- Providing world class service and value for employee benefit group plans since 1987
When group health plans are mentioned, people tend to focus on the aspects that group insurance covers, and not the medical situations that are excluded from group coverage.
Group health insurance covers the risk caused by a wide range of medical costs, but several others are not covered by most group health plans. The exact risks that insurers do not cover vary from one group plan to the other.
Learn about some of the most notable costs that insurance groups tend to avoid.
Also known as investigational treatments, experimental treatments are clinical trials that are yet to be in widespread use. Such treatments are still undergoing development and have not been fully tested and officially approved.
Due to the risk accompanying experimental treatments, they may not be covered by group health insurance. However, experimental treatments are often offered free of charge by the trial sponsor.
In addition, you can appeal to your insurer if the experimental treatments have solid evidence backing their safety.
Alternative medicine refers to medical practices that are not considered to be part of conventional Western treatment. Alternative care is also known as complementary medicine.
Practices under alternative medicine may include massage therapy, acupuncture, herbal medicine, and chiropractic care. These treatments are mostly used in place of orthodox medical care.
Since alternative medicine is different from standard medical practices, insurers may not cover alternative care under group health insurance or individual health insurance.
Insurers are more likely to consider covering alternative medicine under health insurance plans if the alternative care provider is a doctor or has an official license.
Dental care refers to medical treatments that cover everything dental-related – gums, teeth, and the mouth. Vision coverage refers to medical coverage for the eyes including surgeries to correct vision problems, eye examinations, and corrective lenses.
Dental and vision medical expenses are often not covered by group health insurance plans and may require separate or supplemental health plans.
However, some group health insurance plans may include limited benefits coverage for dental and vision care such as vision examinations, discounts on lenses and frames, and dental examinations.
Elective cosmetic procedures, also known as aesthetic or cosmetic surgeries are mostly done to improve an individual’s appearance. Cosmetic procedures include liposuction, tummy tucks, botox, breast augmentation, and rhinoplasty.
Generally, group health insurance does not cover cosmetic procedures, especially when they are considered non-medical.
Injuries and illnesses caused by war are usually not covered by group health plans. However, the type of group health plan and the circumstances of the injury or illness play a crucial role as well.
A person injured while serving in the military may get coverage through the Department of Veterans Affairs.
When considering the services above that might be excluded from group health insurance, you should take note that the extent of group health coverage varies for different group health insurance plans.
The location of the policyholder and the value of the insurance premiums are factors that affect the scope of health coverage.
Pre-existing health conditions refer to health issues, that were present before an individual signed up for group coverage. These conditions could be a physical or mental illness or a health disorder that an individual had prior to receiving health coverage.
Some pre-existing conditions can include cancer, high blood pressure, diabetes, arthritis, depression, asthma, and heart conditions.
While an insurance company might prefer to not provide coverage for a pre-existing condition, the Affordable Care Act (ACA) prevents that. Under the ACA, insurers are not allowed to deny health insurance coverage for pre-existing health conditions.
Also, for both group health insurance and individual health insurance plans, insurers are not allowed to raise your insurance rates simply because of your health.
The specific benefits that a group health insurance policy covers depend on the insurer, the employer, the cost of the insurance premiums, and how many employees the business has.
Some of the general benefits offered to group members include prescription drugs and medical care such as doctor visits, hospitalization, and surgeries.
Emergency care, pregnancy and newborn care, and laboratory services are also offered to insured persons under a group health insurance plan.
A group health insurance plan provides collective healthcare benefits to a group of eligible members or employees of an organization. A group plan is purchased by employers or business owners.
The Affordable Care Act demands that large employers (50 or more full-time equivalent employees) provide health insurance to their full-time employees. However, employees can decide to accept or decline coverage.
Employers can choose between multiple group health insurance options and select a group health insurance coverage structure that best caters to the needs of the members of their establishment.
After purchasing group plans, employers pay a part of the premiums, while employees pay the remaining part, usually through payroll deductions. Then, eligible group members will be provided with medical coverage by health insurance companies.
The terms of the coverage such as deductibles, covered services, and copayments, are established by the insurer, and they remain the same for all members of the group.
Group health insurance sometimes includes family coverage. That is, family members of employees can also be covered under group health insurance plans.
Asides from employers, it is possible to benefit from a group health insurance plan if you are a member of a freelancers’ union and wholesale membership clubs, and if you are self-employed, depending on your location.
Some group plans have lower costs than others based on the insurer and the coverage options. Also, group health insurance can be paired with health savings accounts where employees can save money to pay for healthcare expenses.
Unlike group insurance, an individual health insurance plan is meant for just one person. The premiums under individual coverage often cost more than group health insurance because the insurer’s risk belongs to just a single individual.
Since the insurer’s risk for group health insurance is shared among group members, group plans have lower premiums than individual plans.
As an employee, if you are thinking of signing up for a group health plan from your employer, you need to know what exactly the group health coverage entails. You should find out about the plan’s advantages, and compare them to other options, including individual plans.
As an employer, you need to figure out what plan works for your business, benefiting both you and your employees. Knowing the value of the annual or monthly premium is also very crucial.
An employer should apply during the annual open enrollment period to begin a health insurance plan. Many employers have to wait for months if they miss the enrollment deadline.
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.
Todd Taylor with Taylor Benefits gives our small business the kind of personal service we need. Insurance benefits are important to our employees and Todd helps us find a balance between benefits and value. Todd responds immediately to my phone calls & e-mails. He has even gotten in touch with me on a Sunday when we were in need of coverage answers immediately. We are very pleased with the hands-on service Todd and his staff provide.”
-Ken and Linda Orvick, Orvick Management Group, Inc.
We’re ready to help! Call today: 800-903-6066