It’s November and at this time of year, our thoughts often turn to giving thanks. Let’s take a moment to look at five things about health insurance for which employers and employees can be thankful.

Health Insurance Requirements to be Thankful For

1: No Denial for Pre-Existing Health Conditions

One of the most significant benefits of the Affordable Care Act (ACA) is the prohibition on denying coverage or charging higher premiums for individuals with pre-existing health conditions.

Before the ACA became law, insurance companies routinely rejected applicants. Often it was due to a diagnosed health condition that predated their application for coverage. In some instances, an insurer would accept an individual’s application but would refuse to pay for health benefits for the pre-existing health condition. In other circumstances, the insurance company might charge the applicant more for coverage.

Today, that practice has been eliminated. All ACA-compliant insurance plans must cover treatment for pre-existing medical conditions. Once a person is enrolled, the plan cannot deny treatment for such coverage or raise a person’s premiums based only on health.

Individuals and children insured under Medicaid and the Children’s Health Insurance Program (CHIP) can also not be denied coverage or charged more because of a pre-existing health condition.

Pregnancy is covered from the day an insured person’s plan begins. If an individual is pregnant at the time of application, the insurance plan cannot reject the applicant or charge more because of the pregnancy.

2: Coverage for Preventive Services and Screenings

The ACA requires most private health insurance plans and Medicaid to include coverage for many preventive health services at no cost to the patient.

Covered services include screenings for blood pressure, cholesterol, diabetes, cancer, sexually transmitted diseases and depression. Routine vaccines must also be covered including vaccinations for the flu, pneumonia, tetanus, human papillomavirus (HPV), measles, COVID-19, and hepatitis A and B.

Also covered are well-child-care visits (from birth to age 21), vaccines for health pregnancies, and counseling for smoking cessation, losing weight, better eating, treating depression, and reducing the use of alcohol. Additional services may be part of the 10 Essential Health Benefits (EHBs) listed below.

Services are free only when delivered by a doctor or other professional in the insured person’s health plan network. There are services for all adults, for women, and for children.

3: The ACA Requires Coverage for 10 Essential Health Benefits

ACA Marketplace and ACA-compliant health plans must include coverage for 10 Essential Health Benefits (EHBs), including:

• Ambulatory patient services (outpatient care you get without being admitted 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 (to help people with injuries, disabilities, or chronic conditions gain or recover their mental and physical skills)
• Laboratory services
• Preventive and wellness services and chronic disease management
• Pediatric services, including oral and vision care (Adult Dental and Vision coverage are not considered essential health benefits under the ACA, although states may elect to require them.)

Plans must also include birth control and breastfeeding coverage in addition to any state-mandated benefits, which can vary.

It’s important to know plan specifics to effectively compare plans. Ask your broker for details.

4: Employees Can Keep Children on Their Coverage Until Age 26

Children can usually stay on a parent’s health insurance plan – including an employer-sponsored plan an individual health plan if it covers dependents – until reaching age 26. It doesn’t matter whether they are married, living with the parent, or attending school. The child does not have to be claimed as a dependent on the parent’s taxes either.

It is important to note, however, that an eligible child may prefer to enroll in his/her/their own coverage. Read our related post, Parent’s Policy vs. Employer Plan: What’s Best for Young Adults.

5: Elimination of Lifetime Limits on Insurance Coverage

The ACA generally prohibits health insurers and health plans from setting a lifetime dollar limit on treatment that is part of the EHBs described above (in point 3). The exceptions are “grandfathered” policies that may have been in force prior to the start of the ACA and non-essential health benefits. If a plan has a lifetime or annual maximum benefit, it will no longer pay for covered services after reaching the specified dollar amount limit.

Talk With a Broker to Learn More

The ACA has its critics. And it’s uncertain if a future Congress might consider changes to any of the above advantages built into the ACA. Leading up to the 2024 presidential election, there were conflicting positions about maintaining the ACA or working to change it.

Whatever the future holds, you can learn more about coverage options for your employees by talking with an employee benefits broker. A broker can help you compare plans and find the right balance for your employees’ needs and your employee benefits budget. If you do not have a broker, you can find one in your area on the MyCalChoice website.