Wiki Health plan vs health insurance

[clinic@goldenwellness.net]

I was recently talking with a state of Alaska agency trying to file a complaint on a "insurance company" that wasn't paying for state mandated newborn metabolic screening. Per state and federal regulations this is required to be covered 100% by all health insurance companies. Talking with the state agency I found out that there are very few true "health insurances" in our state, they are all "Self-Funded Health Plans" (Premera, Aetna, Moda, ect.) that don't have to follow health insurance regulations. Diving deeper with the agency rep, most health plan coverage are almost entirely controlled by the HR department/person at the company the patient works for. They get to pick and choose what is covered and what is not.

I'm newer (<3 years) to the coding and billing side, but I have been around the medical field for over a decade. I never knew this and want to see if anyone else has seen or delt with this?

 

[sls314]

I was recently talking with a state of Alaska agency trying to file a complaint on a "insurance company" that wasn't paying for state mandated newborn metabolic screening. Per state and federal regulations this is required to be covered 100% by all health insurance companies. Talking with the state agency I found out that there are very few true "health insurances" in our state, they are all "Self-Funded Health Plans" (Premera, Aetna, Moda, ect.) that don't have to follow health insurance regulations. Diving deeper with the agency rep, most health plan coverage are almost entirely controlled by the HR department/person at the company the patient works for. They get to pick and choose what is covered and what is not.

I'm newer (<3 years) to the coding and billing side, but I have been around the medical field for over a decade. I never knew this and want to see if anyone else has seen or delt with this?

ERISA plans are regulated by the federal Department of Labor, and state insurance mandates do not apply.

You can find out more here: https://www.dol.gov/general/topic/health-plans/erisa

 

[csperoni]

I know I've heard Don Self speak a couple of times about ERISA plans and ways to help navigate them. You may want to see if there are any upcoming virtual events and/or AAPC chapter meetings by him about this subject.