What companies have you heard of providing a special policy exception for an employee on their self-funded health plan?
All big companies have self-funded insurance plans. These plans pass the full cost of the healthcare through to the company, and the usual names you see on your plan (Cigna, Aetna, etc.) are actually just contracted as administrators that handle all the processing or claims, billing, etc. This works out cheaper for larger employee bases.
Legally this means these companies have full control over the plan policy, what is covered, and can actually step in to approve claims if they want to, or to create special exceptions to the policy for an employee if they desire it. This is useful when moving employees and they need to continue coverage for complex medical conditions, or just outright when the default plan policy doesn’t cover their rare or complex condition.
I’ve heard of this happening, and have a friend in a situation where he needs this, but his company is denying it’s a thing. I’d really like to hear what other companies out there have done this (and what were the circumstances if it’s safe to share). It would help him to be able to point to other companies and say they’ve all done it.
- New OOBDCIt's real. Under a self funded plan, company pays claims up to a certain amount, then there's a stop loss insurance contract in place to cover claims over that certain amount. Then, there's sometimes a transplant plan in place for transplants, and for very serious, chronic conditions, there are provisions to create a "life event", to cause the person to be ineligible for the employer dponsored plan, usually making part time for a month or less. Once the prrson is ineligible, the company buys and individual plan for the affected person and either pays for it or cost shares. Employers do the to avoid having very large, expensive claims affecting their claim utlization, which can result in large premium increases for all the people in the company at renewal.