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Health insurance coverage in the United States

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There are two types of funding arrangements that health insurers offer employers (often called plan sponsors) to pay for insurance claims for their employees. The first is called a self-funded plan which means that company you work for pays for any responsibility that the patient does not have (like a copay or deductible or your portion of coinsurance, E.I. 80/20 or 90/10) for a provider that is contracted with the health insurer. For example; you visit a physician and the patient pays a copay of $25.00 a month later you receive an EOB (explanation of benefit) which shows that you paid a copay and also shows additional money that was paid to the provider through the health insurance company. The money that the health insurance company used to pay the provider was given to the health insurance company by your employer. The second type of funding that health insurance companies offer to employers is called a fully-funded plan, meaning that the money used to pay for health services (not including the patient responsibility of a copay or deductible or patient portion of coinsurance) comes from the health insurance company. The difference between the two types of funding is similar to that between an automatic car (fully-funded) and a manual car (self-funded) in that the self-funded plan, the employer has more control over what they will or will not allow for a member's benefits and usually state mandates do not apply to these types of plans. Also with self-funded plans these are usually less expensive to purchase than the fully-funded plans which have to adhere to state mandates, and the benefits usually adhere to the base-line policies and procedures of the health insurance organization.

Contributed by Maria Venderdahl

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