February 22, 2023

Group Health Insurance: The Truth Behind What It Covers and What It Doesn’t


Group health insurance is a type of insurance policy that provides health coverage to a group of people, usually employees of a company or members of an organization. In group health insurance, the cost of the policy is shared between the employer and the employees. However, many people are unaware of what their group health insurance covers and what it does not. In this blog post, we will discuss the truth behind what group health insurance covers and what it does not, to help you make better decisions about your health care needs.

What is Covered by Group Health Insurance?

The coverage offered by group health insurance can vary depending on the specific policy and insurance provider. However, most group health insurance policies offer coverage for the following:

1. Preventive Care: This includes routine check-ups, screenings, and immunizations to prevent illnesses and diseases.

2. Emergency Services: Group health insurance usually covers emergency services such as ambulance transportation, emergency room visits, and urgent care.

3. Hospitalization: Group health insurance typically covers the cost of hospital stays, including room and board, surgery, and medical supplies.

4. Prescription Drugs: Most group health insurance policies cover the cost of prescription medication, although co-pays and deductibles may apply.

5. Mental Health: Group health insurance often covers mental health services, including therapy and counseling.

What is Not Covered by Group Health Insurance?

While group health insurance covers a lot, there are also some services that are typically not covered. Some of these include:

1. Cosmetic Procedures: Group health insurance does not cover cosmetic procedures considered to be elective, such as plastic surgery or cosmetic dental procedures.

2. Alternative Medicine: Group health insurance typically does not cover alternative or complementary medicine, such as chiropractic, acupuncture, or naturopathic treatments.

3. Experimental Procedures: Group health insurance does not cover experimental or investigational procedures that have not yet been proven to be safe and effective.

4. Vision Care: Group health insurance often does not cover eye exams, glasses, or contact lenses.

How Does Group Health Insurance Work?

Group health insurance is typically offered by employers or organizations as a benefit to employees or members. The cost of the policy is shared between the employer or organization and the employees or members. Premiums are usually deducted from the employee’s paycheck on a pre-tax basis. The insurance provider negotiates rates with healthcare providers to ensure that their members receive care at discounted rates. When an employee needs medical care, they typically pay a co-pay, or a percentage of the cost of the service, while the insurance provider pays the remaining balance.

Is Group Health Insurance Cheaper Than Individual Insurance?

Group health insurance is usually less expensive than individual insurance because the risk is spread out among a group of people. This means that insurance providers can negotiate lower rates with healthcare providers, resulting in lower premiums. Additionally, because group health insurance is often offered as a benefit by employers, the employer may contribute a portion of the premium cost, making it even more affordable for employees.

What Happens When I Leave My Employer?

When you leave your employer, you typically lose your group health insurance coverage. However, you may be eligible to continue your coverage through a program called COBRA. COBRA allows you to continue your group health insurance coverage for a limited period of time, usually up to 18 months. However, you will be responsible for paying the entire premium yourself, which can be expensive.

Can I Change My Coverage During Open Enrollment?

Most group health insurance policies have an open enrollment period, during which employees can make changes to their coverage. During this time, you can add or remove dependents, change your coverage level, or switch to a different plan. However, outside of the open enrollment period, changes to your coverage are typically not allowed.

How Do I Choose the Right Group Health Insurance Plan?

Choosing the right group health insurance plan can be a daunting task. Here are some tips to help you choose the right plan:

1. Consider Your Health Care Needs: Look at your past health care expenses and consider any upcoming medical procedures you may need.

2. Look at the Plan’s Network: Make sure the plan has a network of healthcare providers that you want to use.

3. Compare Costs: Look at the premiums, deductibles, co-pays, and out-of-pocket maximums of different plans to determine which one is right for you.


In conclusion, group health insurance provides a valuable benefit to employees and members of organizations. However, it’s important to understand what your policy covers and what it does not. By understanding the specific details of your group health insurance policy, you can make informed decisions about your health care needs and avoid unexpected expenses.


1. Can I use my group health insurance outside of the United States?

It depends on the policy. Some group health insurance policies provide coverage for medical emergencies while traveling outside of the United States. Check with your insurance provider to see if your policy provides this coverage.

2. How long does it take for my group health insurance to take effect?

The effective date of your group health insurance policy will depend on the terms of your specific policy. It’s important to review the policy documents to understand when your coverage will begin.

3. What is a deductible, and how does it work?

A deductible is the amount of money that you must pay out of pocket before your insurance coverage begins. For example, if you have a $1,000 deductible, you will need to pay the first $1,000 of your medical expenses before your insurance provider begins to cover costs.

4. What happens if I don’t enroll in my employer’s group health insurance plan?

If you don’t enroll in your employer’s group health insurance plan, you will not have health insurance coverage. You may be able to enroll in an individual health insurance plan, but this can be more expensive than group health insurance.

5. Can I choose my own healthcare provider with group health insurance?

It depends on the policy. Some group health insurance policies require you to use healthcare providers within their network in order to receive coverage. Other policies may allow you to see any healthcare provider, but you may need to pay more out of pocket for out-of-network providers.

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