Fully insured policies are designed and offered by the insurance company and purchased by the employer. Plans that are “fully insured” are overseen by the Texas Department of Insurance.
If you want to advocate for coverage for a plan that is “fully insured,” then the request will need to be directed to the insurance company itself. They will be the ones to determine if an exception will be made.
In these situations, it is best to obtain the proper steps to apply for this coverage exception directly from the insurance carrier. Also, it is a very good idea for patients to include a letter from their physician explaining the medical necessity of the requested service.
What are self-funded policies? These are policies designed and offered by the employer but then administered by the insurance company. Self-funded plans are overseen by ERISA. (ERISA should only be contacted if the patient wants to file an “insurance” complaint against the employer).
If you’re covered under a “self-funded” plan, understand that the ultimate decision on whether to extend benefits will be made by your employer.
You should inquire with the insurance company to confirm what steps should be taken to make this request properly. However, it never hurts to reach out to your employer’s HR or benefits department directly.
Some people prefer to keep this information private and do not wish to go this route, but for some, this is most effective.
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