Types of Health Insurance
- Major Medical Insurance
- Limited Benefit Plans
- Additional Coverage Options
- Plans that are Not Health Insurance
Under the Affordable Care Act, most of these plans cover the 10 categories of Essential Health Benefits:
- ambulatory patient services (outpatient care you get without being admitted to a hospital)
- Emergency services
- Hospitalization (like surgery and overnight stays)
- Pregnancy, maternity, and newborn care (before and after birth)
- Mental health and substance use disorder services, including behavioral treatment (like counseling and psychotherapy)
- Prescription drugs
- Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
- Laboratory services
- Preventive and wellness services and chronic disease management
- Pediatric services, including oral and vision care (but adult dental and vision coverage isn't required)
These benefits can be delivered in several different ways:
- Exclusive Provider Organization (EPO) Plans: This is a type pf managed care plan where services are typically only covered if you go to doctors, specialists, or hospitals in the plan's network (except in an emergency).
- Preferred Provider Organization (PPO) Plans: In these major medical plans, the insurance company enters into contracts with selected hospitals and doctors to furnish services at a discounted rate. As a member of a PPO, you may be able to seek care from a doctor or hospital that is not a preferred provider, but you will probably have to pay a higher deductible or co-payment.
- Health Maintenance Organization (HMO) Plans: These major medical plans usually make you choose a primary care physician (PCP) from a list of network providers. Your PCP is responsible for managing all of your health care. If you need care from any network provider other than your PCP, you may have to get a referral from your PCP to see that provider. You must receive care from a network provider in order to have your claim paid through the HMO. Treatment received outside the network is usually not covered (except in an emergency).
- Point of Service (POS) Plans: A type of health plan where you pay less if you use providers in the plan’s network. You can use doctors, hospitals, and providers outside of the network without a referral for an additional cost.
These types of policies provide less coverage than major medical insurance. Some of the options that may be available to you are:
- Short-Term, Limited Duration Insurance: Also known as temporary health insurance, this coverage typically lasts several months, but cannot last for longer than 11 months in South Carolina (although it may be able to be renewed). It is primarily designed to fill gaps in major medical health insurance coverage, such as when you are in between jobs or switching coverage. Coverage may be more affordable than major medical insurance, but it does not provide the same protections as major medical coverage and can be subject to pre-existing condition exclusions, among other limitations.
- Basic Hospital Expense Coverage: Covers a period of usually not less than 31 days of continuous in-hospital care and certain hospital outpatient services.
- Basic Medical-Surgical Expense Coverage: Covers costs associated with a necessary surgery, including a certain number of days (usually not less than 21 days) of in-hospital care.
- Hospital Confinement Indemnity Coverage: Covers a fixed amount (usually not less than $40) for each day that you are in a hospital. The benefits paid are not based on your actual expenses.
- Accident Only Coverage: Covers death, dismemberment, disability, or hospital and medical care caused by an accident. Specified accident coverage that covers only certain accidents may also be purchased.
- Specified Disease Coverage: Covers diagnosis and treatment of a specifically named disease or diseases, such as cancer. View the NAIC's Shopper's Guide to Cancer Insurance for more information.
- Other Limited Coverage: You may purchase insurance covering only dental, vision or other specified care.
These types of policies provide added protection should you become disabled, require long-term care, or enroll in Medicare:
- Disability Income: This coverage provides for weekly or monthly benefit payments while you are disabled after a covered injury or sickness. The disability payment is usually a set dollar amount not to exceed a certain percentage of your income. These policies usually expire when you become eligible for Medicare.
- Long-Term Care Insurance: This policy usually pays for skilled, intermediate, and custodial care in a nursing home and also for care in other settings, such as the home, adult day care center, or assisted living facility. The policy usually pays a fixed amount per day while a person is receiving care.
- Medicare Supplement Insurance: The federal Medicare program pays most medical expenses for people 65 or older, or for individuals under 65 receiving Social Security disability benefits. However, Medicare does not pay all expenses. As a result, you may want to buy a Medicare Supplement policy that helps pay for certain expenses, including deductibles not covered by Medicare. View our Medicare Supplement brochure here for more information.
These are not health insurance plans:
- Discount Plans: You may receive advertisements from plans offering discounts on health care for a monthly fee. These are not health insurance plans and participants do not have the same protections as under licensed health insurance plans. The Department of Insurance strongly recommends that you thoroughly investigate any plan promising deep discounts for a “low” monthly fee and weigh the benefits against the cost carefully.
- Non-Licensed Risk-Sharing Plans: You may receive offers to join a group or association that will take your monthly payments, put them in a savings account (or trust) with other participants’ money, and then help pay some of your health care costs, as needed. Such arrangements are not insurance and the participants do not have the protections available to purchasers of licensed insurance plans. The Department of Insurance strongly recommends that you thoroughly investigate such plans before joining.