The Affordable Care Act requires every legitimate health insurance plan to cover 10 essential health benefits. No exceptions. If a plan doesn't include them, it legally cannot be called insurance.
For church administrators and pastors evaluating coverage options, this is the most important place to start. Understanding what's required helps you spot the gaps — and avoid plans that look like insurance but don't offer the same protections.
Here's what the 10 essential health benefits are, what they mean for your church staff, and what else to look for in a plan.
What Are the 10 Essential Health Benefits?
The ACA requires insurance companies to provide coverage for 10 essential (and mandatory) services. Companies differ in how they fulfill the requirements for each essential, but they must provide some level of coverage.
It’s designed to ensure that barriers to healthcare access are removed and provide a few benefits for children. The 10 essentials are:
- Ambulatory patient services (outpatient services)
- Emergency services
- Hospitalization
- Maternity and newborn care
- Mental health and substance use disorder services, including behavioral health treatment
- Prescription drugs
- Rehabilitative and habilitative services (those that help patients acquire, maintain, or improve skills necessary for daily functioning) and devices
- Laboratory services
- Preventive and wellness services and chronic disease management
- Pediatric services, including oral and vision care
If the insurance you are looking at doesn’t include these, it's time to start asking questions. It can’t legally be called insurance if these items aren’t offered.
Covering the essentials is the baseline. But a plan that works well for your church staff goes a step further. There are two other things worth evaluating before you commit to a plan.
What Else Should Church Employee Health Insurance Include?
Having a health plan is a big step towards staying healthy and getting help when you need it. But there are still fees and out-of-pocket costs to consider. You have to balance what you most likely need with how much you are willing to pay upfront.
Let's take a look at some of the most common fees you will find in an insurance plan.
Affordable Fees and Cost Structure
Premium
Each plan has a cost. These typically break down into monthly payments. This is also known as your “premium.”
Some churches cover the entire premium for their staff. Others split it with staff based on a percentage. In a few cases, the staff member must pay the entire premium, which is usually deducted from their paycheck before taxes.
Generally speaking, the larger the premium, the more comprehensive the benefits will be. You will also find that your out-of-pocket costs tend to be lower with a higher premium plan. If you are younger and generally healthy, a lower premium plan may save you money.
Deductibles
Your deductible is the money you have to pay out of your own pocket before insurance pays anything.
These are usually based on a yearly total. If your plan has a $2,000 deductible, then the first $2,000 of costs must be paid by you. After that, insurance begins to cover your services.
Copays
Copays often work hand-in-hand with deductibles. A copay is a percentage of the cost that you have to pay for a service.
A lot of plans have an 80/20 split. This means after you have met your deductible, services will be covered 80% by insurance, and 20% by you.
Maximum out-of-pocket expenses
Your benefits will include the maximum amount of costs you are on the hook for. Once you hit this amount, then the insurance plan pays 100% of the costs.
Here’s an example.
Imagine you have medical expenses of around $30,000. If you have a plan with a $1,000 deductible, 20% copay, and maximum out-of-pocket expenses of $5,000, it works like this:
The first $1,000 of insurance costs have to be covered by you. After that, the next $20,000 of expenses will cost you $4,000. Now that your total is $5,000 the remainder of that $30,000 is covered in full.
Supplemental Add-Ons
Another thing your health plan should include is options you can add to the base plan to extend your coverage.
A standard healthcare plan covers a lot of potential expenses — but not everything. Many plans offer supplemental coverage. These are add-ons that extend and enhance your protection.
Over 68 million people in the U.S. don’t have dental coverage. But as we age, almost everyone experiences trouble with their oral health. Without coverage, people tend to ignore the warning signs and put off treatment. However, if you have ever had tooth problems, you know how much this can reduce the quality of life.
Adding things like dental coverage helps keep out-of-pocket costs down. It also removes barriers to preventive services. It's one of the most common add-ons people choose.
Vision is another popular add-on. The natural aging process often leads to problems with eyesight. Contacts or glasses become more common and essential as people age. Having a vision plan allows you to reduce the costs of check-ups, glasses, and contacts.
Your church’s health plan should also have opportunities to add life insurance and coverage for catastrophic injuries.
But remember, every add-on increases your plan’s premium. However, not selecting them can also put you at higher risk for a variety of ailments.
The right health plan partner will help you find the insurance options that are best for you and your church
Searching out the right health insurance for church employees can feel overwhelming. If you need help understanding or making a choice, we’ve got your back.
Reformed Benefits Association specializes in working with 100% faith-based organizations. We offer access to multiple group insurance plans backed by nationally recognized insurers. Plus, we provide personal service directly to your church, so you never feel like you are on your own.
Download our benefits guide to learn what's included in a benefit plan from Reformed Benefits Association.
The information contained in this blog is for educational purposes only. Please seek professional advice before acting on the information you have read above.
