Employer-Sponsored Health Coverage

What it Covers

Health insurance coverage is now much more standardized than it used to be. In the past, many plans did not cover important services, such as childbirth or mental health services. Now, all plans must cover a set of benefits which are called Essential Health Benefits (EHBs).

All employer-sponsored, individual, or public health coverage options must cover your needs when it comes to these EHBs. The biggest thing that will vary is how much you’ll have to pay, which we’ll look at later; and even then, there are limits to how much your insurance can charge you for your care.

Essential Health Benefits

These are the Essential Health Benefits that all plans must provide:

  • Ambulatory patient services (care you get without being admitted to the hospital)
  • Emergency services
  • Hospitalization
  • Maternity and newborn care (care before and after your baby is born)
  • Preventive and wellness services and chronic disease management, including:
  • Prescription drugs
  • Laboratory services
  • 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)
  • Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)
  • Pediatric services for children, including oral and vision care

Nonessential Health Benefits

There are some types of health care that plans do not have to provide. Here are some examples of services that may not be covered:

  • Fertility treatments
  • Cosmetic surgery (unless medically necessary)
  • Dental care for adults
  • Vision care for adults
  • Alternative medicine, such as acupuncture

There may be employer-sponsored plans you can get that cover these items. However, no plan has to provide them and the plans that do offer them will likely cost more.

Differences Between Plans

Your employer (or your spouse’s or parent’s employer) may let you choose between more than one health coverage option. All of those options must offer the same Essential Health Benefits. The real differences between plans are whether they offer nonessential benefits, which doctors you are allowed to visit, how much of the monthly premium you must pay, and how much you have to pay each time you visit the doctor or need another medical service.

Fully insured and self-insured plans

Employers in California can offer either fully insured or self-insured plans:

  • With a fully insured plan, an employer purchases insurance through an insurance company and pays premiums to that company. The insurance company is responsible for covering the costs of health care, as agreed upon in the policy. Most employers offer fully insured plans.
  • With a self-insured plan, an employer sets aside its own funds to cover the costs of employee medical expenses directly, not through an insurance company. To the employee, a self-insured plan may seem to function much like a fully insured plan.

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