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Self-Insured Plans

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Many large employers have self-insured plans. Self-insured plans are also called self-funded plans.

The employer sets aside a pool of money to pay health costs. The employer may manage the claims, or hire an insurance company to manage them.

The state does not regulate self-insured plans. Be sure to ask for a plan handbook, so you can learn the rules for the plan.

 

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What kind of health plan do you have?

Ask your employer or union if your health plan is self-insured. And ask if it is grandfathered. This affects the laws it must follow. The plan is grandfathered if your employer started it before March 23, 2010 (though you may have joined the plan later).

 

Rights under self-insured plans

Generally, you will have fewer patient rights if you have a self-insured plan than if your plan is regulated by the state.  You will have some protections under federal law, including the Employee Retirement Income Security Act (ERISA) and the health care reform law.

 

New health care reform laws

All self-insured plans must follow these new laws (including grandfathered plans):

  • Children can stay on their parent’s or guardian’s plan until age 26.
  • Health plans cannot cancel your coverage unless you do not pay your premiums or you did not fill out your application truthfully.
  • Plans cannot put a lifetime limit on how much care they will pay for if you get sick. And yearly limits will end in 2014.

If your plan is not grandfathered, it must also follow these new laws:

  • It must cover no-cost preventive care such as vaccines and cancer screening. You do not pay a co-pay, co-insurance, or deductible for these services.
  • A clear process for complaints, including the right to a federal appeal.


Filing complaints and appeals

You have a right to file a complaint (grievance) if you have a problem with your health plan, provider, or health care facility.

If your plan is not grandfathered, it must have a clear process for complaints that includes the right to a federal external appeal.

The U.S. Department of Labor oversees many self-funded plans under federal ERISA law (not including government, church, school, and foreign plans). You can contact this department for more information about appeals and your rights.

Health Plan Problems?

For HMOs  888-466-2219
For PPOs   800-927-4357

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