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Glossary of Plan Types

  • 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 (FEHB) plan is one that is offered to civilian federal employees and is administered by the U.S. Office of Personnel Management.
  • 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.
  • 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 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.

How can you tell whether you have a self-funded health benefit plan?

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. 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.

Why is it important to know your plan type?

Accurately identifying plan type is the first step in determining whether a patient is entitled to coverage for the treatment of autism.

Fully insured health benefit plans (large and small group), individual plans and state employee health benefit plans are regulated by state law. State lawmakers can establish baseline benefits that must be provided by these plan types. Over 30 states have enacted laws that require meaningful coverage for the treatment of autism in state-regulated health plans.

However, some state autism insurance laws exempt one or more plan types from these requirements. Therefore, it is possible that you could be covered by a state regulated health plan and live in a state that has enacted an autism insurance law, but not be entitled to coverage for the treatment of autism.

Most people in the U.S. are covered by a “self-funded” health benefit plan. Self funded plans, Military Health Care Programs and Federal Employees Health Benefits plans are federally regulated and therefore not subject to the requirements in state autism insurance laws. However, a growing number of these plans do provide coverage for the treatment of autism.

Does your health benefit plan cover treatment for autism?

Please visit “Autism Speaks Insurance Link