postheadericon State Regulated Plans

Kids with teacherState regulated plans are also known as fully funded or fully insured plans. If your insurance is state regulated, it generally means that the state has specific laws which govern how health insurance is practiced.  In California, there are two state regulators:  the Department of Managed Health Care (DMHC) which generally regulates all HMOs (Health Maintenance Organizations) and most of the Blues (formerly, Blue Cross of California, now called "Anthem", and Blue Shield of California); and  The California Department of Insurance, which generally regulates all other PPOs, traditional indemnity plans, POS (point-of-service) plans, and Blue Shield and Anthem Life and Health Insurance.

If your insurance is issued in a state that differs from where you live, read the evidence of coverage manual carefully and see if it addresses this issue.  Contact the regulators in both states if it is not clear which state regulates your insurance.  If they both try to tell you that they are not responsible, try to get them to talk to each other and sort it out.

 

postheadericon Self-funded

Self-funded or ERISA (Employee Retirement Income Security Act)

Plans are generally paid for by the employer. Employers often pay health insurance companies to administer their plans. Employers can decide which health benefits they will provide. ERISA regulates the employer through the Employee Benefits Security Administration (EBSA) of the Department of Labor (DOL). Filing a Claim for Your Health or Disability Benefit, written by the EBSA, provides a general description of consumer rights under ERISA, but the specifics will be written out in your Plan Description. You may need to contact your plan administrator or human resources department to get additional information.