Note: For purposes of this application, "the patient" refers to the individual with autism.
#1: Is the person with autism currently covered by private health insurance, public coverage (e.g., Medicaid, CHIP), or uninsured?
Military Health Care Programs (e.g., TRICARE) are provided to military personnel, retirees and their dependents and are administered by the Department of Defense. A Federal Employees Health Benefits plan is one that is offered to civilian federal employees and is administered by the U.S. Office of Personnel Management.
#2: Please select the most appropriate response:
In "self-funded" health benefit plans, the employer assumes the financial risk for providing health care benefits to plan participants. While any size company may provide a self-funded plan, it is much more common in companies with greater than 200 employees. Employers that self fund their health benefit plans may administer the plan themselves, or more often will contract with a third party (e.g. XYZ Health Insurance Company) to administer the plan.
In "fully insured" plans, the employer contracts with another organization (e.g. XYZ Health Insurance Company) to assume financial responsibility for plan participants' medical claims and for all incurred administrative costs.
A challenge for consumers is that the insurance cards issued by XYZ Health Insurance Company may look identical for participants in both self-funded and fully insured plans. How can you tell whether you have a self-funded health benefit plan?
A few states require that insurance companies specify whether the plan is "self-funded" or "fully insured" on the insurance card itself. If this information is not printed on your insurance card, you may need to review your Summary Plan Description or contact your Human Resources Department. If you are still not certain whether the plan is self funded, please call the Employee Benefits Security Administration (EBSA), U.S. Department of Labor at 1-866-444-3272.
#3: Is the patient covered by a self-funded health benefit plan?
The state where your employer-sponsored health insurance policy is issued is generally the state where your company is headquartered. This information should be on the patient's health insurance card - for example, "XYZ Health Insurance Company of New York." If you are not certain, please contact the primary insured's Human Resources Department.
#4: In which state was the health insurance policy issued?
#5: In which state does the patient reside?
If you have accurately answered the preceding questions, then the patient is insured by one of the following types of state-regulated health benefit plans, which are subject to state law:
A State Employee Health Benefit Plan is one that is offered to state employees and is administered by a state agency.
An individual policy is a policy that is not purchased in connection with an employer group. This term also refers to coverage purchased by self-employed persons who have no other employees.
As described earlier, in "fully insured" plans the employer contracts with another organization to assume financial responsibility for plan participants' medical claims and for all incurred administrative costs. A fully insured small group plan is one offered by an employer with 50 or less employees.
A fully insured large group plan is one offered by an employer with more than 50 employees.
#6: By which of the following state-regulated health benefit plans is the patient insured?