider in order to have your claim paid through the HMO. Treatment received outside the network is usually not covered, or covered at a significantly reduced level.
POS: Point of Service
These major medical plans are a hybrid of the PPO and HMO models. They are more flexible than HMOs, but do require you to select a primary care physician (PCP). Like a PPO, you can go to an out-of-network provider and pay more of the cost. However, if the PCP refers you to an out-of-network doctor, the health plan will pay the cost.
FAQ & Questions
Questions? We’ve got you covered.
Will there be a penalty for not having minimum essential coverage?
Before, consumers would pay a penalty if they were not enrolled in a health plan. Starting Jan. 1, 2019, that tax penalty will be reduced to nothing. If you don't have major medical health insurance for the 2019 coverage year, you'll be on your own for major health care costs, but you won't be penalized at tax time.
What is disability income?
This coverage provides for weekly or monthly benefit payments while you are disabled after a covered injury or sickness.
What is long-term care insurance?
This policy usually pays for skilled, intermediate and custodial care in a nursing home, as well as care in other settings, such as the home, adult day care center or assisted living facility. The policy usually pays a fixed amount per day while a person is receiving care.
What is Medicare supplemental coverage?
The federal Medicare program pays most medical expenses for people 65 or older, or for individuals under 65 receiving Social Security disability benefits. However, Medicare does not pay all expenses. As a result, you may want to buy a Medicare supplement policy that helps pay for certain expenses, including deductibles not covered by Medicare.
What is a Medigap policy?
A Medigap policy is health insurance sold by private insurance companies to fill the "gaps" in Original Medicare Plan coverage. Medigap policies help pay some of the health care costs that the Original Medicare Plan does not cover. If you are in the Original Medicare Plan and have a Medigap policy, then Medicare and your Medigap policy will each pay their share of covered health care costs.
How do I know if I’m eligible for a Medigap policy?
To buy a Medigap policy, you generally must have Medicare Part A and Part B. You are guaranteed the right to buy a Medigap policy if you are in your Medigap open enrollment period or covered under a Medigap protection. You might not be able to buy a Medigap policy if you are in a Medicare Advantage Plan, have Medicaid, already have a Medigap policy or are under the age of 65 and you are disabled or have End-Stage Renal Disease.
When should I apply for a Medicare supplement policy?
When you elect coverage under Medicare Part B either due to age or disability, you have a 6-month open enrollment for a Medicare supplement policy, which guarantees you coverage with a plan and company of your choice. You may choose from a list of standardized plans – listed as A through L. If you do not purchase a plan within your 6-month open enrollment, any company you apply to can deny coverage based on your health conditions. There are some limited additional open enrollment periods available to some persons disenrolling from a Medicare HMO.
Do Medicare supplement policies cover prescription drugs?
After January 1, 2006, Medicare supplement policies may not include prescription drug coverage. Those that currently have a policy with prescription drug coverage may opt to keep that coverage or switch to the new Medicare prescription drug plans after January 1, 2006.
What are MedicareAdvantage plans?
MedicareAdvantage plans (formerly known as Medicare+Choice plans) are private managed care plans that provide the standard Medicare benefits plus additional supplemental benefits for a monthly fee. These plans may include prescription drug coverage, even after January 1, 2006, if the benefits are similar to the new Medicare benefit. MedicareAdvantage participants may even receive a subsidy for their prescription drug benefits in most cases.
What are Medicare Select plans?
Medicare Select plans provide supplemental benefits through a network of providers similar to a Preferred Provider Organziation (PPO). If the participant received care for a provider under contract with the insurer the cost will be lower.
What isn’t covered in my Medicare that is covered by Medigap?
You may want to buy a Medigap policy because Medicare does not pay for all of your health care. There are “gaps” or “out-of-pocket” costs that you must pay in the Original Medicare Plan. Some examples of costs not covered are hospital stays, skilled nursing facility stays, blood, Medicare Part B yearly deductible and Medicare Part B covered services. A Medigap policy will not cover long-term care, vision or dental care, hearing aids and private-duty nursing.
What are my rights with Medigap?
You need to know that under Federal law, you have rights and protections regarding your Medigap coverage. These include your right to buy Medigap coverage, protections if you lose or drop your health care and your protections for people with Medicare under the age of 65. You should know it is illegal for anyone to pressure you into buying a Medigap policy, lie or mislead you to switch to another company or sell you a second Medigap policy when they know that you already have one. It is also illegal to sell you a policy that cannot be sold in your state. Call your State Health Insurance Assistance Program to better understand these rights and protections.
What is COBRA?
Under COBRA, if you leave your current job you have the option to continue your health care coverage for up to 18 months. You are required to pay the full premium yourself, even if your employer paid part of your premium while you were employed, and the employer may charge an additional, limited administrative fee.
You can find out more about COBRA continuation of group health benefits from the Federal Department of Labor Office of Employee Benefits Security Administration website.
To be an "eligible individual," you must meet all of the following criteria:
- You must have had 18 months of continuous creditable coverage, with at least the last day having been under a group health policy (coverage is considered continuous if it is not interrupted by a break of 63 or more consecutive days).
- You must have used up any COBRA group continuation coverage for which you were eligible. See the above section for information on COBRA.
- You must not be eligible for Medicare, Medicaid or a group health policy.
- You must not have other major medical health insurance.
- You must apply for health insurance for which you are deemed an "eligible individual" within 63 days of losing your prior coverage.
What is HIPAA?
HIPAA is the Health Insurance Portability and Accountability Act of 1996. It limits insurers' power to deny or delay claims, reduces your chances of losing existing coverage, makes it easier and less risky to switch health plans, and prohibits insurance discrimination based on health problems.
Key HIPAA Protections
- Non-Discrimination: In a group plan, the insurer may not apply different eligibility rules, offer different benefits, or charge a higher premium to any individual on the basis of certain "health factors" – health status, claims experience, medical history or genetic information.
- Guaranteed Issue: Insurers providing small group coverage must offer coverage to any small employer that applies, regardless of health status or prior claims experience of the employees.
- Guaranteed Renewability: Insurers may not cancel a health plan unless the beneficiary fails to pay the premiums or the insurer stops doing business in the market.
- Limits on Preexisting Condition Exclusions: Insurers may not exclude (refuse to cover) treatments and services related to medical conditions that existed before the beneficiary purchased the health plan for a period ofmore than 12 months. If the person has had continuous coverage prior to purchasing the new plan there can be no coverage exclusions.
Be prepared before you buy.
Look Closely For Changes
Don’t automatically renew the option you had before; many employers are making changes due to rising costs.
Take Advantage Of Wellness Incentives
Find out if your employer offers a wellness program that includes money-saving incentives for healthy behaviors such as exercising regularly or not smoking.
In addition to your health insurance coverage, you may be eligible to open a Flexible Spending Account (FSA) or a health savings account (HSA). And don’t forget about dependent care savings accounts.
Basic Hospital Expense Coverage
Covers a period of usually not less than 31 days of continuous in-hospital care and certain hospital outpatient services.
Basic Medical-Surgical Expense Coverage
Covers costs associated with a necessary surgery, including a certain number of days of in-hospital care.
Hospital Confinement Indemnity Coverage
Covers a fixed amount for each day that you are in a hospital.
Accident Only Coverage
Covers death, dismemberment, disability or hospital and medical care caused by an accident.
Specified Disease Coverage
Covers diagnosis and treatment of a specifically named disease or diseases, such as cancer.
Other Limited Coverage
You may purchase insurance covering only dental or vision or other specified care.