Employer-Sponsored Coverage

Under the Affordable Care Act, plans sold to individuals and small businesses are required to meet federal standards for the adequacy and affordability of coverage, including minimum standards for benefits and cost-sharing, limits on the factors that insurance companies can use to set premiums, and more standardization of plan benefits to make it easier for consumers to compare plans. Some Affordable Care Act reforms also apply to group health plans sponsored by large employers, including limits on out-of-pocket costs, coverage of preventive services with no cost sharing, and a prohibition on annual and lifetime limits. Whether and how the Affordable Care Act rules apply to coverage will vary based on insurance market, type of coverage, and status as a grandfathered or non-grandfathered plan. See the Resources page for more information on how the Affordable Care Act's insurance rules apply to different plans.

The Affordable Care Act also established new appeal rights for consumers facing a denial of a benefit or service from their health plan. Consumers in new (non-grandfathered) plans have a right to an “internal appeal,” in which consumers have a right to ask their health plan for a full and fair review of an unfavorable decision, and an “external review,” in which an independent third party reviews the health plan’s decision.

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