Understanding The Differences In Health Plan Types

Apr 6 | , , , ,


By Steven Allred, PT, President

PREFERRED Therapy Providers, Inc.

Recently, I read an article, “For Millions of Insured Americans, State Health Laws Don’t Apply”. It hit home to me, as we as an industry navigate which insurer is allowing what. It can get confusing.

When a state law comes out giving direction to what health insurers need to do, on the surface it may seem clear. Unfortunately, it is a bit more nuanced.


There are three (3) “buckets” of health plan types: Fully Insured, Self-Insured, & Workers Compensation.  Each one is governed by a different set of regulations and a different regulating body:

Fully Insured plans administer the benefits and underwrite the claims payment. This means they process the claims but they also pay for it out of the premiums they receive. These types of plans are governed by the state laws.

Self-Insured plans come from companies that decide to pay premiums to themselves and pay for the claim but usually outsource the claims processing and provider network to another company such as Aetna, United, BCBS etc. These plans are governed by federal law commonly known as ERISA.

Workers Compensation plans are governed by state workers’ compensation boards that are separate from the ones that govern the Fully Insured plans.

So, when a state health law directs what benefits must be covered or how they must be paid, keep in mind that applies to Fully Insured plans, not Self-Insured plans or Work Comp plans. The Self-Insured plans may choose to follow what the state laws direct but they are not obligated to do so.

Historically, Self-Insured plans were associated with large employers. While that remains true today, there are more and more smaller companies who are going self-insured. In fact, approximately 61% of the commercial market is Self-Insured.


Let’s take Telehealth benefits during the COVID-19 pandemic. Aetna or Blue Cross/Blue Shield may add telehealth as a benefit for their Fully Insured plans, but each employer that is Self-Insured must decide to include it their benefit plan.  It is not Aetna’s or Blue Cross/Blue Shields decision. They are processing the claim, not determining the benefit for self-insured plans.


Therefore, when you call to verify benefits, ask if telehealth is a covered benefit for PT/OT/SLP and what the benefits are as well.

This is not a new thing in the market. The different plan structures have been around for many years but is not always well understood; leading to more questions with all the changes that are going on right now.


Do you have questions about the different health plan types and how they work? I’d love to hear your questions and comments. You can contact me here.


About the Author

Steven Allred is a physical therapist and the president of PREFERRED Therapy Providers, Inc.

This article is brought to you by PREFERRED Therapy Providers Inc. PREFERRED is the nation’s leading payor management services network. Our expertise is working with physical, occupational and speech therapy practices – from single clinics to multiple clinic locations.