How do I know if I have a fully insured plan?
Your insurance card has “DOI” (for department of insurance) or “TDI” printed on it. See examples.
If you bought a plan yourself – through an insurance company, HMO, or HealthCare.gov – it’s likely a fully insured plan. They’re called fully insured plans because you pay a premium to an insurance company or HMO and they pay your health care claims.
How can I get help with a fully insured plan?
TDI regulates fully insured plans and can help if you’re having issues.
What rights do I have with a fully insured plan?
You have certain rights under Texas law. Some of these are:
- Benefits. Your plan must include certain mandated benefits, like maternity care, emergency care, and telemedicine. Learn more about benefits.
- Appeals. You have the right to appeal a health plan’s decision if it denies you a medical service or treatment. Learn more about appeals.
- Bills you didn’t expect. You shouldn’t get a medical bill for emergency care or when you didn’t have a choice of doctors. Learn more about surprise medical bills.
What plan do I have if it’s not fully insured?
Most people with a health plan in Texas have a self-funded plan. If you have a health plan through your employer you probably have a self-funded plan.
A self-funded health plan is one in which the employer pays claims itself. They usually hire insurance companies to handle claims and paperwork.
Your insurance card will say that the plan is administered by the insurance company or HMO. The card might also say "ASO" to indicate that the insurance company or HMO is providing administrative services only.
Who can help me with a self-funded plan?
The federal Department of Labor (DOL) regulates self-funded plans and can help with issues and complaints.
Self-funded plans are exempt from state laws under the Employee Retirement Income Security Act (ERISA). This means they don’t have the same required coverages and right to appeals that fully insured plans do.
ERISA requires self-funded plans to have an appeals process. Look in your plan documents for more information about appeals.
Visit our page to learn where to get help with other types of plans, like military plans, city, county, state, and federal employee plans, and teacher plans.
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