Senate Insurance Committee Informational Hearing

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Self-insured Plans

An employer may have set up a financial arrangement that helps cover employees’ health care expenses. Sometimes employers do this and have the "health plan" administered by an insurance company, but sometimes there is no outside administrator. With self-insured health plans, certain federal laws may apply and may not be affected by certain other state regulations.

HMOs, PPOs, and fee-for-service plans often share certain features, including pre-authorization, utilization review, and discharge planning.

For example, an authorization may be required from your plan or insurer before admission to a hospital for certain types of surgery. Utilization review is the process by which a plan determines whether a specific medical or surgical service is appropriate or medically necessary. Discharge planning is an approach that facilitates the transfer of a patient to a more cost-effective facility if the patient no longer needs to stay in the hospital. For example, if, following surgery, the patient no longer needs hospitalization but cannot be cared for at home, the patient may be transferred to a skilled nursing facility.
Almost all fee-for-service plans apply managed care techniques to contain costs and guarantee appropriate care, and an increasing number of managed care plans contain fee-for-service elements. While the distinctions among plans are growing increasingly blurred, the number of options available to consumers increases every day.
Health insurance is generally available through groups and to individuals. Premiums (the regular fees paid for health insurance coverage) are generally lower for group coverage. When group insurance is received at work, the premium usually is paid through the employer.

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