Who’s Insured Under a Group Health Insurance Plan?

December 3, 2021by Alex Strautman

As an employer, you may be wondering if your employees are eligible for Group Health Insurance. Under the Affordable Care Act (ACA), more individuals than ever are eligible for coverage. Federal law now requires that qualified small businesses provide their employees access to health insurance coverage.

ACA Requirements

The current health of your employees isn’t a factor in that requirement. The ACA ensures all have the ability to enroll. If the business meets the legal entity requirements and the group meets underwriting and other guidelines, coverage is likely available through multiple health plans.

Even if a group does not meet a carrier’s enrollment and premium contribution rules, it may still be eligible to enroll employees for coverage. The ACA’s Special Open Enrollment Window occurs annually from November 15 to December 15.

Consumer Protection and Coverage Standards

The ACA expanded health insurance access and increased consumer protections. It established coverage standards for Individual and Small Group plans. And, it created a coverage mandate for Applicable Large Employers (ALEs).

Whether a business is an ALE is determined annually based on the average size of the employer’s workforce during the prior year. If an employer has fewer than 50 full-time employees, on average during the prior year, the business is not an ALE. It is not subject to the ACA’s employer shared responsibility provisions. (This is often referred to as the employer mandate.)

If an employer has at least 50 full-time employees, including full-time equivalents, on average during the prior year, the business is an ALE for the current year. That means the business is subject to the employer shared responsibility provisions as well as annual employer reporting requirements.

If you’re unsure of your ALE status, an ACA Full-Time Equivalent calculator is available on the CaliforniaChoice website. Also available are ACA Penalties and ACA Safe Harbor calculators and HR Calculators for absenteeism, cost per hire, and employee turnover. More information on ALEs is on the IRS website.

Deciding Who to Cover

If you are not an ALE, it’s up to you who’s covered by your health plan. You can make coverage available to:

  • All full-time employees
  • Full-time employees and their eligible dependents
  • Full-time and part-time employees (subject to insurer rules)
  • Full-time and part-time employees and dependents

You must make coverage available to all who qualify under your benefits guidelines. If you include full-time and part-time employees and dependents, you have to offer coverage to all equally. You can set your own minimum work hours per week for benefit-eligible part-time employees. Just be sure your rules work within insurer participation guidelines.

What you put toward the premium for full-time employees, part-time workers, and dependents can be different. Many employers pay 50% or more of full-time employees’ premiums. An employer may pay less (or a flat amount) for dependents and part-time workers.

Who May Not Qualify

If you operate a business on your own, without other employees, you do not qualify for group health coverage. But, you should be able to purchase coverage on your own. You can get it directly through an insurer, a broker, or the Covered California public exchange.

If you run a family business, and you work with other members of your family (such as a spouse, in-law, son or daughter, or a combination), you may qualify as a group. It depends on if all employees are members of your family, or if family members are a part of your group’s total enrollment.

ACA-Compliant Plans

The ACA established a standard for Health Insurance offered to individuals and small groups. All plans considered ACA-compliant must include 10 essential health benefits (EHBs), including:

  • Ambulatory patient services (outpatient care without admittance to a hospital)
  • Emergency services
  • Hospitalization (like surgery and overnight stays)
  • Pregnancy, maternity, and newborn care (both before and after birth)
  • Mental health and substance use disorder services, including behavioral health treatment (including counseling and psychotherapy)
  • Prescription drugs
  • 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)
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services, including oral and vision care (not deemed essential for adults)

Coverage for birth control and breastfeeding must also be included.

Ask About Value-Adds

Be sure to look for or ask your broker about any value-added benefits. For example, CaliforniaChoice includes a range of free products and services for you, your business, and your employees.

The CaliforniaChoice Business Solutions Suite and Member Value Suite include:

  • Dental Care: The Dentegra® Smile Club offers instant savings, no waiting period, and no claim forms. It includes a nationwide network of more than 20,000 providers.
  • Discount Vision: The EyeMed Vision One plan offers savings on frames, lenses, and eye examinations. You can visit participating LensCrafters, Pearle Vision, or Target Optical stores.
  • EPIC Hearing Program: Enjoy discounts of up to 50% on hearing-related products and testing.
  • HR Support: Get online human resources support from Mineral (formerly Mammoth HR/ThinkHR). Download customizable forms and get updates on regulations affecting your business and employees.
  • Active&Fit Direct®: Access 4,000+ digital workout videos, lifestyle coaching, and fitness center membership at just $25 per month at 10,000 participating centers nationwide.
  • Cal Perks® Discounts: Save on movie, theme park, or sporting event tickets, travel, food delivery, and more.
  • California Rx Card: Get up to 80% savings on prescription drugs at more than 68,000 pharmacies nationwide. Includes CVS, Safeway, Vons, Kroger, Ralphs, Rite Aid, Walgreens, and others.

Comparing Coverage

If you’re considering Group Health Insurance for your business and employees, you can:

Shop on your own

Shop using a broker

  • Ask your broker to research and compare plans and provide you with one or more quotes
    • Get a quote from a single health plan
    • Get a quote from multiple group health plans
    • Get a quote for coverage through the state’s public exchange

How you research your options is up to you. Using a broker can help simplify the process and won’t cost you more. A broker will know the benefits, provider networks, and health plans available in your area, and can help you sort through the details. If you don’t have a broker, you can search for one here.

Shopping for group health insurance?

This guide compiles a list of common questions you may have before you start offering health insurance coverage.