Overview of Major Medical Health Insurance

Critical medical health insurance is a type of medical insurance that covers expenses related to serious illness or hospitalization.

Primary health insurance is the term historically used to describe comprehensive health plans that cover the most necessary care. Since the implementation of the Affordable Care Act, the term “minimum essential coverage” has been used frequently, although they are not entirely interchangeable.

The minimum essential coverage is the coverage you must have between 2014 and 2018 to avoid ACA penalties for not having coverage. While the ACA’s individual mandate still exists, the federal penalty for not having minimum basic coverage was removed in late 2018 (some states have their own penalties).

But the concept of minimum essential coverage is still important because several qualifying life events will only trigger a special enrollment period (those who are insured outside of the annual public enrollment period) if you already have valid minimum essential coverage prior to the qualifying event. opportunity).

With the exception of short-term health insurance (discussed below), all major health insurance plans count as minimum basic coverage.

“Real” Health Insurance

In layman’s terms, primary health insurance is what people usually think of as “real” health insurance. It does not include limited benefit plans, defined indemnity plans, dental/vision plans, accident benefits, shared ministry plans or critical illness plans, which are not regulated by the Affordable Care Act.

Major medical plans usually have a fixed amount or deductible that the patient is responsible for paying. Once the deductible is paid, the plan typically pays for most of the remaining cost of care; coinsurance is typically available after the deductible is reached, which includes the patient paying a percentage of the bill (20% is a common amount) and the remainder covered by Insurance company pays.

Once the patient’s total share of in-network expenses (including deductibles, coinsurance, and any applicable co-payments) reaches the plan’s maximum out-of-pocket limit, the health plan will pay the patient 100% of the remaining in-network covered medical expenses for the year .

By 2022, all ACA-eligible plans must cap in-network out-of-pocket costs (for essential health benefits) to no more than $8,700 for individuals and $17,400 for households. By 2023, the cap on out-of-pocket expenses will increase to $9,100 for individuals and $18,200 for families.

The main medical plan is no Fully ACA compliant (i.e. grandmother and grandfather plans) can have higher out-of-pocket limits, but it’s very unusual for even these plans to have unlimited out-of-pocket costs (note that there is no Medigap traditional health insurance supplement, for There is no cap on out-of-pocket costs, but this is not a model that private insurance typically follows).

Major medical plans can be very robust with low out-of-pocket costs, but they also include HSA-compliant high-deductible health plans, as well as ACA-defined catastrophic plans.

Major Medical and Plans no primary medical insurance

There is no official definition of primary health insurance. It is generally accepted that a plan with minimum essential coverage (as defined) provides primary health coverage. But even this isn’t always true. By definition, all employer-sponsored plans are minimum essential coverage, but some employers choose to offer stingy plans that cannot be considered primary health coverage.

There are no hard and fast rules that apply to minimum basic coverage in terms of what a plan must cover. ACA compliance programs are more clearly defined, but ACA compliance programs are only a subset of minimum essential coverage (and primary health coverage).

Specifically, grandfather and grandmother health plans are primary health insurance, the minimum essential coverage, but they don’t need to cover everything an ACA-compliant plan must.

Even for ACA compliant plans, the rules for large group plans differ from individual and small group plans. For example, large group plans do not need to cover the ACA’s basic health benefits, while individual and group plans do. But they all count as minimum basic guarantees.

Large group plans will also be considered primary health insurance in almost all cases, although as noted above, some large employers offer “skinny” health plans to circumvent the more severe penalties employers demand. These “slim down” policies do not provide comprehensive coverage and cannot be considered primary medical coverage. If employers offer these plans, they will still be subject to employer-mandated penalties, but if they don’t offer coverage at all, they will likely face lighter penalties.

On the other hand, limited benefit plans, defined compensation plans, accident benefits, dental/vision plans, and critical illness plans are very different. They are usually designed to supplement a major medical plan, not as a person’s main insurance. So they will help cover some of the out-of-pocket costs a person may incur with a major medical plan, or provide some coverage for things not covered by a major medical plan, such as dental and vision care, or some expenses related to having to travel far away for medical care . But a person who is completely reliant on one of these plans — without a major medical plan — will be seriously underinsured for serious illness in the event of an injury.

Premiums for exceptional benefit plans tend to be much lower than major health insurance premiums, but that’s because they have far less coverage. (Remember, the ACA’s subsidized premiums make primary health insurance more affordable for millions of people than having to pay full price. And employers cover most of the cost of employer-sponsored health insurance.)

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Some states consider short-term health plans, primary health insurance

Short-term health insurance is also not regulated by the ACA, but it is not considered an exceptional benefit. It differs from the exception benefit in that some states apply their respective primary Medicare laws to short-term plans (however, some states make a clear distinction between primary and short-term coverage).

While short-term health insurance is considered primary health insurance by some state regulators, and is sometimes referred to as “short-term primary medical care,” it has never been considered minimum essential coverage.

Short-term health insurance plans are closer to “real” health insurance than exception benefits. They are similar in many respects to the grandfather and grandmother major medical plans that were sold before the ACA was enacted and implemented, and they are still available for sale today (unlike the grandfather and grandmother plan, which has not been sold since 2010, 2013).

In 2018, the Trump administration relaxed short-term plans, allowing them to have an initial term of up to 364 days and a total term (including renewals) of up to 36 months. However, states can implement stricter rules, and many have already done so, meaning there are many whose short-term plans are limited to shorter deadlines.

When a short-term plan can last up to 36 months and is comparable to some grandfather and grandmother health plans that are still in effect, it’s easy to see how it could be considered primary health insurance. Conversely, exception benefits are never considered primary health insurance.

Where can you get primary health insurance?

The insurance you get from your employer may be your primary health insurance. If you work for a large employer, they must provide minimum value insurance to comply with the ACA’s employer requirements. The plan that offers the lowest value is also usually considered primary health insurance because it’s fairly comprehensive.

As noted above, a small number of large employers—especially those with a low-wage, highly mobile workforce—choose to offer plans that offer no minimum value and cannot be considered primary health insurance. These employers face fines (though probably smaller than if they don’t offer coverage at all), but their employees have the option of getting primary health insurance on the exchange if their income can get a premium subsidy to qualify them.

Any plan you buy on an exchange in your state will be considered primary health insurance. Over-the-counter plans (purchased directly from an insurance company, not from your state’s health insurance exchange) are also major medical plans, as long as they are fully ACA compliant. Since 2014, all new major medical plans must meet ACA standards, including those sold off exchanges. But supplemental insurance, limited benefit plans, and short-term plans can still be sold off-exchange; these plans are not regulated by the ACA and are not considered primary health insurance.

If you buy insurance on an exchange in your state, you may be eligible for a premium subsidy to offset the cost of purchasing primary health insurance. Subsidy eligibility is based on income and extends to the middle class (at the lower end of the income scale, you cannot get the subsidy if your income is below the poverty line or if you qualify for Medicaid).

Medicare and most Medicaid plans also count as minimum essential coverage, so can be considered a major medical plan (some people qualify for limited benefit Medicaid coverage—for example, Medicaid only covers pregnancy-related services—this is not considered a minimum basic insurance or primary medical insurance).

Grandmother and grandfather health plans count as primary health insurance, although they can no longer be purchased. However, if you still have coverage from these plans, you’ll get minimum basic coverage (and primary health coverage). Grandfathering plans can remain in effect indefinitely, as long as they are not substantially changed. Grandmother-level plans are currently available until December 31, 2022 (the deadline may be extended again) at the discretion of states and insurers.


There is no official definition of the term “major health insurance.” But it usually refers to comprehensive health insurance, which provides a solid safety net in the event of a serious illness or injury. Major health plans can have high deductibles and out-of-pocket costs, even if they do offer comprehensive coverage. Most plans that provide minimum basic coverage (a term as defined by the ACA) can be considered primary health coverage.

VigorTip words

Having primary health insurance is essential; it gives you peace of mind and protects your health and finances in the event of a serious illness. Primary health insurance comes from a variety of sources, although most people get it from their employer, the government (Medicaid and Medicare), or as a self-purchased plan.

If your employer does not provide coverage and you are ineligible for Medicare or Medicaid, then you must purchase coverage at your state’s health insurance exchange to ensure you have true primary health coverage. You can start with HealthCare.gov; if your state uses its own registration platform, HealthCare.gov will guide you there.