Limited Benefit Health
Insurance Plan Considerations

Limited benefit health insurance plans usually offer basic but limited medical coverage for surgical, hospital, outpatient, maximum benefits and some specific services. Some insurers offer a basic plan, a better plan and a best plan, with increasing benefits and maximum amounts at increased cost.

The objective is to minimize premium or to restrict coverage for known pre-existing conditions, while covering other services and new illnesses or injuries. These plans are not as benefit rich so not as expensive as comprehensive major medical plans.

Coverage may be written as an impaired risk plan or a pre-existing conditions plan. This could be an option for people who have a condition that is usually rejected as uninsurable for major medical plans, and who are not eligible for a Medicaid or a state guaranteed-issue risk pool. Such an impaired risk plan may be written with an initial exclusion period before coverage begins for specified conditions and may have specific coverage limits for said conditions.

Who Needs This Coverage?

People who are :

Employees who have no access to employer or group insurance.

Ineligible for comprehensive major medical insurance;

Seeking a lower cost alternative to a comprehensive major medical plan;

Seeking an alternative to major medical plans that exclude all coverage for a specific pre-existing condition;

Temporary, seasonal or part-time workers not qualified for a group plan;

Who’s Eligible For Typical Restricted Coverage Plans?:

People who are :

Healthy and between the ages of 30 days and 63 years, 11 months;

Dependent children through age 18, or through age 24 if full-time students, may be covered under their parent’s plan. Children only option may be available;

Foreign residents living in the US for at least one year at time of enrollment. Must have proof of appropriate documentation;

Who’s Not Eligible For Typical Impaired Risk Plans?:

People who are :

Confined to a wheelchair, a nursing home or in a hospital;

On oxygen therapy;

Pregnant or in the process of adoption or surrogate pregnancy;

Engaged in hazardous or ineligible occupations;

Typical Plan Features:

Doctor Office Visits: Covered for unexpected illness or injury, subject to selected moderate-to-high copay and to a maximum amount per office visit and to a maximum number of visits per year per covered person;

Hospital Benefits: Inpatient benefits range from not covered for basic plan to better and best plan benefits of several hundred to several thousand dollars per day, subject to 80% / 20% coinsurance and to specified six figure maximum benefits per year;

Emergency Room Services: Coverage ranges from none for basic plan to several hundred dollars for better plans, subject to a deductible and to a maximum number of visits per year;

Outpatient Services: Coverage ranges from X-ray and lab only for basic plans to several hundred dollars for better plans and a thousand dollars plus for best plans, subject to high deductible and to 80% / 20% coinsurance and to specified maximum benefits per year;

X-Ray and Labs: Included in outpatient services;

Transplant Benefits: Either not covered or included in inpatient benefit limits;

Prescription Drug Benefits: Limited maximum annual benefits, subject to moderate to high copays;

Typical Limited Benefit Plan Exclusions:

* Pre-existing (past five years) conditions, including any not disclosed or inquired about at enrollment, for first 12 months of coverage;

* Illness or injury that is self-inflicted or caused while engaged in a felony or under the influence of alcohol or drugs or in military service or in a hazardous occupation;

* Vision or dental treatments, unless added by option;

* Maternity, genetics, fertility treatment or care or foot care;

* Custodial care or private nursing;

* Cosmetic, experimental, investigational or unnecessary medical treatment;

* Treatment of mental illness or drug abuse;

* Expenses incurred or drugs procured outside US;

* Covered charges in excess of reasonable and customary amounts;

* Charges reimbursable by Medicare, Workers Compensation or an automobile insurance carrier.

Pseudo Group Plans:

For full-time or part-time employees or independent contractors who do not have access to an employer sponsored group plan, a limited benefit health plan can be a good component for a “pseudo group plan” with other employer group benefits. For information on this program, go to

Pseudo Group Plans.

To secure a limited benefit Personal Health Plan Quote, go to the Limited Benefit (Individual) Quote Page.

For information on Fitness Culture, go to Fitness Culture.

For information on Medical Self Care Prevention, go to Self Care Prevention.

For information on Medical Self Care Management, go to Self Care Management.

For information on Patient Care, go to Patient Care Plan.

If you have questions or need additional information, go to our Contact Us Form.

WARNING: NEVER CANCEL YOUR CURRENT INSURANCE UNTIL REPLACEMENT COVERAGE IS APPROVED AND IN PLACE.