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Employer-Sponsored Health Coverage

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    Employer-Sponsored Health Coverage

    What it Covers

    Health insurance plans are much more standardized than they used to be. In the past, many plans did not cover important services, such as childbirth or mental health services. Now, most plans do:

    • Small group plans (employers with 100 or fewer employees) and individual plans must cover a set of benefits which are called Essential Health Benefits (EHBs). Note: Some small employers may offer "grandfathered" plans that don't cover the EHBs, if the plan was in place before the Affordable Care Act (ACA) was enacted in 2010.
    • Large group plans (employers with more than 100 employees) have more flexibility, but still have to provide a minimum level of coverage. If you work at a large employer, check with your employer about the exact services their plans cover.

    The biggest thing that will vary between different plans is how much you’ll have to pay; and even then, there are limits to how much your insurance can charge you for your care.

    Common Benefits

    These are the Essential Health Benefits that employer-sponsored plans must provide at employers with 100 or fewer employees (larger employers often offer similar benefits):

    • 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

    Less Common 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. Differences between the options can include whether they offer certain 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.

    Learn more

    Buying Health Coverage on CoveredCA

    You can get private health coverage on CoveredCA. The government may help you pay for it.

    Medi-Cal

    Medi-Cal covers people with and without disabilities who have low income.

    Medicare

    Medicare is public health coverage for people with disabilities and seniors.