What Does Group Health Insurance Cover?

Wednesday, January 11, 2023 13:47 Posted by Admin
What Does Group Health Insurance Cover

As an employer or a business owner, providing health insurance coverage for your employees or members of staff is beneficial. Buying health insurance from your preferred provider organization will improve the standard of life of your employees, keeping them healthier and more productive.

When businesses need health insurance for their employees, group health insurance is the way to go. Before choosing a group health insurance plan, businesses should understand details surrounding group health coverage, such as the workings and associated benefits.

What Is A Group Health Insurance Plan?

Group health insurance plans are made for members of a particular circle, usually as employees of a company or a business establishment.

The main difference between a group health insurance plan and individual health insurance is that any person can gain individual coverage while a group health plan only targets members of an organization.

Some group health plans allow the inclusion of immediate family members or dependents of the employees. However, including families in a group health plan might lead to an additional cost. The extra cost depends on the number of individuals added to the group health plan.

What Is A Group Health Insurance Plan

How Do Group Health Insurance Plans Work?

While a lot of employees enjoy group health benefits, a lot of people might not be aware of how group plans from health insurance companies work. This possible lack of awareness is because group health insurance is mostly employer-sponsored.

A group health plan is purchased by an employer or the head of a business on behalf of their employees and the monthly premium is split between the employers and the employees. To buy group health insurance, a company often needs participation from at least 70% of its employees.

One difference between individual and group coverage is the value of their health insurance premiums. With group health insurance, the risk is shared among the employees of a company, so, group coverage often has lower premiums than an individual plan.

Unlike a group health plan, beneficiaries of individual health insurance bear the risk alone, leading to higher premiums on average.

Benefits Of Group Health Insurance

In general, insured persons can cut down on healthcare costs with the help of their health insurance coverage, but when it comes to group health plans, this cost is further reduced. Group plans are less expensive than individual plans and tend to offer better benefits to group members.

There are a lot of companies that provide group health insurance plans, and the specifics of their health insurance policies vary. This means that the group health benefits covered by one health insurance company might be different from the other.

Regardless of an insurance company’s regulations, the Affordable Care Act deems some healthcare services to be necessary. These vital benefits of the Affordable Care Act are split into 10 categories, each of which is explained below.

Ambulatory patient services

An ambulatory service is a form of medical care that does not require a person to be admitted or to stay at a healthcare facility overnight. Also called outpatient care, this is one of the most fundamental forms of care covered by most group health insurance plans.

Emergency services

Emergency healthcare is another benefit enjoyed by members of companies with a group health insurance plan. Recent health insurance laws require the insurance company to cover visits to an emergency room, even if the facility is not within the health insurance network.


Health insurance providers offer medical coverage for when you get admitted to the hospital, including the cost of overnight stays and surgery. Your health insurance plan might require you to handle part of the bill since inpatient care can get very expensive, depending on its duration and the required medical procedures.

Pregnancy, maternity, and newborn care

Members of a health plan are covered by their insurance for the medical services required at various stages of pregnancy including prenatal care (before childbirth), the delivery cost, and postnatal care (after childbirth).

Benefits Of Group Health Insurance

Mental health substance use disorder services

Mental health coverage is another notable service that is required of health insurance providers. Mental health services consist of behavioral health treatment (including counseling and psychotherapy), treatment for substance use disorders (substance abuse), and inpatient services for behavioral and mental health.

Prescription drugs

While prescription drug coverage has been around for a long while, there have been limitations because it often comes with an extra cost, and insurers do not cover all drugs. The recent changes in drug law have made things easier, as insurers need to cover at least one drug in every drug category.

So, if a drug prescribed by a doctor is not covered by a health insurance plan, the insurer must have at least one other drug in the same category that performs the same function as the prescribed drug.

Rehabilitative and habilitative services and devices

Rehabilitative services are targeted at helping people recover or return to their level of functionality before getting an injury or illness. On the other hand, habilitative services serve to develop already existing skills and functions.

Rehabilitative and habilitative services that are covered by insurance include physical and occupational therapy. Employees with injuries, long-standing illnesses, and disabilities can regain and improve physical and mental skills through a group plan.

Laboratory services

Diagnostic procedures and lab tests are also under health coverage since they are required for a doctor to make an accurate diagnosis. Depending on the type and cost of a lab test and the type of your plan, you might need to pay part of the laboratory bill.

Preventive care and chronic disease management

Preventive care is vital since it helps confirm that an individual is healthy, and as such, is covered by health insurance. The components of preventive care include vaccinations, screenings, and tests.

Management of long-term diseases falls under this category, and the details of your plan determine how much coverage you get.

Group Health Insurance - What It Is, How It Works, Benefits

Pediatric services

Children and infants are beneficiaries of medical coverage including immunization, vaccinations, and oral and vision care. However, for adults, access to dental and vision coverage is not classified as essential.

For a group health insurance plan for employees, pediatric services are applicable since family members can be added to a plan.

Written by Todd Taylor

Todd Taylor

Todd Taylor oversees most of the marketing and client administration for the agency with help of an incredible team. Todd is a seasoned benefits insurance broker with over 35 years of industry experience. As the Founder and CEO of Taylor Benefits Insurance Agency, Inc., he provides strategic consultations and high-quality support to ensure his clients’ competitive position in the market.

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