Comprehensive Major Medical Benefits Policy Features
Comprehensive major medical benefits policy features typically include:
- Essential health benefits: Covered services must include the ten essential health benefits (EHBs) as defined by the Affordable Care Act (ACA), including hospitalization, outpatient care, preventive care, prescription medication, mental health and addiction counseling, laboratory services, emergency services, pediatric care, maternity and newborn care, and rehabilitative and habilitative services.
- Coverage for a wide range of medical services: Comprehensive major medical policies typically cover a wide range of medical services, including preventive care, physician visits, diagnostic tests, hospital stays, surgery, prescription drugs, and mental health services.
- A deductible: A deductible is the amount of money you must pay out-of-pocket for covered medical services before your insurance will start paying. Deductibles can vary widely from plan to plan.
- Copayments and coinsurance: Copayments are fixed amounts of money that you pay for certain covered medical services, such as a doctor’s visit or prescription drug. Coinsurance is a percentage of the cost of covered medical services that you pay after you have met your deductible. Coinsurance rates can also vary widely from plan to plan.
- Out-of-pocket maximum: An out-of-pocket maximum is the most you will have to pay for covered medical services in a given year. After you have reached your out-of-pocket maximum, your insurance will pay 100% of the cost of covered services. Out-of-pocket maximums can also vary widely from plan to plan.
In addition to these basic features, comprehensive major medical benefits policies may also offer other benefits, such as:
- Preventive care coverage: Many comprehensive major medical policies cover preventive care services, such as annual checkups and immunizations, at no cost to the member.
- Prescription drug coverage: Comprehensive major medical policies typically cover prescription drugs, but the level of coverage can vary from plan to plan. Some plans may have a formulary, which is a list of covered drugs. Other plans may allow members to fill prescriptions at any pharmacy, but may charge higher copayments or coinsurance for non-formulary drugs.
- Mental health and addiction coverage: Comprehensive major medical policies typically cover mental health and addiction services, but the level of coverage can vary from plan to plan. Some plans may have limits on the number of sessions that are covered or the type of services that are covered.
- Out-of-network coverage: Comprehensive major medical policies typically cover some services that are provided by out-of-network providers, but you may have to pay higher copayments or coinsurance for these services.
- Vision and dental coverage: Some comprehensive major medical policies offer vision and dental coverage, but this coverage is not required by the ACA.
It is important to note that comprehensive major medical benefits policy features can vary widely from plan to plan. When choosing a plan, it is important to carefully review the plan’s summary of benefits and coverage (SBC) to understand what services are covered and how much you will have to pay for those services.
