The basics of major medical insurance
At DFW Direct Insurance, we offer a wide array of brand name major medical plans from qality companies like Aetna, Assurant, Blue Cross Blue Shield of Texas, Humana and Goldenrule United Healthcare.
Major medical health insurance is typically characterized by a system of “you pay first, they pay later”. These plans typically cover only major hospital and medical expenses above a certain deductible. You pay out of pocket for everything else (other than routine wellness visits), such as routine doctor visits and prescription drugs. For example, if you have a $10,000 deductible and you have surgery that costs $5,000, you must pay for that surgery – unless you've already paid $10,000 toward covered medical expenses this year. Some plans also featue low copays for doctor's office sickness visits that are not subject to the annual dedictible.
The majority of major medical health plans cover expenses for hospital stays, surgery, intensive care, diagnostic X-rays and lab tests only after your deductible is satisfied.
If you choose this kind of plan, your deductible could range from $500 to $10,000, depending on what benefits are offered in the plan. It depends on the type of plan you purchase and the range of coverage.
Also, with most plans, after you have satisfied your annual deductible. your plan will cover about 70% to 90% of your medical expenses for the reminder of the calendar year. So you would still have a 10% to 30% portion called coinsurance that you would be responsible for paying.
By law, all true major medical plans have a maximum dollar amount of coinsurance, also called a stop loss. Most carriers have set the maximum amount of coinsurance at $3,000 to $5,000.
Your total maximum out-of-pocket is your annual deductible plus your maximum coinsurance amount.
Once an individual hits the annual stop-loss, or annual max out-of-pocket, all coverage goes to 100% for the remainder of the calendar year with most plans.
By law, true major medical plans are no longer allowed to have any annual or lifetime maximum benefit limits.
Often major medical plans are sold in combination with supplements that cover the annual deductible in case of an unforseen accidental injury or a critical illness such as cancer.
Also, if your major medical health plan qualifies under IRS definitions as a high-deductible health plan, you can open a health savings account (HSA), in which you can put aside money, tax-deferred, to pay for medical expenses.
In addition, prescription drug coverage within major medical health plans often carries a separate deductible you must meet before you get the prescrtion drug copayment benefit.
Major medical plans are available both on and off of the Federal Healthcare Marketplace.
To find out your best options, call to speak to one of our friendly agents at DFW Direct Insurance. Our lines are answered 7 days a week at 1-866-999-1215.