What is comprehensive health coverage? | healthinsurance.org (2024)

Ready to enroll? See how much you could save on coverage.

Home &gt Glossary &gt comprehensive coverage

What is comprehensive coverage?

Comprehensive coverage – when we’re referring to health insurance, as opposed to automobile insurance – refers to a health plan that provides broad coverage of a wide range of healthcare services such as physician visits, hospitalization, and emergency room visits. Covered care can be preventive or provided to treat injury or illness. Comprehensive health insurance coverage is also known as major medical health insurance.

All new individual/family and small-group major medical policies sold after January 1, 2014, must cover the ten essential health benefits outlined in the Affordable Care Act (ACA) with no annual or lifetime benefit caps.

Major medical plans that were in effect prior to March 23, 201 can still remain in effect, but can no longer be sold to new individuals or employer groups. And major medical plans that were in effect in the individual and small group markets prior to 2014 can still remain in effect in most states, although they also can no longer be sold. These grandfathered and grandmothered plans are considered comprehensive, but they are generally not as robust as post-2014 policies, and do not include all of the same consumer protections.

Other than comprehensive health coverage, what other type of health insurance options do I have?

Health insurance plans that are not ACA-compliant are still for sale in most states. These non-compliant plans include short-term medical (STM) plans, fixed-indemnity plans, and narrowly focused coverage such as accident plans and critical illness plans. In most cases, however, these plans are not designed to serve as stand-alone coverage (they’re supposed to be supplemental to a major medical plan, as opposed to taking the place of it), and in some cases, like direct primary care plans, health care sharing ministry plans and Farm Bureau plans in some states, they’re specifically not even considered insurance at all.

What’s the difference between comprehensive coverage and other types of health insurance?

Comprehensive coverage policies are typically more costly than limited-benefit plans, but they provide significantly more protection in the event of a medical claim. And with premium subsidies via the marketplace/exchange, comprehensive plans can end up being very inexpensive or even free, depending on the person’s income, age, and location (this is especially true for 2021 and 2022, thanks to the American Rescue Plan‘s subsidy enhancements).

The same is true of employer-sponsored coverage; even though it’s quite expensive overall, employers typically subsidize a significant portion of the premium, making it fairly affordable for employees to have coverage.

In contrast to comprehensive coverage, limited-benefit plans or supplemental policies may cover only specific conditions (e.g., cancer) or type of service (e.g., hospitalization), or have a dollar cap on coverage. These types of policies are not considered comprehensive, they are not minimum essential coverage, and they do not fulfill the ACA’s individual mandate if a consumer relies on them without any other coverage in place.

(While the ACA’s individual mandate is still officially in place, the associated federal tax penalty was eliminated effective with the 2019 tax year. The Internal Revenue Service (IRS) no longer imposes a penalty for individuals who do not have coverage, although DC and four states do impose a penalty on people who go without minimum essential coverage. And for people who experience a qualifying event and wish to enroll in a health plan outside of the annual open enrollment period, many situations require that the person already had minimum essential coverage in place in order to qualify for a special enrollment period. )

What types of health plans are considered comprehensive coverage?

Comprehensive coverage is provided by various types of health plans or policies:

  • Most employer-provided health plans (All employer-sponsored health plans are considered minimum essential coverage by definition, but large employers can still choose to offer skimpy plans and simply pay the employer mandate penalty if their employees end up qualifying for subsidized coverage in the marketplace instead. This is fairly rare, however, and most employer-sponsored plans do provide comprehensive coverage.)
  • ACA-compliant policy purchased in your state’s health insurance exchange/marketplace
  • ACA-compliant plan purchased off-exchange
  • Medicaid and CHIP plans (There are some exceptions with Medicaid; some people qualify for limited-benefit Medicaid coverage, which is not considered comprehensive coverage.)
  • Medicare (either Original Medicare or Medicare Advantage, although Original Medicare is typically combined with a Medigap plan and Part D plan in order to provide truly comprehensive coverage)

Be aware, however, that the term “comprehensive” in regards to health insurance is sort of like the term “natural” in regards to groceries. It’s not an officially defined term, and has no particular marketing rules associated with its use. So a short-term health insurance plan — which is not minimum essential coverage and not regulated by the ACA — could still use marketing materials that describe it as “comprehensive.” This is a buyer-beware situation, and it’s important to read the fine print and understand the terminology that is legally defined, such as essential health benefits and minimum essential coverage.

What does a comprehensive health insurance policy cover?

Since 2014, new comprehensive health insurance policies issued in the individual and small group markets must cover the ACA’s ten essential health benefits.

For large group plans (in most states, this means more than 50 employees, although there are four states where the limit is 100 employees), there are no particular benefit requirements other than preventive care, but plans are required to provide minimum value, which means they have to cover at least 60% of average costs and provide substantial coverage for inpatient care and physician services.

COVID-19 vaccines as preventive care: There is normally a waiting period of a year (after a service is newly added to the recommended preventive care list) before health plans must start to cover it at no charge – and even then, it only has to be added when the plan is renewed or a new policy takes effect. But an exception was made for COVID-19 vaccines:

Under the terms of the Coronavirus Aid, Relief, and Economic Security (CARES) Act, all private non-grandfathered health plans must offer coverage for COVID-19 vaccines, with zero cost-sharing, within 15 business days of the date the CDC’s Advisory Committee on Immunization Practices voted to add it to the list of recommended vaccines. This happened on December 13, 2020, so all comprehensive health plans in the U.S. are covering the cost of COVID-19 vaccines at this point.

Is comprehensive health insurance expensive?

Comprehensive (major medical plans) are more expensive than limited-coverage plans, but premium subsidies can bring down the price substantially, sometimes even resulting in free comprehensive health insurance. Even if you’re not eligible for a premium subsidy and have to pay full price for your coverage, a low-cost, limited-benefit option might not be a good deal in the long run. Insurance brokers are excellent resources to help you compare cost and value and find the option that makes the most sense for you (but you’ll want to make sure you work with a broker who is certified by the health insurance exchange in your state, to ensure that you’re being shown ACA-compliant plans and any subsidies for which you might be eligible).

Prior to the full implementation of the Affordable Care Act in 2014, there was a lack of transparency as to the benefits actually covered with any given health insurance policy. “Junk policies” with low prices and limited coverage led some consumers to believe they were protected against costs for illnesses and injuries when, in fact, the insurance companies had very limited liability – and consumers were stuck with big out-of-pocket bills. These plans are still available in most states, but if consumers shop in the health insurance marketplace in their state, they’ll avoid non-ACA-compliant plans and won’t inadvertently purchase sub-par coverage.

How much does comprehensive health coverage cost?

The overall cost of a health insurance policy includes premiums and cost-sharing.

A premium is an amount that people pay each month for health insurance coverage. A premium is the “cover charge” for having health insurance coverage. You are responsible for this expense whether or not you visit a doctor or use any other healthcare service.

Premiums vary significantly from plan to plan. According to the Kaiser Family Foundation (KFF), the 2020 average premium for employer-provided coverage for a single employee was $7,470. Of that total, the average worker share was $1,243 and the average employer share was $6,227 (these are annual amounts, so that works out to a little more than $100/month being payroll deducted for the average single employee).

KFF reported the average 2021 premium for marketplace individual plans by metal rating: $328/month for Bronze plans, $470/month for Silver plans, and $501/month for Gold plans. But those are before premium subsidies are added into the mix (you can think of premium subsidies as being sort of like the amount that employers pay to offset the cost that employees would otherwise have to pay for their employer-sponsored coverage).

In 2021, before the American Rescue Plan’s subsidy enhancements were applied, 86% of all marketplace enrollees nationwide were receiving premium subsidies, paid directly to their insurers on their behalf. While the average full-price premium amounted to $575/month, the average subsidy came to $486/month — covering the large majority of the average total premium.

And now that the American Rescue Plan (ARP) has made subsidies larger and more widely available, people are paying even less in after-subsidy premiums. For HealthCare.gov enrollees who have logged back into their marketplace account to activate their new ARP subsidies, the average after-subsidy premium for 2021 has dropped from $104/month to $62/month.

Cost-sharing is the patient’s portion of costs for healthcare services, therapy, or prescription drugs covered by their health insurance plan. The patient is responsible for paying cost-sharing amounts out-of-pocket. Cost-sharing is paid as a deductible, copayment, or coinsurance. KFF reported the average 2020 deductible for employer-provided coverage for a single employee was $1,644.

KFF also reported deductibles for marketplace plans: The average 2021 deductible was $6,921 for Bronze plans; $4,816 for Silver plans; and $1,641 for Gold plans, and $0 for Platinum plans (although Platinum plans are not available in many areas, and tend to be very expensive in terms of monthly premiums).

Related terms

  • ACA-compliant coverage
  • essential health benefits
  • limited-benefit plan
  • major medical health insurance
  • minimum essential coverage

Related articles

How to verify that your health plan is ACA-compliant

A growing number of marketers are pretending to sell 'Obamacare.' Before you buy, ask these five questions to make sure you're paying for the real deal.

How to buy health insurance today

Signing up for coverage today doesn't mean your coverage will be effective immediately. Here's what you need to know to get coverage in place ASAP.

Obamacare: the Affordable Care Act (ACA)

Sweeping health reform legislation delivered a long list of provisions focused on health insurance affordability, consumer protections.

Accident Insurance

Accident insurance is a type of insurance that pays cash benefits, up to a predetermined limit, if the policy holder experiences an accidental injury that’s covered by the plan. Accident insurance is designed to supplement major medical health insurance.

What is comprehensive health coverage? | healthinsurance.org (2024)


What is comprehensive health coverage? | healthinsurance.org? ›

Comprehensive health insurance coverage is also known as major medical health insurance. All new individual/family and small-group major medical policies sold after January 1, 2014, must cover the ten essential health benefits outlined in the Affordable Care Act (ACA) with no annual or lifetime benefit caps.

What is the meaning of comprehensive health insurance coverage? ›

Comprehensive health insurance coverage should include:

Preventative care: regular screenings, check-ups, and vaccinations. Hospital care: in-patient stays, surgery, medication, and hospital services. Emergency services: unexpected trips for emergency evaluation and treatment.

What is the meaning of comprehensive coverage? ›

What is comprehensive coverage? Comprehensive coverage helps cover the cost of damages to your vehicle when you're involved in an accident that's not caused by a collision. Comprehensive coverage covers losses like theft, vandalism, hail, and hitting an animal.

Why is having a comprehensive health insurance plan important? ›

A comprehensive health insurance program is important since it covers a wide range of services that most other health insurance policies do not. A comprehensive medical insurance policy covers all significant medical expenses. It is an important component of health maintenance because it is preventative in nature.

What is the difference between limited coverage and comprehensive coverage? ›

A limited plan is only going to cover a predefined amount per incident, while comprehensive will pay a significant percentage of your expenses. To put this into perspective, say you buy a $80 limited plan rather than a $150 comprehensive plan.

What is an example of comprehensive coverage? ›

Comprehensive covers damage to your car caused by something other than a collision. For example, comprehensive can cover damage from fire, theft, vandalism, windstorm, flood, falling objects, etc.

What provides comprehensive healthcare for all individuals? ›

Medi-Cal is the name for the Federal Medicaid Program in California. If you have limited income, the Medi-Cal Program provides comprehensive health coverage to you and your family for free or low-cost.

What is a good comprehensive deductible? ›

» MORE: How much car insurance do you need? However, let's say you want extra coverage for your car, so you sign up for comprehensive insurance. The average auto insurance deductible is $500, but you could also select amounts like $250, $1,000 or $2,000; this will also affect your policy's premium.

Is comprehensive the same as deductible? ›

Comprehensive coverage, which protects your car from damage caused by unexpected events, includes a deductible that applies every time you file a comprehensive claim.

Is it better to have a $500 deductible or $1000? ›

If you're more likely to get into an accident, you won't want to pay out a higher deductible. However, if you're generally a safer driver, your car insurance premiums will be lower with a $1,000 deductible.

Why is comprehensive insurance so expensive? ›

The cost of your comprehensive insurance might increase if you file a claim, live in an area with high crime or bad weather, or if repair costs rise.

Does Medicare cover 100% of hospital bills? ›

Medicare doesn't typically cover 100% of your medical costs. Like most health insurance, Medicare generally comes with out-of-pocket costs including copayments, coinsurance, and deductibles. As you'll learn in this article, Original Medicare (Part A and Part B) costs can really add up.

Which of the following is not included in a comprehensive major medical plan? ›

Which of the following is NOT included in comprehensive major medical plans? First-dollar coverage is not normally associated with comprehensive major medical plans. Medical expense policies will typically cover which of the following? Medical expense policies will typically cover injuries caused by accidents.

Is comprehensive insurance worth it? ›

The coverage also pays to replace your car if it's stolen. Most lenders require you to have comprehensive coverage if you finance or lease your car. Comprehensive insurance could be worth it if you'd have a hard time coming up with cash to repair or replace your car on your own if misfortune strikes.

What is one thing comprehensive coverage doesn t cover? ›

Comprehensive insurance covers damage to your car from animals, falling trees, natural disasters, theft, and vandalism. It does not cover damage to other vehicles or people.

Is it worth having full coverage on an older car? ›

It's usually worth dropping full coverage on an older car if its value is less than a few thousand dollars, as long as there's no loan on it. The more your car depreciates, the less you'll get from the insurance company after an accident or theft.

Which of these policies is considered to be a comprehensive health policy? ›

Final answer: A Major Medical Policy is considered a comprehensive health policy because it generally covers a wide range of health-related costs, unlike other types of policies which may only cover specific procedures or illnesses, or use a different financial approach.

Which type of insurance pays part or all of the surgeon's fees for an operation? ›

In addition to room and board, hospital expense insurance typically covers incidental expenses, such as use of the operating room, x-rays, drugs, anesthesia, and laboratory charges. Surgical expense insurance pays surgeons' fees and related costs associated with surgery.

What is covered under a limited accident and health insurance policy? ›

What do Limited accident and health policies normally cover? Limited accident and health insurance policies cover ONLY a specified illness or event.


Top Articles
Latest Posts
Article information

Author: Aron Pacocha

Last Updated:

Views: 5795

Rating: 4.8 / 5 (68 voted)

Reviews: 91% of readers found this page helpful

Author information

Name: Aron Pacocha

Birthday: 1999-08-12

Address: 3808 Moen Corner, Gorczanyport, FL 67364-2074

Phone: +393457723392

Job: Retail Consultant

Hobby: Jewelry making, Cooking, Gaming, Reading, Juggling, Cabaret, Origami

Introduction: My name is Aron Pacocha, I am a happy, tasty, innocent, proud, talented, courageous, magnificent person who loves writing and wants to share my knowledge and understanding with you.