FYI: Self-funded Health Insurance Plans and ERISA

With the state legislature sessions opening soon and the likelihood of insurance reform legislation submissions, it seems timely to point out information on reimbursement (and limitations) under self-funded health insurance Plans, and to make note either as an advocate or potential beneficiary of legislation as to the language of a bill (or law) in regards to the matter of self-funded policies.

As noted by Autismvotes, in its webpage, Information for Families With Self-Funded Health Insurance Plans

"Even in the states that have passed autism insurance reform , many children are still unable to receive treatment because they are insured through self-funded plans that are not regulated by the state.  If you work for a large company or government, there is a chance your health plan is a self-funded insurance plan.  For self-funded insurance plans, federal ERISA [Employee Retirement Income Security Act of 1974 (ERISA)] law preempts most state insurance regulations, including benefit reforms like autism insurance reform..."

Some of the useful resources at Autismvotes are,

• Self-funded plans: Establishing an autism benefit
• How Private Health Insurance Works: A Primer
• Companies with self-insured health plans that have opted to provide coverage for autism therapies

The Association of Professional Behavior Analysts (APBA) also recently published an article on self-insured entities, with pointers on which self-insured companies provide ABA coverage in their policies,

Self-Insured Employers Cover ABA Intervention for Autism and Other Special Needs
Laurie Stuebing, APBA Autism Task Force
APBA Reporter Issue # 3 - February, 2009.

One other useful reference is from the State of Colorado, Division of Insurance - this has some Colorado-specific clauses, but in general is a clear, lay-friendly explanation of ERISA, self-funded plans, and information on departments in the Federal Government dealing with this area.

ERISA -- Employer-sponsored Self-funded Health Benefit Plans
Colorado Division of Insurance January 2009

• What is ERISA?
• What is the difference between a health insurance plan and an employer-funded health benefit plan
• (ERISA)?
• What steps can I take if I am covered under an ERISA plan and my claim is denied?
• Who has regulatory authority for ERISA plans?
• What are required procedures for Employee Welfare Benefit Plans (Self-funded Plans)?
• What is the “summary plan description” and how does it work?
• Do states have the authority to regulate Employer-sponsored Self-funded Health Benefit Plans?
• How many people in Colorado are insured under an employer-sponsored or self-funded health benefit plan (ERISA plan)?
• Who can provide more information on Employer-Funded Health Benefit Plans?

This post originally posted
Tuesday, December 22, 2009
FYI: Self-funded Health Insurance Plans and ERISA
Practitioner Issues in Behavior Analysis SIG blog

© 2010 Regina G. Claypool-Frey

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