Understanding Insurance

Insurance Guide

Navigating the intricacies of health insurance can be very difficult. The services covered under your insurance plan depend on many factors, one of the most important being who regulates your policy – a state or the federal government.

Below are a series of questions designed to help you determine who regulates your policy and learn what autism treatment is covered under your health insurance plan. It may be helpful to have a copy of your Summary Plan Description or policy handy. Your company’s benefits office or the carrier should be able to provide you with your policy, an explanation of benefits, and may also be able to assist you in answering the following questions.

1. Is the patient covered under a Federal Employee Health Plan, Military Plan or Medicaid?

Yes 

NO – go to next question

 

2. Is the patient covered under the Maryland State Employees’ Health Plan?

Yes

NO – go to next question

 

3. Did the patient purchase their policy on the Maryland Health Benefits Exchange (Affordable Care Act/Obamacare)?

Yes

NO – go to next question

 

4. Is the patient covered under an Individual Plan?

An individual plan is a policy that is not purchased in connection with an employer. The policy may be purchased by self-employed persons who have no other employees.

Yes

NO– go to next question

 

5. Is the patient covered under a Self Funded or Fully Funded Plan

Self-funded Plans (Self Insured) – A plan offered by employers who directly assume the major cost of health insurance for their employees. Some self-insured employers contract with insurance carriers or third party administrators for claims processing and other administrative services (e.g. Carefirst, Cigna) while other self-insured plans are self-administered (e.g. JHU EHP, county government). Self Funded Plans are regulated by the Federal Government and are not subject to state mandates. Employers may offer both self-insured and fully-insured plans to their employees

Fully Insured Plans – A plan where the employer contracts with another organization (such as CareFirst, Cigna, United, etc.) to assume financial responsibility for the enrollees’ medical claims and for all incurred administrative costs. Fully Insured plans are subject to all mandates in the state in which they are purchased.

If you are not sure which type of policy you have, review your Summary Plan Description and/or contact your employer benefits office, insurance carrier, or the Maryland Insurance Administration at 410-468-2000 or 800-492-6116.

My plan is Self-funded

My Plan is Fully Funded – go to the next question

 

6. In which state was your Fully Funded Plan purchased?

Just because you live or work in Maryland does not mean your insurance plan was purchased in Maryland. Your employer may have its’ home office headquartered in another state in which case your health insurance policy may have been issued in that state and be subject to that state’s laws. Only plans purchased in Maryland are subject to Maryland law.

There are several ways to determine if your policy is regulated by Maryland law: review your Summary Plan Description and/or contact your employer benefits office, insurance carrier, or the Maryland Insurance Administration at 410-468-2000 or 800-492-6116.

My Employer Fully-Funded plan was purchased in another state.

If your employer Fully-Funded plan was purchased in another state you may still have coverage for habilitative services and/or autism treatment. Find out if the state that regulates your plan has an Autism Mandate.

 

My Employer Fully-Funded plan was purchased in Maryland

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