What Do Major Medical Policies Typically Cover?

Major medical policies provide comprehensive health coverage designed to protect individuals from the substantial financial burden associated with serious illness or injury. These plans offer broad coverage for a wide array of healthcare services, ensuring access to necessary medical care without exposing individuals to catastrophic out-of-pocket expenses.

Core Healthcare Services Covered

Major medical policies typically encompass a comprehensive set of services, largely influenced by the Affordable Care Act’s (ACA) Essential Health Benefits. These benefits ensure that plans offered in the individual and small group markets provide fundamental coverage. While specific plan details vary, certain core categories of services are almost universally included to address diverse medical needs.

Ambulatory patient services, often referred to as outpatient care, cover visits to doctors and other healthcare professionals. This includes routine check-ups, specialist consultations, and various procedures performed outside of a hospital inpatient setting.

Emergency services are also a standard inclusion, covering care received in an emergency room for sudden and severe medical conditions. These services are covered regardless of whether the patient is ultimately admitted to the hospital.

Hospitalization coverage extends to inpatient care, encompassing stays for surgery, serious illnesses, or recovery from injuries. This includes room and board, nursing care, and other services provided during an inpatient admission.

Maternity and newborn care provide comprehensive services throughout pregnancy, childbirth, and postpartum care for both the mother and the newborn.

Mental health and substance use disorder services cover diagnosis and treatment for behavioral health conditions, including counseling, psychotherapy, and other behavioral health treatments.

Prescription drugs are also typically covered, though plans may have different tiers and formularies that dictate coverage levels and costs for various medications. Formularies are lists of covered drugs, often categorized by cost-sharing levels.

Rehabilitative and habilitative services help individuals acquire, maintain, or improve skills necessary for daily functioning, often following an injury, disability, or chronic condition. This can include physical therapy, occupational therapy, and speech therapy.

Laboratory services, such as blood tests, urinalysis, and other diagnostic screenings, are covered to aid in the diagnosis and monitoring of health conditions.

Preventive and wellness services, along with chronic disease management, focus on maintaining health and preventing illness. This includes immunizations, screenings, and regular check-ups, often covered without cost-sharing. Pediatric services ensure that children receive necessary care, including oral and vision care, addressing their unique healthcare needs from infancy through adolescence.

Financial Responsibilities of the Insured

Understanding the financial aspects of a major medical policy helps manage healthcare costs. Beyond the monthly premium, individuals typically share the cost of covered medical services through deductibles, copayments, coinsurance, and out-of-pocket maximums.

A deductible represents the amount an individual must pay for covered healthcare services before their insurance plan begins to share costs. For example, if a policy has a $2,000 deductible, the insured is responsible for the first $2,000 of eligible medical expenses incurred within a policy year. After meeting the deductible, insurance coverage for subsequent services often begins.

Copayments, or copays, are fixed dollar amounts paid for certain covered services at the time of care, such as a $30 copay for a doctor’s office visit or a $15 copay for a prescription drug. Copays generally do not count towards the deductible but do contribute to the out-of-pocket maximum. They provide a predictable cost for routine services.

Coinsurance is a percentage of the cost of a covered service that the insured pays after the deductible has been met. For instance, a plan might feature 20% coinsurance, meaning the individual pays 20% of the cost for a service, and the insurer pays the remaining 80%. This cost-sharing continues until the annual out-of-pocket maximum is reached. Coinsurance is common for services like hospital stays, surgeries, or specialist visits.

The out-of-pocket maximum is a protective cap on the total amount an individual will pay for covered medical expenses within a policy year. This limit includes payments made towards deductibles, copayments, and coinsurance. Once this maximum is reached, the insurance plan typically covers 100% of all additional covered services for the remainder of the year. For 2025, the out-of-pocket limit for Marketplace plans cannot exceed $9,200 for an individual and $18,400 for a family.

Services Not Typically Covered

While major medical policies offer broad coverage, certain services are generally excluded or have limited coverage. These non-covered services are often elective, experimental, or not directly related to the treatment of illness or injury.

Cosmetic procedures, such as elective plastic surgery or certain dermatological treatments, are typically not covered unless deemed medically necessary. For example, reconstructive surgery following an accident or mastectomy might be covered, but procedures solely for aesthetic enhancement are usually excluded. Experimental treatments and off-label drug uses are also commonly not covered, as insurers often require established evidence of effectiveness and safety. This includes therapies or medications that have not received full regulatory approval for a specific condition.

Long-term care, such as nursing home care or extended home health aide services for chronic conditions, is generally not included in standard major medical policies. These services, which address custodial needs rather than acute medical treatment, often require separate long-term care insurance policies. Elective procedures that are not medically necessary, such as certain fertility treatments or sterilization reversals, may also be excluded, though coverage for some fertility services can vary by plan or state requirements.

Many standard major medical plans do not cover routine adult dental services, vision care (beyond medically necessary eye exams), or hearing aids. These benefits are often offered through separate, specialized insurance plans. Additionally, certain alternative therapies like acupuncture or chiropractic care may have limited coverage or require specific medical necessity justifications.

Navigating Your Specific Policy

Understanding the specifics of an individual major medical policy is important. Policy details can vary significantly, even among plans that appear similar. Locating and interpreting your policy documents provides precise information regarding coverage, limitations, and financial responsibilities.

The Summary of Benefits and Coverage (SBC) is a standardized document designed to help individuals compare health plans. This easy-to-read summary outlines covered services, limitations, exclusions, and cost-sharing amounts like deductibles, copayments, and coinsurance. It also includes coverage examples to illustrate how the plan might pay for common medical events, such as pregnancy or managing a chronic condition.

Individuals should review their SBC, which is typically provided by the insurer during enrollment, renewal, or upon request. This document offers a snapshot of the plan, including information on in-network versus out-of-network costs and annual out-of-pocket limits. For more detailed information, the complete policy document provides the full terms and conditions of coverage.

These documents detail specific coverage limits for certain services, such as a maximum number of therapy sessions or days of inpatient rehabilitation. Exclusions, which are services not covered by the plan, are also detailed within the policy. Understanding the plan’s formulary, or list of covered prescription drugs, and any network restrictions, like those found in Health Maintenance Organizations (HMOs) or Preferred Provider Organizations (PPOs), is also important.